An Intersectional Narrative of Two Epidemics
June 14, 2020
COVID-19 is not the only epidemic sweeping America, and it certainly is not the only public health emergency threatening the lives of millions. Accidental drug overdose is the leading cause of death in Americans under the age of 50, exceeding fatality rates of gun violence and car accidents combined. Opiates, a sedative substance for pain relief, account for the bulk of these overdose-related deaths. This social and politically neglected reality is known as the opioid epidemic. The opiate crisis derives from the nationwide misuse of and addiction to prescription painkillers, illicit opiates, and synthetic forms of opioids. Importantly, with implications for public health practice, the opioid epidemic has largely been framed as a ‘white epidemic’.The crisis has resulted in substantial rates of accidental overdose, hospitalizations, and mortality, killing an average of 130 Americans a day. The opioid epidemic is a preventable social problem that has been thrown on the back burner of legislation and public awareness for years, and its collision with COVID-19 will plague those struggling with substance abuse in the United States at an unparalleled level.
The novel coronavirus is a life-threatening viral infection with a fast-moving fatality rate far greater than seasonal flu. Patients with serious cases of COVID-19 experience side effects that include persistent coughing, wheezing, shortness of breath, chest pain, fever, and fatigue. Little information presently exists on COVID-19 and it’s interaction with opiate users, however, it is clear that there is a dangerous link between the two. The use of opioids create unrealistic feelings of euphoria but cause very real, physical side effects such as sedation, respiratory depression, weakened immune system, and a lack of oxygen to the brain. Because the coronavirus attacks the lungs and respiratory system, high-dosage opiate users are susceptible to detrimental repercussions due to impaired lung capacity and slow levels of breathing. On average, more than two million Americans misuse opioids. With that being said, this information suggests that more than two million youth and adults in the U.S. are a high-risk group of severe illness to the virus.
COVID-19 has universally disrupted lives amidst nationwide quarantine and the enforcement of shelter-in-place laws. Social isolation is key to slow the spread of the virus, however, social distancing is a privilege that many current drug users and reformed addicts cannot afford. Addicts and former users rely heavily on the solace of support groups, such as AA or NA, and other socially supportive environments for recovery, maintaining sobriety and preventing relapse. Social isolation, disconnection, and drastic changes in routine increase the chance of overdose and places recovering users at risk of relapse. In light of COVID-19, active users are faced with obstacles on account of the closure or restricted hours of needle exchange operations and treatment facilities. Individuals already undergoing addiction treatment that are reliant on Methadone, a replacement pain reliever used to treat opiate use disorder, are faced with similar complications. The only way to receive Methadone is through specific methadone clinics that require in-person drug testing and daily monitoring of medication. Although alternative guidelines were enabled to permit prescription fills for two to three-week intervals, these methods have been inconsistent. Witnesses from a Minneapolis methadone clinic reported waiting rooms packed with patients and long queues extending in and outside of the facility. These backward attempts not only exhibit restrictive healthcare access and broken treatment systems but also place immunodeficient users and staff members in a state of vulnerability. Efforts to contain the virus and flatten the curve are necessary, but these tragic circumstances will reinforce and spread the flame of the opioid epidemic like wildfire.
Americans facing COVID-19 have, and still are, experiencing radical losses of income, mass and long term unemployment, fears of contracting the lethal virus, and a fundamental, bleak hope for the unprecedented future. Millions of substance abusers, former addicts, and even non-addicts might be inclined to self medicate with drugs or alcohol in order to cope with pending fear and socioeconomic unease brought upon by the pandemic. The National Institute on Drug Abuse states that “environmental and social stresses are an important predictor of many mental disorders and these stresses increase the risk for substance use and even make the brain more prone to addiction”. It is imperative to note that the opioid epidemic disproportionately and overwhelmingly attacks individuals with insecure housing, poor education, criminal charges, inadequate or lack of healthcare, and those of low socioeconomic status. An investigation conducted by The National Institute of Health found that individuals living below the poverty line represented 24.6% of opioid overdose deaths, in which only 11.7% were alive by the study’s completion. All of these socioeconomic factors contribute not only to the risk of addiction but to contracting and spreading COVID-19. Similar to the opioid epidemic, the coronavirus affects individuals from all walks of life but largely threatens low-income communities with a lack of economic mobility and medical care. Although necessary, it would be all too easy to point blame on prescribing practices and inadequate treatment and prevention without first looking at the existing social disparities.
The coronavirus pandemic has revealed fatal flaws in our for-profit health systems, just as the opiate crisis has unveiled systemic class discrimination and social disparities of healthcare. It remains to be seen how racial issues play out in the government and public health responses to the opioid epidemic, branded as a ‘white problem’, and the pandemic for which ample evidence exists that the novel coronavirus is hitting many communities of color in the U.S. drastically harder than majority white communities. These inconsistencies are not not a result of biological differences but are in fact due to structural racism.
