The Health Equity Network of the Americas: inclusion, commitment, and action.

The Health Equity Network of the Americas (HENA) is a multidisciplinary network that promotes knowledge sharing and intersectoral action for equity in health and human rights in the Americas. The objectives of HENA are: 1) to share successful experiences in the development of interventions, considering the social determinants and determination of health, to achieve participatory and community-based health responses; 2) to analyze the health, social, political, environmental and economic impacts of the COVID-19 pandemic; 3) to identify the effects of pandemic care on populations most at risk because of their age and pre-existing health conditions; 4) examine the situation at borders and population movements in the spread of the pandemic and its effects on migrant populations; 5) propose strategies to ensure access to comprehensive care for pregnant women in order to reduce maternal and neonatal suffering, morbidity, and mortality; and 6) analyze violations of human rights and the right to health of historically marginalized populations, including street dwellers and other communities that depend on public spaces and the street for survival. The analytical and intervention models for health equity at HENA are based on various approaches, including social medicine, social epidemiology, medical anthropology, human ecology, and One Health.

The Health Equity Network of the Americas

The Health Equity Network of the Americas (HENA) is a multidisciplinary network whose objective is to promote knowledge sharing and intersectoral action for health equity and human rights in the Americas. Initially, HENA was based at the University of California Los Angeles (1). In 2020, the network moved to the University of Costa Rica where it forges partnerships with other academic and nongovernmental entities, scientific societies, and international organizations.

HENA fosters a multidimensional analysis model—social determination (2); determinants of health (3, 4); well-being (5); health in all policies (6); and planetary health (7)—a perspective that considers the imbalanced interaction between humankind and natural systems to promote health, well-being, and equity and to attain the Sustainable Development Goals (SDGs) developed in the 2030 Agenda for Sustainable Development (8, 9). To this end, intersectoral and collaborative implementation of public health, education, and social protection policies is indispensable, along with human security and preservation of the planet. This requires an integrated approach to economic, social, and environmental dimensions, which constitute the social determinants of health (Figure 1).

FIGURE 1.

Conceptual framework of the impact of the social determinants of health on health equity

HENA’s theoretical framework includes the concept of health equity whereby all people have the opportunity to reach their maximum potential and, faced with the same need, have equal access to quality health care (10), as well as the concept of health inequity or differences in health that are “systematic, avoidable, and unjust” (11). HENA’s analytical and intervention models for health equity incorporate several approaches, such as social medicine, social epidemiology, medical anthropology, human ecology (12, 13), and the One Health initiative, which highlights existing synergies by promoting greater cooperation among human, animal, and environmental health (14).

Building equity into national and international public goods in health—such as health systems, public health research institutions, and intangibles such as health promotion and disease prevention, control, and elimination—provides effective means for the pursuit of health equity. All this represents peoples’ will and struggles, and in many cases stems from solidarity among people and nations.

HENA’s short and medium term objectives

Share successful intervention experiences, considering social determination and determinants, to achieve engaged community responses for health. In the Americas, health analyses show persistent symptoms of inequity in relation to gender, sexual identity, age, ethnicity, skin color, and socioeconomic status––characteristics that are associated with inequality and social injustice and non-fulfillment of human rights (15-21). Many of the biggest public health problems are concentrated in the poorest and most neglected areas of large cities (22) and in indigenous and Afro-descendant communities (23).

HENA studies health systems with a focus on primary health care (PHC) and community services that provide public health actions, such as in Costa Rica and Cuba (Table 1). Both countries have based their response to the COVID-19 pandemic on PHC, which has been marshaled to continue functioning normally, because contact tracing is done at the community level with active community participation. Both cases show that the most effective pandemic responses come from PHC models embedded in the community and not in hospitals.

TABLE 1.

Cases identified by the Health Equity Network of the Americas that contribute to health equity or that require action

