Pandemic, Year 2. Different Experiences, Shared Dilemmas and Multiple Reflections from Medical Anthropology Around Covid 19

Receipt: June 4, 2021

Acceptance: August 16, 2021

The pandemic that was generated by the virus sars-cov-2 from the end of 2019 has been affecting us globally in several waves for a year and a half now. At present (June 8, 2021), approximately 175 million confirmed cases have been recorded, of which nearly 3.8 million people have died.1

Mexico has been one of the countries hardest hit; it is the fourth in terms of the total number of deaths registered from this cause (228,800), behind only the United States and Mexico. usaBrazil and India. The data reflect a significant underreporting, so that, in the case of Mexico, the federal health authorities themselves have stated, based on a study of excess mortality since the beginning of the pandemic, that deaths associated with the pandemic have been significantly higher than in other countries. covid are 61% more than officially accounted for.2

The global competition for vaccines began in the early 2020s. Today, the World Health Organization reports that more than two billion doses of vaccines have been administered worldwide.3 These figures, like the previous ones, do not account for the huge disparities between and within countries in terms of who has been most infected, who has faced mortality surges, and who is receiving vaccines as a priority. In the latter case, we have already seen a process of hoarding of available vaccines by the wealthier countries. Only in the last two months have there been incipient processes of distribution and supply that are beginning to be considered from the perspective of international solidarity, while the possibility of discussing the possible elimination of restrictions on production and distribution as a result of the patents of large pharmaceutical companies, a process to which they are fiercely opposed, is barely glimpsed.

Against this complex backdrop, we address in "Discrepancies" the problem of the covid-19 from some of the major debates that this pandemic has raised from the beginning. We have invited three specialists from the field of medical anthropology to reflect on their respective experiences and knowledge of Mexico, Great Britain, the United States and India, all of them countries deeply affected by the pandemic, even if in very different ways, and whose management of the pandemic has been oriented in different directions. This allows us to contrast the diversity of official responses to the health and economic crisis.

The first discussion concerns the relationship between inequality and covid-19. We start from the very idea of a pandemicwhich evokes the image of a contagion that is universal and by definition can affect us all. However, the pandemic has unmasked deep structural inequalities between and within countries, where infection and death have disproportionately affected those social groups that are in a situation of much greater structural vulnerability due to their living, working and health conditions and access to medical services.

The second debate concerns vaccinations and the simultaneous emergence of new nationalisms -or the reissue of old ones- in times of covidVaccines: various vaccines are developed and approved by the health regulatory agencies of each country or conglomerate of countries (European Union), but they have been scarce in terms of availability, especially in the first months of 2021. Access to them has been differentiated between rich and/or vaccine-producing countries and poor and/or non-producing countries; there is also the issue of patents and the costs of vaccine doses produced by pharmaceutical companies. We have witnessed on a global scale a nationalistic race for the production, distribution and purchase of vaccines, at least until April 2021.

Finally, we could not avoid the obligatory debate between public policies and measures to contain the pandemic, in contrast to the enormous concern of seeing our national economies collapse, including interconnections and supranational costs, which are inevitable in a globalized world. In this case, we were interested in discussing the crossroads between public health and economics based on the respective experiences and positions of our three participants.

Post scriptum: Since June 2021, when the texts were finalized, a new wave of infection by the Delta variant of sars-cov-2 has been unleashed globally. This new variant has a very high infectivity and is affecting population groups (unvaccinated people, younger adults, adolescents and young adults) differently from previous waves, according to the very different progression of vaccination campaigns in each country. This new wave of infection raises questions based on the realization that the pandemic is here to stay for a long time, that herd immunity is becoming unattainable and that new variants will continue to appear. The current situation reaffirms the need and urgency of developing generalized vaccination campaigns, agreed and implemented equitably on a worldwide scale and not only in the countries of the global North which have gained privileged access to vaccines. This pandemic is changing rapidly and constantly, forcing us as committed social scientists to continue to reflect on its changing consequences and its tremendous social costs, the distribution of which is increasingly unequal. The views presented below by our three participants are imbued with a new sense of foreboding and urgency.

The pandemic by covid-19 has been affecting us in waves for more than a year now. The very idea of a pandemic evokes the image of a contagion (and the death that may accompany it) that is universal, that is, that can affect us all. However, the pandemic has unmasked deep structural inequalities between countries and, within countries, between different social groups. From your perspective and your experience in your own country or in other country(ies) where you have worked, what are your reflections on this dilemma between the universal and the specific, between a shared vulnerability as humanity and a differentiated vulnerability with added costs for certain social groups?

