Brazil and Mexico: southern experiences of a global pandemic
Canada, the USA and UK are leading the way in global vaccine inequality with orders in excess of nine, seven and five doses per person, compared with countries such as Brazil and Mexico with orders of around one dose per person.13 Despite Brazil’s robust universal healthcare system and long history of successful immunisation programmes, vaccine hesitancy and politicisation by the Bolsonaro government resulted in roll-out that was initially ‘painfully slow, inconsistent and marred by shortages’.14 National and global vaccine policies are legitimated by the globalisation of trade legislation that adheres to the ideology of neoliberalism. This is the coloniality of power at a global scale. Since writing this both Brazil and Mexico have accellerated their vaccine rollout, yet it continues to be the case that vaccination rates in the global north far outweigh those in the global south.
CMA also draws out epistemic hegemony in the treatment of experiences of COVID-19 and the impact of these absences on ontologies of causality and response—these are forms of epistemic violence.7 In the UK and throughout most of the Global North, COVID-19 mortality and vaccine hesitancy have been consistently higher among black and minority ethnic groups,15 an early finding that has rightly led to considerable research as well as discussions of institutional racism. However, such inequities have taken an entirely other dimensions in Mexico and Brazil, which have also produced two of the highest national death tolls in the world. On 6 April, Brazil recorded an astounding 4211 COVID-19 deaths16 in the previous 24 hours, while by 15 March Mexico had recorded 444 722 deaths based on excess mortality, a figure that includes non-COVID-19 fatalities. The cumulative excess death rate in Mexico is 49.9%,17 while globally the average is 17%. If Mexico had had this overall average excess mortality, the number of COVID-19 deaths would have been 189 465 fewer.18
The Brazilian government’s handling of the pandemic should be understood as an intensification of Bolsonaro’s abdication of responsibility for public health governance, itself defined by consistent scientific denialism, promotion of discredited treatments (hydroxychloroquine), dissemination of fake news and freezing of public health funding. Moreover, while this neglect has far-reaching implications, its most destructive effects are predominantly being felt among black and indigenous communities.19 In a repeat of colonial history, alarming death rates among Yanomami leave the Amazon tribe threatened with extinction.20 How these stories are articulated in global health discourse defines cause and response, and deaths among Brazil’s black and indigenous populations cannot be subsumed under the general inevitability of excess mortality in marginalised groups. From a CMA positionality, governments’ ability to decide who lives and who dies is necropolitics,21 and we argue for a more central implication of political responsibility for deaths in global health framings of COVID-19 causality.
For Mexico, like Brazil, the pandemic has predominantly affected populations who are structurally vulnerable. While at a national level the case fatality rate stands at 9%, among indigenous people this figure is 15%.22 Geographical inequalities and the already precarious health infrastructures in rural areas have led to differential regional patterning in the effects of COVID-19.18 Yet, indicators used globally to measure impact, such as active cases, mortality, case fatality and hospital occupancy, do not capture the effects of the virus in regions where these data and services are lacking.
The country’s already high rates of chronic diseases have translated into a severe shortage of medical staff, ensuring that the Mexican COVID-19 epidemic has become a generalised health crisis across the full range of illnesses from non-communicable diseases to infections, maternal health and geriatric care. In parallel, and in contrast to a pattern that has not been associated with the European pandemic, by July 2020, COVID-19 had become the principal cause of maternal mortality accounting for 21% of deaths, leading to an increase in the maternal mortality ratio from 33.8 in 2019 to 46.6 by December 2020.23 In the absence of clinical services and resources, populations have resorted to varying strategies of self-care to treat COVID-19 as well as ongoing chronic and degenerative conditions. As yet, unpublished data on important qualitative indicators, such as loss of employment and crop production, alarming levels of debt and the collapse of entire economies of tourism that have led to acute impoverishment, will further extend the excess mortality brought by this pandemic (Research in process: ‘Documentation of the effects of COVID-19 in afroamerican and indigenous communities of the Costa Chica of Guerrero and Oaxaca. University of California, Santa Barbara and CIESAS, Mexico with funding from Kellogg Foundation’). These experiences are barely considered in the global panorama and provide further evidence of the fact that regions that initially seemed to have had few deaths are in fact dealing with a multidimensional pandemic with case fatality rates far higher than in metropolitan centres or Western nations and yet to be estimated numbers of non-COVID-19 avoidable deaths. In contrast, the case fatality rate in the UK is currently around 1%.24 The wide social determination of COVID-19 that is more apparent in the Global South means the biomedical explanatory models—or aetiologies—and hospital treatment are of less relevance, and other ontologies must be given prominence.
For Shamasunder and collaborators,25 the pandemic has exposed the emptiness of the rhetoric of equity in global health. The land border between the USA and Mexico is closed and Mexico operates a vaccination policy based on age and need. Yet paradoxically, wealthy Mexicans can cross the border by air to pay for a vaccine in the USA. Hence, the globally agreed criteria for deciding who is to be vaccinated first are subordinated to economic criteria.26 Inequality is the driving force in the pandemic and confronting it requires global cooperation, solidarity, coordination and community participation. A social medicine approach that promotes a more complex understanding of the social can, as Adams and colleagues point out, ‘open up the black box of inequity’,27 elucidating the structural determinants and social determination of inequalities and helping to reconceptualise global health.
These examples demonstrate how despite being a catastrophe on a global scale, the pandemic is not a universal phenomenon, nor is it homogeneous. Each outbreak that constitutes it has unique and contingent forms, intensities and qualities, which impel qualitative research efforts.28 CMA can give prominence to localised experiences, including the intersections between gender, race and labour; cultural and religious differences, social injustices and environmental inequalities. In so doing, it alters the perception of risk by bringing into view how, for example, conditions of extreme racialised violence, economic insecurity associated with the global narcotics market such as those experienced in Colombia29 and Mexico, alter perceptions of the severity of COVID-19.
These are only two examples of nations where the state has taken poor leadership in the response to the pandemic, political situations that have combined with economic weaknesses such as high reliance on the informal sector, pointing to a political economy of COVID-19 causality and response that is heavily determined by neoliberal state structures. As one of the fathers of CMA, Rudolf Virchow (1821–1902) famously declared, ‘Medicine is a social science and politics is nothing but medicine writ large.’30 The political economy must be considered as causal and it is no surprise that the rise of populism, which has nurtured COVID-19 conspiracy theories, is also reflected in patterns of high mortality in Mexico, Brazil and the USA.31 32