Share successful intervention experiences, considering social determination and determinants, to achieve engaged community responses for health Cuba and Costa Rica have been identified as countries in which the public health system is characterized as highly coordinated, based on equitable PHC, with considerable response capacity, and linked to the hospital network (29, 30). Analyze the health, social, political, environmental, and economic impacts of the COVID-19 pandemic Since the epidemic could continue, reactivate, or give rise to new outbreaks, HENA’s efforts are aimed at achieving, at community, national, and regional levels, a deeper understanding with a focus on those who have less access to health and well-being, and on aspects where the lockdown has proven to be unfeasible, unattainable, or clearly harmful to the most vulnerable sectors. The Network tries to identify what changes would have to be introduced—e.g., in food management (31) or in attention to other health problems (32)—in the face of a hypothetical resurgence, to be able to apply measures that do not increase inequity but rather compensate for it and effectively diminish the risk of illness and death. It also seeks to identify civil society responses that have filled gaps or offered important support or constructive criticism of governmental actions not taken. Identify the effects of COVID-19 care on populations at high risk due to age or preexisting conditions In Costa Rica, HENA has a strategy to ensure access to medicines for chronic diseases. The Costa Rican Social Security Fund signed a public-private cooperation agreement to use vehicles from rental agencies, the post office, and municipalities with available vehicles, and to provide gasoline and drivers, to distribute medicines to homes and keep people from having to travel. This delivery system includes medicines for chronic diseases, such as antihypertensives, insulin, and antiretrovirals, as well as contraceptives, though it excludes high-risk medicines. The program has been highly rated by the public. Examine the role of borders and population movements on the spread of the pandemic and their effects on migrant populations HENA proposes monitoring the situation in the Amazon region, where difficult and unjust living conditions are inflicted on indigenous nations whose territories have been invaded and whose people are being decimated by diseases such as COVID-19, to which they are particularly vulnerable (33, 34). Propose strategies to ensure access to comprehensive care for pregnant women, in order to reduce maternal and newborn suffering, morbidity, and mortality HENA has identified the Monsignor Sanabria Hospital in Puntarenas (Costa Rica) as a case illustrating a transformation, initiated in 2015, from a biologistic model of care that did not satisfy users toward a woman-centered model of care with a gender perspective and rights approach. Analyze violations of human rights and the right to health of historically marginalized populations, including street dwellers and other communities that depend on public spaces and the street for survival HENA proposes three lines of action for working at street and health-policy levels: 1) Coordinate a regional community board that brings together community voices from different countries in the Americas, including Colombia, Brazil, Argentina, Uruguay, and Mexico, where there are grassroots movements defending the rights of street dwellers, sex workers, and drug users. This board will meet three times a year to coordinate regional actions against state violence and exclusion from the health system that this population experiences. 2) Coordinate a regional system for community reporting negligence in the health system, operating in a live streaming format on HENA’s website (with regional community board contact people to speak out about reports). 3) Coordinate a response system that mobilizes public policy and health policy actors to catalyze immediate responses to cases. This system of community reporting and regional network action by HENA is the manifestation of participatory action research that informs our actions.

In Costa Rica, information on every person, family, and community stored in electronic health records has been used for risk assessment of chronic patients, home delivery of medications, teleconsultation, and electronic monitoring. In addition, a policy was enacted to contact low-risk pregnant women by telephone to confirm that they have received the care they need. If a woman is found to have moderate risk, she should go to a primary health clinic, and if she is at high risk, to a hospital. For COVID-19 care, regional hospitals have been strengthened with personal protective equipment and COVID-19 tests. Everyone who arrives at a hospital has their temperature taken and symptoms assessed; if COVID-19 is suspected, they are directed to an emergency area to separate them from the rest of the people who come in. An area in the National Rehabilitation Center, which has respiratory therapy, was designated for COVID-19 care.

Cuba relies on the strength of its family medicine model and comprehensive PHC services network. From the onset of the pandemic, using a community epidemiological surveillance system, it began case-finding of symptomatic and asymptomatic people, and carried out surveillance of international travelers. This enabled around 50% of confirmed cases to be found at an asymptomatic stage (24). Contacts of positive cases were advised to remain in quarantine for 14 days at designated hospitals or at home, with restricted movement, monitoring by first-level PHC centers, and PCR testing on the third or fourth day. People with symptoms were referred to hospitals with a higher level of care. At no time did emergency services or intensive care units collapse. Governmental authorities implemented another group of interventions to accomplish physical distancing by the population in the different stages of the epidemic, focusing more on communities with local outbreaks or a higher number of cases, as well as public information campaigns, all recognized as effective interventions for control of transmission (25).

Other countries of the Region have also implemented successful strategies. In Brazil, for example, the Oswaldo Cruz Foundation (FIOCRUZ) has sponsored projects for the protection of populations most vulnerable to the pandemic (26). This initiative launched a large number of actions that, with modest funding and the commitment of a large number of people and organizations, achieved innovative promotion of health protection, food security, education, social protection, culture, and public health care. FIOCRUZ also develops and produces diagnostic kits and medicines, provides clinical services to people with COVID-19, trains health workers on a large scale, and is moving forward with preparations for development, production, and distribution of a vaccine in Latin America and the Caribbean.