The covid-19 pandemic has been affecting us in waves for more than a year now. The very idea of a pandemic conjures up the image of a contagion (and the death that may accompany it) that is universal, that is, that can affect us all. However, the pandemic has unmasked deep structural inequalities between countries and, within countries, between different social groups. From your perspective and your experience in your own country or in other country(ies) where you have worked, what are your reflections on this dilemma between the universal and the specific, between a shared vulnerability as humanity and a differentiated vulnerability with added costs for certain social groups?

The effects of the pandemic have made it clear that the processes of health/disease/care and prevention constitute "a spy of the contradictions of the system", as stated by G. Berlinguer (1975), making visible, enhancing and/or exacerbating the interests, inequalities, conflicts and injustices underlying any society.

In the case of Mexico, a study recently published by the unam about him The impact of the social determinants of covid-19 in Mexico (Ponciano-Rodríguez and Cortés-Meda, 2021) detected differentiated affectations according to age, sex, marital status, ethnicity or socioeconomic status, due to differential exposure to the risk of infection. For example, according to sex, there is a similar incidence between men and women, but in terms of mortality, two men die for every woman; the age groups with the highest incidence are between 30 and 34 years of age, but with higher mortality between 60 and 69 years; people with comorbidities such as hypertension, diabetes and obesity have a higher risk of dying and it has been shown that these three diseases have a greater association in low socioeconomic strata; almost half of the deaths from covid-19 were located in sectors with a low level of schooling (complete primary schooling); but perhaps what is most evident in these inequalities is the labor/socioeconomic affiliation of the people who died. According to this report, 94% of the deaths corresponded to manual workers, operatives, housewives and retirees. This indicates that these are the sectors with the greatest vulnerability from various angles, who due to their living conditions could not carry out a protective confinement and had to go out to work; those who lived in precarious conditions, dwellings with poor ventilation and overcrowding, where it was simply impossible to carry out "healthy distance" practices, hygiene or other preventive measures; workers in sectors essential to the national economy - food supply centers, public transportation, cleaning services, street vendors, construction workers and other industrial branches - who had to continue working for their families' subsistence, social sectors that now and always have been exposed to a greater risk of falling ill and dying, they and their families. Another aspect of social inequality is timely and effective access to health services, marking a great difference between urban and rural populations, indigenous or urban populations in marginal neighborhoods. Only a quarter of the infected population had access to hospital services, while the rest stayed at home or perhaps were treated in a pharmacy or by a private doctor, of which there is no record. Even in those cases in which access to hospital services was achieved, the chances of a seriously ill patient accessing intensive care were minimal (4% in the imss and 20% on a national scale) or to a fan.

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It is already a truism to say that the pandemic of covid-19 has exposed inequalities globally and locally, but it is a truism that it has been a continuing and striking feature of the pandemic in the UK. The UK government's messages in March 2020 that "we are all in this together" were part of an emphasis on the need to act collectively. Prime Minister Boris Johnson said at the beginning of the pandemic that "society exists," directly contradicting the individualism of previous Conservative governments. However, what has developed and continued to be revealed throughout the first and second waves of the pandemic in the UK is that "we are not all in this together," that the virus discriminates, and that some are not only more directly affected by the virus itself, but also by efforts to mitigate its effects. The covid-19 in the United Kingdom has provided one of the most powerful illustrations of the syndemic effects of epidemics (Singer, et al., 1999). et al., 2017), of how existing social inequalities and political and social factors impact the resulting health conditions. As Emily Mendenhall (2020) points out, it is context that matters when considering the global and uneven spread and consequences of the pandemic of covid-19.

In the United Kingdom, the data came to light in March 2020 through anecdotal accounts of higher rates of covid-19 and deaths among ethnic minority communities, first among health professionals, then among janitors, cleaners and later other key workers. As data began to be collected more systematically, it became increasingly clear that those unable to work from home and living in overcrowded housing in deprived urban areas were more exposed and structurally more vulnerable to the virus. The UK has experienced one of the worst mortality rates in Europe, with not only age, disability, gender and regional location determining the varying contours of the pandemic, but also black, Asian and other ethnic minority communities have been significantly disproportionately affected. Although the findings of the recent Sewell Report on racial and ethnic disparities,4 commissioned by the UK government, highlight the role of some of these structural vulnerabilities (e.g. employment, income, location and housing) in health disparities in the UK. covid-19, what remains unaddressed is how historically embedded and ongoing forms of "structural racism" have shaped the inequalities of the pandemic in the UK. As myself and my colleagues have argued elsewhere, there is a biopolitics of the covid-19 in the United Kingdom that has not been examined enough to consider how historical processes, including colonialism and forms of nostalgic nationalism, have shaped and continue to shape the inequalities that are still occurring in the United Kingdom (Gamlin et al., 2021).

The work of medical anthropologists has long demonstrated how the "leitmotiv of inequalities" is a central and consistent feature of infectious disease epidemics (Farmer, 1996). It is unclear to what extent the unmasking of these inequalities in the pandemic of covid-19 in the UK will precipitate the interventions needed to address the structural and social determinants of health or the "causes of the causes". At this point, the continued failure of the current UK government to address and ameliorate social and health disparities does not bode well.

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The tension between sovereign rights and global responsibilities relates not only to issues of resource acquisition, supply and distribution, border closure and the like, but also to cultural values. An apt example is the perception that best practices for pandemic control in low- and middle-income countries and in countries such as the United States should be different. It is argued that U.S. citizens value their freedom to the extent that quarantines, closures, and other state-imposed mitigation strategies will be resisted politically, even if they are based on scientific evidence. We saw this during the 2009 H1N1 pandemic. The United States did not follow the scientific evidence-based strategies issued by the cdc (Center for Disease Control and Prevention)5 that were strongly promoted in other countries. Those guidelines were not considered suitable for Americans, although they were considered suitable for nations accustomed to what is perceived as "more authoritarian governments."

The covid-19 presents us with a pandemic scenario quite the opposite of a catastrophe that fosters global solidarity. The débâcle we are witnessing today is the result of a global "free-for-all". Each country has been left to its own devices to formulate mitigation policy and compete for scarce essential resources, be they masks, ventilators, oxygen tanks, drugs or vaccines. Control of any pandemic requires the four Cs: international cooperation (information sharing and transparency), collaboration (adoption of common mitigation strategies based on scientific evidence), coordination (implementation of centralized and decentralized protocols for disease mitigation and data collection), and compassion (recognition of human rights and a global responsibility for the distribution of vital resources within and across borders). Instead of the four Cs, under Donald Trump's presidency we have seen "America First" policies driven largely by right-wing populist nationalism and identity cult politics that foster polarization and isolationism. What we saw was a ruler who not only abdicated America's moral responsibility as a global health leader, but who undermined the very credibility of the whoThe breakdown of trust has led millions of U.S. citizens to question the validity of the emerging knowledge about the science of medicine, as well as the advocates of evidence-based science within their own country. This breakdown of trust has led millions of U.S. citizens to question the validity of the emerging knowledge about the covid-19 for considering them fake newsand has fueled an "infodemic" of conspiracy theories and other forms of disinformation propagated by pseudo-experts in media outlets such as Fox News.

Questioning government overreach and demanding the freedom to do so as one sees fit has become the rallying cry of a sizable percentage of the Republican party, at the same time that the number of deaths by covid-19 has increased and the impact of structural vulnerability and health system disparities has become apparent. Minority groups of USA have shown mortality rates due to covid19 that are double or triple those of mainstream society due to overcrowded, often multigenerational housing, employment in high-risk work environments, poor access to medical care, and mistrust. Mortality rates among the elderly in assisted living facilities for the elderly, and among their caregivers, mostly people of color and poorly paid, have been extraordinarily high due in large part to the lack of personal protective equipment (epp) and poor security measures. In addition, denialism and politicization of the pandemic have led to underfunding of services and support networks in many states, essential networks for dealing with any pandemic. Prominent among these are safety nets for the poor, including food security, and the support needed for physical isolation of those who test positive and do not have the means to do so.

To divert attention from failed U.S. domestic policies, mortality statistics have been manipulated and, in some cases, suppressed. Verbal attacks on China and immigrants as disease carriers have also intensified, especially during the Trump presidency. As a result, there has been a dramatic increase in violence against Asian Americans and growing fear among undocumented immigrants, many of whom are essential workers. This has led many people to avoid the tests of covid-19, which undoubtedly contributes to the spread of the disease within their own homes, communities and workplaces.

Allow me to end on a positive note related to the covid-19 and global solidarity. More scientists from around the world have researched and published about covid-19 than any previous pandemic. The global scientific community has mobilized as never seen before. This bodes well for health and medical research in preparation for future pandemics.