HENA is also urgently seeking and promoting viable medium- and long-term ways to achieve greater equity by identifying agents of transformation that can promote changes through social policies and programs and practices focused on promoting health equity. This sense of urgency has been bolstered by the COVID-19 pandemic, which threatens to reverse achievements toward meeting the 2030 Agenda targets (27, 28).

Analyze the health, social, political, environmental, and economic impacts of the COVID-19 pandemic. Due to the COVID-19 crisis, the Americas is facing an unprecedented situation. In almost the entire Region, outpatient services (except for emergencies) were suspended for health problems unrelated to COVID-19 and people were confined to their homes, allowed only brief trips to stock up on food, and required to observe mandatory physical distancing, use of masks, and other measures. Considering the potential negative impact of these restrictions on the national and household economy, some countries offered economic support packages, attempting to prioritize neglected population groups (27, 35, 36).

In Peru, HENA recognized that the experience with the epidemic and lockdown has differed widely within the country and is always more difficult for people dependent on the informal subsistence economy (e.g., micromarketing, vehicle cleaning/care, or housecleaning), while the majority of those who have formal employment kept their jobs and income. The most vulnerable frequently lacked bank accounts, delaying transfer of their support subsidies by more than 45 days. They also lacked pensions or ‘Compensation for Length of Service’ (which functions as unemployment compensation), funds that in both cases were partially released. Consequently, they went hungry, ventured out in search of income to feed their families, and often got infected, some becoming critically ill or dying. Although in their overcrowded homes it was not easy to prevent family members from becoming infected, the media often blamed them for their ‘irresponsibility’ by not ‘staying home’ (37, 38). Very early in the epidemic in Peru, a small group of professionals in public health and the social aspects of health connected on WhatsApp and promptly established contact with the Ministry of Health, organizing weekly virtual meetings to discuss various aspects of the crisis, developing technical briefs for the government, and issuing statements of constructive criticism. Now known as the Citizen Platform for Health Policy-making and Human Rights, it is putting together a long-term vision centered on comprehensive health system reform (39).

In Mexico, HENA collaborates with the Rosario Castellanos Women’s Studies Group (GESMujer) in the area of prevention and treatment of violence against women. From the beginning of the isolation period to May 2020, gender-based violence rose 26% in Oaxaca (40) and the problem has exacerbated the economic situation, since most women have subsistence jobs. On the first day of the quarantine, GESMujer set up a telephone hotline for women, staffed by psychologists and legal advisors, which has handled numerous cases of sexual violence due to the difficulties in seeking medical care given the risk of contagion (40). It has also maintained contact with government agencies that provide other services to victims of violence. Recognizing that the pandemic’s effects will have implications for violence and sexual and reproductive health beyond the end of the lockdown, GESMujer will be promoting actions in the areas of prevention, assistance, and monitoring of health and justice services. With regard to prevention and detection of warning signs in cases of violence or sexual and reproductive health, GESMujer will produce audio and video clips with multicultural content, translated into the three major indigenous languages with the collaboration of indigenous leaders trained in the organization. In the area of care, GESMujer will continue to provide psychological and legal counseling, focusing on sexual violence and its consequences. It will also document cases to learn about the care provided in public health and justice services and to make recommendations to government agencies on how to improve their response to women.

Identify the effects of COVID-19 care on populations at high risk due to age or preexisting conditions. In view of the increase in the number of people sick with COVID-19 in the Americas, HENA is involved in activating and strengthening protection, promotion, and prevention systems for the rural and urban population aged >60 years (Table 1). These are the highest-risk groups when considering hospitalizations and deaths, as their age is related to preexisting chronic diseases (41, 42). From a public health perspective, prevention and identification of risk factors are necessary to design strategies for initial and continuing training of health workers and to have appropriate equipment and sufficient supplies in primary care centers (43). It is also necessary to guide and encourage the engagement of community members and the public and private sectors to comprehensively address the health emergency from the perspective of the social determination and determinants of health. Unfortunately, health equity and exclusion are the leading challenges for public health and well-being in this population group. Giving priority to those aged >60 years with the participation of PHC health teams is an area of opportunity that should be leveraged during the pandemic, with strategies for prevention, promotion, information, education, and communication of risk factors for comorbidities to prevent infection and reduce demand for treatment services in secondary and tertiary hospitals, which are at greater risk of contamination and transmission of SARS-CoV-2 (44).