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Various vaccines are developed, approved by the health regulatory agencies of each country or conglomerate of countries (European Union), but they are scarce in terms of availability and access to them has been differentiated between rich and/or vaccine-producing countries and poor and/or non-producing countries; in addition to the controversies regarding patents and the costs derived from them. We are witnessing worldwide a nationalistic race for the production, distribution and purchase of vaccines. What ethical, political and/or health dilemmas are involved when governments give priority to their own people, thus responding to the mandate to protect their own people first? What would be the implications, on the other hand, if a policy of solidarity prevailed on a global scale, as promoted by the WHO? Finally, is all health nationalism necessarily antagonistic or opposed to international solidarity?

It is an unprecedented effort that in the space of just one year several vaccines against the virus have been generated. sars-cov-2, which demonstrates the importance of the investment that certain countries allocate to science and technology, while at the same time corroborating the inequitable distribution of vaccines.

The conditions for the generation of knowledge and associated biotechnology are intrinsically linked to the policies for financing basic and applied research in a joint effort of research centers, governments and the pharmaceutical industry. These conditions are articulated with the control of the processes of production, marketing and distribution of vaccines, and it is these criteria that determine which populations are priorities in the vaccination process, beyond the health crisis or their specific vulnerability and risk factors associated with the covid-19. Hegemonic positions and economic-political interests in a global system involve both the pharmaceutical industry and the negotiation, management and purchasing power of each government.

In this global market, there is a gradual growth in the supply of vaccines, at least in the six dominant pharmaceutical brands (Moderna, Pfizer-BioNtech, Oxford-Astra Zeneca, Sinovac, Cansino, Sputnik-V) which would meet - according to the criteria adopted by each country - the requirements of efficacy, safety and accessibility in the market, even if the supply turns out to be absolutely insufficient to cover the required demand in the short term worldwide.

The ethical-political dilemmas involved in a more equitable distribution of vaccines would point to a duty to be of international solidarity, in which the liberation of patents or the reduction of profits or power reserves appear as utopias or ideals of an ethical, morally desirable duty to be. The obligation of any government is to maintain or recover the health of its citizens. However, the hoarding or political use of vaccines for other lucrative, mercantile or hegemonic purposes is neither legitimate nor ethical. Nationalism in vaccines is not only selfish but also short-sighted, since we will only be able to mitigate the impact of the pandemic and achieve the much-mentioned herd immunity if we act on a global scale and not only on a national scale. Restrictive mobility measures, such as a health passport, testing pcrThe use of vaccines, selective vaccination cards or compulsory quarantines aimed at certain nationalities would lead to hierarchical citizenship for health reasons, control policies, discrimination and racism. We live in a global world with a high level of interdependence and interrelation between countries, and a nationalist policy of concentrating vaccines will not prevent cross-border crossings due to migration and globalization, nor will it prevent new waves or variants of the virus.

International organizations (who, ops, un) through the mechanism covax should play a much more active and proactive role in the local production and supply of vaccines to poor countries, actions that are truly binding and not just enunciative, to have a substantive effect on redistribution and avoid hoarding, in order to alleviate this pandemic at the global level as much as possible.

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The rhetoric of collective national solidarity evoked by the UK government at the onset of the pandemic, in an effort to mobilize around adherence to the social constraints of isolation, has been reissued and repositioned in relation to vaccines against the covid-19, where a "bullish" post-Brexit "do-it-yourself" attitude of influence has often dominated. The UK, even as it proudly advertises one of the highest population vaccination rates across all age groups (partly a product of reliance at least on the National Health Service,6 in the UK scientific community and regulators, if not the government), is also at the forefront of the vaccine nationalism we are currently witnessing. Like the U.S. and Canada, the U.K. is leading the way with orders in excess of five doses per person, while many other countries cannot access even one dose sufficient for the population, and those countries are unlikely to be fully vaccinated next year, if not much later. Moreover, unlike other wealthy northern countries, the UK has also been embarrassingly slow and inactive in ensuring production and more equitable distribution of vaccines. This includes both the failure to fulfill a stated commitment to share vaccines through global initiatives such as covax such as opposition to the patent and commercial intellectual property rights exemptions that many, including the president of USA and the whoare now calling for. While outside the UK there seems to be a realization that ultimately the understandable desire to protect and prioritize their national populations by each government has to be squared with the needs of international solidarity and cooperation, this has not yet translated into meaningful understanding and action by the UK government.

The situation we are currently experiencing in the UK, with the emergence of a possible third wave linked to new variants, not only calls into question the "success" of vaccinations in the country, but also makes it powerfully clear that triumphalism about national vaccination rates is inadequate and misguided. As many scientific commentators have continually emphasized, global vaccination is the only way to achieve success with vaccines against the covid-19 in any national context. The variant now considered dominant in the UK, the so-called Delta variant, first emerged in India, a country that is an international hub of vaccine production and where, however, rising infection rates have also disrupted the transnational supply chains on which the UK depends to meet its own national vaccination schedule. This illustrates the entangled trans-global dependencies and geopolitics in which vaccination against the covid-19. We can only hope that, in this so-called "race" between variants and vaccines, the value of long-term health and the ethics of international, not just national, solidarity will lead to action to realize global equity in vaccine access and distribution in the UK and elsewhere.

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The chances of soon achieving global herd immunity against the covid-19, if reached at all, are debatable, considering 1) the ease with which the virus can be transmitted indoors and in crowded spaces by both asymptomatic and symptomatic virus carriers, 2) the significant percentages of populations that have rejected or adopted an attitude of laissez faire in terms of mitigating the impact of the covid-19, 3) the millions of immunocompromised people, 4) some 80 million displaced people worldwide, of whom more than 26 million are refugees, 5) the logistical difficulties in the global deployment of vaccines, 6) the emergence of variants that have turned out to be more or less transmissible and pernicious, and 7) the global travel and transport of goods that connect us all.

For the time being, the best most countries can hope for is community immunity, which translates into regional viral transmission rates low enough to keep businesses and schools open, and cases of serious illness low enough that hospitals are not overwhelmed. When hospitals are overwhelmed there is significant collateral damage in the form of delays in the treatment of all kinds of health problems, the health system is overburdened to the point where the quality of care falters, and health worker burnout increases, leading to attrition and staff shortages. Communities lose their safety net.

To achieve community immunity and to reduce the covid-19 to the point where it becomes a manageable threat is the first priority of any nation. Mobilizing a national response to a pandemic is necessary, but not sufficient. No community is an island, and the priority of maintaining the security of one's homeland must be balanced with the broader global priorities necessary for pandemic containment given that viruses know no borders. In the case of the covid-19, support for global response efforts is not just a matter of altruism, but a means to avoid the very real possibility of future waves of variants of covid-19 enter the population. Health equity is impossible to ignore, because it is likely that more pernicious variants of covid-19 in places where mitigation practices and access to health care are poor and health disparity is pronounced. These places literally become breeding grounds for the mutation of the covid-19.

This brings us to vaccine nationalism, vaccine diplomacy, and the geopolitical struggle to secure both vaccines and the materials and rights to produce them. Vaccines against covid-19 have been shown to be remarkably effective in the prevention of covid-19 hospitalization and death, as well as in reducing the transmission of the disease. covid-19 and its variants. Although compliance with public health guidelines, such as physical distancing, the use of masks, testing for covid-19 and contact tracing have contributed to community immunity in valuable ways, it is vaccines that are needed to ensure and maintain high levels of immunity. As we have already seen, even countries that apply strict guidelines for mitigating the effects of vaccines and contact tracing have made a valuable contribution to community immunity. covid-19 have experienced spikes that have led to blockades that have disrupted the lives of the population and caused economic and psychological distress.

The acquisition and worldwide distribution of the vaccine against the covid-19 poses a dilemma. Despite goodwill pledges to help ensure that poor countries have access to effective vaccines, the vast majority of highly effective vaccines have been procured by wealthy countries. Following the emergency approval of Pfizer's and Moderna's, the Biden administration has done a remarkable job in deploying vaccines throughout the United States. Today, nearly half of the U.S. population has been vaccinated, with campaigns underway to reach all those who want to be vaccinated and encourage those who are hesitant to join them. By comparison, the number of vaccines deployed in Africa amounts to just over one dose per person for about 2% of the 1.2 billion people living on the continent.

While the United States is beginning to make progress in combating the disparity in the covid within its own borders, its overall pandemic response record remains less than stellar, although it is improving. The presence of USA The global fight against the pandemic has moved at a snail's pace, while the number of severe cases of covid-19 have soared in low- and middle-income countries (prbm) with no end in sight.

Let me briefly highlight three global pandemic control priorities.