Examine the role of borders and population movements in the spread of the pandemic and their effects on migrant populations. There are special situations in border areas where we see both solidarity and human drama as a result of forced migration due to environmental changes and human insecurity. This new threat to indigenous nations, at a time of weakened oversight mechanisms, also threatens the Region’s cultural assets. The United Nations has made recommendations and established guidelines to recognize indigenous peoples’ representative institutions, authorities, and governments and to include their representatives; provide effective support to indigenous communities to stop the spread of COVID-19; improve the access and management of clean water and sanitation (particularly for indigenous peoples living in remote communities); ensure availability of disaggregated data on indigenous peoples; obtain the freely given, prior, and informed consent of indigenous peoples before initiating any program or activity; establish post-pandemic reconstruction activities and programs that are specifically aimed at indigenous peoples and that support traditional livelihoods; and involve indigenous youth (45).

In Latin America, many factors drive regional migration, and difficult pre- and post-pandemic economic and social conditions make this a growing and unjust challenge. HENA will establish ties to study responses to the pandemic on the borders of the Amazon region (Table 1), in Central America, and between Haiti and the Dominican Republic.

Propose strategies to ensure access to comprehensive care for pregnant women, in order to reduce maternal and newborn suffering, morbidity, and mortality. HENA is conducting research aimed at identifying best practices in the care of pregnant women and challenges to dignified and respectful care; and analyzing the contribution of obstetric violence to inequity in maternal and neonatal health indicators in different population groups in the Americas (Table 1). Verbal abuse, noncompliance with treatment protocols, poor rapport between women and health practitioners, and certain health system conditions and limitations frequently constitute types of obstetric violence (46). This is a critical but neglected issue that requires accurate knowledge of its frequency and impact (47). To ensure optimal health outcomes, the clinical and non-clinical dimensions of obstetric violence must be understood and addressed as drivers of inequity in maternal and neonatal morbidity and mortality, as they can lead to poor or negligent health care delivery (23, 46-48). Although maternal death is considered a rare event in epidemiological terms, in the Americas, there are approximately 8 500 deaths every year (23 every day), usually as a result of preventable causes (49). These deaths occur disproportionately in indigenous, Afro-descendant, and poor women (21). Learning about successful experiences and their impact on maternal and child health is a great contribution to the development of strategies and programs, both to improve care practices and health-workers’ decisions about women’s rights and to encourage more women to seek skilled care in childbirth, without fear of violence.

Analyze violations of human rights and the right to health of historically marginalized populations, including street dwellers and other communities that depend on public spaces and the street for survival. For HENA, it is a priority to elevate the experiences and voices of historically marginalized and socially excluded communities that survive in the midst of extreme poverty, government neglect, and barriers that block access to the right to health at multiple levels (Table 1). The street community includes street dwellers, sex workers, and street vendors who depend on the daily “hustle” to survive. This line of action is informed by the principles and praxis of participatory action research, which we understand as a philosophy of life rather than a research methodology (50). This philosophy recalls the essence of people power and fixes the Network’s analytical gaze on the streets, which we understand as a cemetery of extreme poverty, where people die every day from police violence, health system negligence, and stigmatization that criminalizes the bodies of poverty. We want to accentuate the political space of the street as a key socio-spatial hub for our participatory action research agenda. Millions of people in the Americas take to the streets, surviving in the exclusion and violence of informal work. During the pandemic, the death of Alejandra “La Monocuco,” an Afro-descendant trans woman and sex worker living with HIV in Bogotá, is a tragic example of state violence that happens every day in the Americas (51). Alejandra died 40 minutes after she was abandoned by the ambulance her friends had called in response to a health emergency she was having. Like so many people who survive in the midst of extreme poverty and structural and police violence, Alejandra was one of the millions of people in the Americas who take to the streets to fight for their lives. This historic moment is an opportunity to catalyze institutional changes that will ensure at least a decent life for these communities.

Joining forces

HENA maintains partnerships with academic and nongovernmental entities, scientific societies, and international organizations, such as the University of Costa Rica; Collaborative Group for Health Equity at Tulane University; Rosario Castellanos Women’s Studies Group; Cayetano Heredia Peruvian University; Oswaldo Cruz Foundation; Pedro Kourí Institute of Tropical Medicine, University of California Los Angeles; Investigación en Salud y Demografía (INSAD, Mexico); National Academy of Medicine of Mexico; Pan American Health Organization; Association of Schools and Programs of Public Health; Latin American Alliance for Global Health (ALASAG); University College London’s Institute of Health Equity; and the Robert Wood Johnson Foundation, in addition to multilateral agencies.

Networking among HENA’s members facilitates socially engaged collaborative research with planned actions for social change aimed at promoting social inclusion, health equity, and human rights in the Americas. The bonds that HENA forms with other institutions make it possible to develop plans for initial and refresher training of human resources for health and to monitor and evaluate interventions aimed at achieving health equity.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or PAHO.