First of all, it is necessary to temporarily suspend the intellectual property rights governing the manufacture of vaccines against covid-19, increase the flow of materials needed to increase vaccine production in the prbm and invest in increased regional capacity to meet vaccine needs as a cornerstone of global pandemic preparedness.

Second, before prioritizing vaccination of the entire population in the immediate future, it is vital that countries such as the U.S. help countries like the U.S. to provide the necessary prbm to achieve community immunity and protect front-line healthcare workers of all types (and I would add their immediate family). Protecting healthcare workers and reducing the number of severe cases of covid-19 through targeted vaccination of those most at risk of hospitalization will go a long way toward protecting fragile health systems. The consequences of not doing so are dire, as evidenced by the collateral damage experienced during past pandemics such as Ebola.

Third, India should be a priority recipient of pandemic assistance, both for humanitarian reasons and because it is the largest supplier of vaccines to the world's most vulnerable populations. prbm. Exports of vaccines from India to the United States are prbm abruptly stopped to respond to the exponential increase in domestic demand. Helping India to contain the covid-19 and increasing vaccine production will allow vaccines to be exported again. By helping India, the first-world countries will in turn help the second-world countries. prbm to receive much-needed vaccinations.

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One of the earliest and most permanent measures implemented by governments has been social distancing and confinement to reduce the number of contagions and possible loss of life. This has implied the consequent closure or reduction of economic activities and strong debates within each country on how to guarantee collective health without destroying the economy. More than a year after the beginning of the pandemic, what is your assessment of the measures adopted in your country (or in your professional experience in other countries) in relation to health management in terms of sustaining the economy in the context of the pandemic?

In the case of Mexico, a false dichotomy was posed between health and economy. Paradoxically, the necessary, timely and effective measures were not taken in terms of health, nor were economic support strategies designed. Measures of indiscriminate closures of companies, industries and businesses were established, which was accompanied by a confinement of the population ("national day of healthy distance"), but without systematic and exhaustive measures to contain the pandemic by increasing the number of tests for the detection of contagion.

Since June 2020, an Epidemiological Traffic Light regulation was established that sought to articulate the conditions of evolution of the pandemic (basically measured through the indicator of availability of hospital beds) with the possibilities of closing, partial or total opening of certain productive, service, educational, recreational, etc. activities. However, after a year we have seen that this traffic light policy responded more to economic-political criteria than to epidemiological ones.

In terms of economic policy, it can be said that there is a lack or insufficiency of fiscal and financial support programs for the productive plant, which has led to the closure of up to one million businesses and has resulted in higher unemployment, a reduction of the GDPeconomic decline, increase of people at the extreme poverty level, decrease in income, increase in the number of people living in extreme poverty, decrease in the number of people living in extreme poverty, decrease in income per capitaamong other consequences. The Mexican State has ignored this social responsibility and leaves the population adrift, in a "every man for himself, every man for himself", or in the words of President López Obrador: "if they have to go bankrupt, let them go bankrupt".

According to data from the cepalLatin America is perhaps the region of the world where the pandemic has had the greatest economic impact and where poverty and extreme poverty have increased as a direct consequence of the pandemic, depending on the specific measures each government has taken to mitigate these impacts. Three countries have fared worst, with the share of extreme poverty soaring between 2019 and 2020: Mexico, Honduras, and Ecuador. Across the region, the average public spending and fiscal support was 4.5% of the GDP8%, but with notable differences, since while Brazil allocated 8%, in Mexico it was only 0.7% of the total. GDP. In a context of a weakening domestic market, public spending has been used to finance infrastructure projects with questionable technical, operational and financial viability, channeling resources needed to invest in the health system and vaccines, and on the other hand in economic reactivation programs, soft loans and tax incentives, among others.

The covid-19 became the leading cause of mortality in Mexico during 2020. According to these official data, Mexico is one of the four countries that concentrate the highest number of deaths in the world, high case fatality rate, high mortality rate, the highest number of deaths among health personnel and with a vaccination percentage below countries with a similar level of development. The health crisis was exacerbated by the conditions of the health sector in Mexico since the end of 2018; a health system that the year before the pandemic was in an extremely critical situation. The disappearance of Seguro Popular led to defunding and disorganization of services, shortages of medicines, budget reductions in health programs and services, cuts to health and administrative staff in hospital centers, and left insufficient infrastructure and poorly paid staff. This was the context in which the pandemic of covid-19, thus witnessing the "perfect storm" in health terms.

In sum, the lack of consistent public health policies and an adequate contingency plan for the pandemic, confusing or misleading communication policies regarding the seriousness of the problem, preventive measures, as well as the concealment or manipulation of information, economic policies of austerity at all costs, lack of support and the diversion of financial resources to obsolete or unnecessary projects, among other aspects, result in the worst epidemiological and economic catastrophe of recent Mexico.

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In the face of the pandemic, all countries have faced difficult choices in choosing how to balance social constraints and economic shutdowns to protect public health and avoid short- and long-term economic disaster. Once again, the inequalities of the covid-19 have been starkly highlighted, as some sectors have been unevenly affected by public health measures to reduce the spread of the virus. While the U.K.'s job preservation scheme or paid sick leave has offered vital economic protection for some, though certainly not for all those affected by the economic restrictions, the limited period of such government support raises new questions about the long-term economic consequences of the covid-19.

Although UK scientific commentators have consistently stressed the need, in this context, not to see public health and economics in opposition, but as interdependent, this has not always been recognized by government. On the contrary, there has been a history not only of going "behind the curve" by not acting quickly to introduce national containments, but also, in the first wave of the pandemic, implicitly or explicitly, of adopting an approach of laissez-faire in pursuit of "herd immunity", which took precedence over economic needs. In the UK there is evidence that only after epidemiological models indicated that such a policy would lead to hundreds of thousands of excess deaths by the end of March 2020, the government then introduced its first national containment, despite evidence of exploding cases and deaths in Italy and Spain many weeks earlier.

Unfortunately, this has been the pattern of response from the UK government throughout 2020; it has been slow to act and has sent mixed messages to the public about the need to open up the economy while protecting public health. This was most visible in late autumn 2020 with the increase in cases linked to the new and much more transmissible "Alpha variant" first identified in Kent, and many scientific commentators calling for a brief confinement to act as a "switch" to stop the rapid increase in cases. The pleas were ignored by the government, which instead chose to stand firm on its promise of "no Christmas cancellation." Unlike other European countries, whose rising rates of cases and deaths prompted the shutdown of the economy through nationwide lockdowns since early December, the UK government resisted, allowing some family gatherings to be held in certain regions of the country over the Christmas period, despite the rise in cases. On January 4, the UK entered its third national containment, which lasted for more than three months, while experiencing a period of sustained and shockingly high mortality rates that ultimately proved far more deadly than that of the first wave. Although the planned official inquiry into the government's management of the pandemic has yet to fully reveal how prompt action and the imposition of national containments could have prevented the devastating second wave of deaths from covid-19 in the UK, many remain convinced that government delays and failures in decision making at this time were a contributing factor.

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The most controversial political question that has arisen during the pandemic of covid-19 is the extent to which it is necessary to balance public health measures and the pursuit of public health outcomes with the economic and psychological costs of disease suppression. In other words, what is the balance between saving lives by adopting disease mitigation measures and the economic and psychological costs of disease suppression? covid-19 (i.e., use of masks, physical distancing, lockdowns, vaccination mandates) and place other community members in a precarious position when considering the economic costs of these measures on their life trajectories?

Over the past year we have witnessed pandemic decisions guided by both public health and economic interests. In general, the countries that have been most proactive in suppressing the covid-19 have fared better than those who have delayed interventions in favor of keeping economies open as long as possible. Beyond this general observation, let me share some reflections on what has happened in the United States as a way of broadening our thinking about the balance between public health and economic priorities in the era of the covid-19. Volumes will undoubtedly be written about the tug-of-war that has occurred between states that have favored pro-business strategies in the management of the covid-19 (e.g. Florida and Texas) and states that have prioritized public health (e.g. New York and California).

Let me briefly share three observations. The first comes from my participation in public health teams charged with advising my own university, the county, and the state of Arizona on the emerging pandemic. In all cases, the information routinely provided to administrators by these expert groups was of high quality and encompassed data on the importance of testing for covid and contact tracing, the presence of the virus in sewage from university buildings, hospitalization and mortality rates, vaccination uptake, etc. Although they were well received, my public health colleagues and I often felt as if we were rowing against strong currents that wanted to keep business open and privilege the economy, except during waves of covid-19, when transmission and hospitalization rates have been unusually high. Like the frontline health care workers I supported as a member of the nonprofit organization hcwhosted (Healthcare Workers Hosted), my public healthcare colleagues have often felt a sense of moral distress, if not outrage, when confronted with blatant disregard for common sense mitigation practices by the general public, and premature changes in policies on wearing coverings and reopening for business.

A second observation is that the changes in policy related to the covid-19 sanctioned by our state government in the name of keeping our economy strong have not always been embraced by the general population, which has remained cautious and wary of politicians' motivations. Employers have had to decide their own policies of wearing masks and physical distancing, given the concerns of their employees and customers. My point is that in assessing what has happened in my state, it is important to take into account not only government policies, but also the practices of businesses and educational institutions, the public trust, and what people have decided to do over time, taking into account both their subjective sense of risk and their forms of health citizenship. In the United States, the media tends to sensationalize noncompliance with public health measures. I would argue that adherence to reliable measures of public health, in the face of policy changes laissez-faire of covid-19, is equally important. For many, good public health is equally good for business.

A third observation relates to what it means to be pro-business during the pandemic of covid-19, viewed through the lens of public health. Essential worker safety needs have not been well addressed during this pandemic. This extends beyond the provision of personal protective equipment, improvements in ventilation, routine testing, and supportive housing should workers need to be isolated from their homes. Good business practices should also include paid leave for testing and for workers not to remain at work while contagious or sick, and paid leave if they suffer side effects after vaccination. In the future, these provisions should be considered fundamental to pandemic preparedness.

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Paola Maria Sesia is a tenured professor-researcher at the ciesas-South Pacific. She is a historian, medical anthropologist and health specialist, with a doctorate in sociocultural anthropology and a master's degree in public health. Her areas of expertise include maternal, neonatal and reproductive health, maternal and infant mortality, as well as nutrition issues. Her interests stem from a perspective that contemplates public policies in health, social inequality, structural violence and human rights, with a particular focus on the health of indigenous peoples. She has coordinated the publication of eight books and has published more than forty articles or chapters. She has been regional director of ciesas-She has been a member of the National System of Researchers since 2003. She has been a member of the National System of Researchers since 2003.

Lina Rosa Berrio Palomo D. in Anthropology from the uam-Iztapalapa and research professor of the ciesas-South Pacific in the line of medical anthropology. She is a member of the National System of Researchers level I. She is currently working on a research project on reproductive health of Afro-Mexican and Ikoots women in the Costa Chica and Isthmus of Oaxaca. She has coordinated several projects on reproductive health and is the author of several publications and has accompanied organizational processes of indigenous women and midwives for several years. Her research interests are reproductive health, gender, feminist anthropologies, indigenous and Afro-Mexican peoples.

Rosa Maria Osorio is a professor-researcher at the ciesas-Mexico City. Physical anthropologist, master in Social Anthropology and later in Anthropology of Medicine and PhD in Social and Cultural Anthropology. She teaches at the Graduate School of Anthropology at the ciesas-cdmx and in various national and international institutions. He is currently coordinating the Permanent Seminar on Medical Anthropology at the ciesas. Her lines of research include maternal medical culture and self-care structure, care trajectories, chronicity processes, health services and public policies. Her publications include Understanding and caring for illness. Maternal knowledge in the face of children's illnesses., Medical Anthropology in Mexico and the Bibliography of social research in health in Mexico (1918-2018).

Sahra Gibbon is Associate Professor of Medical Anthropology in the Department of Anthropology at University College London. She has conducted ethnographic research in the UK, Cuba and Brazil, examining the development of genomics, public health, activism, gender and identity. She coordinates the Biosocial Birth Cohort Research Network, funded by the Wellcome Trust, and the newly created MA in Biosocial Medical Anthropology at ucl. His recent publications include Routledge Handbook of Genomics, Health and Society (2018), and with colleagues from uclMexico and Brazil, Critical Medical Anthropology. Perspectives in and from Latin Americapublished in 2020. She is an editor with Jennie Gamlin of the ucl Press titled Embodying Inequalities. Perspectives from Medical Anthropology.

Mark Nichter is Regents Professor Emeritus and former coordinator of the Graduate Program in Medical Anthropology at the University of Arizona. He has a Ph.D. in Anthropology and a Masters in Public Health, and postdoctoral training in cultural psychiatry and clinical anthropology. A member of the Department of Family and Community Medicine and the School of Public Health at the University of Arizona, he has published widely and is well known in the academic communities of health social science and global health. He has been a consultant to international health and development organizations and a member of several panels of the Institute of Medicine at the University of Arizona. eu. Currently, he is a member of three working groups related to covid-19 and co-founder of, a coalition supporting health care workers and their families in the pandemic.

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