The government worked rapidly to initiate an urgently needed COVID-19 response, meanwhile, Congress and State Legislatures dawdle in addressing the opiate outbreak which has plagued the country’s disadvantaged for years. The intersectional narrative of these two epidemics is sheer proof that in the United States, financial standing and social status, and, often, racial classification, are the deciding factors of one’s quality of life or imminent death. It is of the essence that we raise the standard of care, implement strong safety nets, diversify accessibility, and provide healthy conditions for all communities and the generations to come. This is the moment to take collective action.
The Global Medical Supply Chain, Neoliberalism, and COVID-19
June 2, 2020
The coronavirus has challenged the immunity of millions worldwide, and the global medical supply chain is certainly not immune to the toll of COVID-19. In practice, the global supply chain is a worldwide network of companies that distribute, trade, and purchase goods and services transnationally in order to maximize profits and meet global demand. Universally, countries across the map are heavily dependent on the global medical supply chain for preventive supplies and affordable pharmaceutical drugs. China ultimately dominates the entire global medical supply chain with a firm grip on the world’s production and administration of raw materials, such as active pharmaceutical ingredients (API), for drug manufacturing. If this wasn’t enough cause for concern, China is also responsible for the majority of the world’s international trade of personal protective equipment (PPE), such as face masks and other hospital gear. India is, similarly, a leading force in the world of medicine and the global medical supply chain. At the head of the generic drug market, India is the world’s largest provider of affordable, effective, and unpatented pharmaceuticals. Both developed and developing countries are contingent on India’s relatively cheap exports, however, India is likewise reliant upon China’s shipments of APIs and raw materials in order to manufacture these highly-demanded generic drugs. The world depends on these cost-effective exports of drugs to combat COVID-19. The global medical supply chain has been relatively successful, however, COVID-19 proved that the dependency on a single country for medicine and supplies can result in cataclysmic events that threaten both the health and economy of every nation across the globe.
A global pandemic hand-in-hand with a faulty supply chain is a recipe for disaster, posing the risk of material shortages and limitations on the capacity to produce and distribute worldwide. On the eve of 2020, the deadly coronavirus was initially reported to have emerged from the province of Wuhan, China. In order to manage the outbreak, China prompted strict quarantine restrictions and the closure of dozens of chemical plants and factories across the country. Not only did China’s lockdown halt work for millions, but the abrupt closure of these manufacturing facilities impeded the production of APIs. Amplifying this horror, international travel bans and China’s prohibition of COVID-19 PPE exports hindered the shipment of supplies overseas. Without their safety net, India was subsequently left to scramble for other sources and traders. In preparation for potential drug shortages and preservation of domestic supply, India’s Ministry of Commerce and Industry banned the export of masks, sanitizers, and 26 pharmaceutical products. Since then, China’s manufacturing chains have returned to usual operations and India sequentially lifted their bans on overseas shipments. Despite the return to original procedures, however, moral panic due to COVID-19 has raised concern over the underlying insecurities behind our global supply chains and the driving socio-political ideologies that support them.
Neoliberalism, the leading force behind the world’s social and economic ideologies, favors free market capitalism, market deregulation, lower trade barriers, and the limitation of state power. Neoliberal ideologies that support the global medical supply chain serve with the intent to increase market sales and maximize overall profit revenue. Ironically, neoliberal approaches to commodify health and healthcare systems inevitably give rise to defective institutions and weakened global health at a substantial cost. Dr. Owain Williams, an expert on the political economy of health policy and access to medicines, elaborated in my recent interview with him that COVID-19 has exposed both neoliberalism and it’s interaction with the pandemic as well as aggressively exposing fragility in collective faith in the market as a means of distributing and allocating resources. The global supply chain is just one example of these faulty cracks of free market neoliberalism. During a pandemic, global medical market failure is imminent as high demands couple with limited supplies and stock shortages.
Dr. Williams stated that, “the neoliberal heartlands are where governments have failed the most spectacularly”, such as in Brazil, the United Kingdom, and the United States. State sovereignty is crucial for economic stabilization, however, “all of these countries have unravelled, because the role of the state has eroded . . .and our redistribution mechanisms are completely broken”, Williams disclosed. Dr. Williams’s hope for the future is that “we as people, not the government, will use power to negotiate a new settlement” for the economy, for the climate, the people, and so on. The return of a well-resourced state, reallocation of taxes, and administration of new social welfare programs are imperative. COVID-19 has shown that the global supply chain is a ticking time bomb. The only way to put out the fuse is to reexamine the systems in place and arrange a settlement that prevents PPE rationing, avoids drug shortages and eliminates transnational vulnerability. Instead of pinching pennies, figureheads and policy makers should invest patience and money toward domestic drug manufacturing and the federal office for global pandemic preparedness. The world was unprepared to deal with the novel coronavirus but, with clear evidence of preventable market failure, there is no excuse to not begin preparing for the next pandemic.
Pharmaceuticals, a Vaccine for COVID-19, and Questions of Equitable Access
May 13, 2020
The global pandemic of COVID-19 is something that has never before been seen in recent history. CEPI, the Coalition for Epidemic Preparedness Innovations, is a company established by the Bill & Melinda Gates Foundation that finances independent research in developing vaccines for emerging diseases and centralizes on pandemic preparedness in low and middle-income countries (LMIC). In wake of the COVID-19 pandemic, CEPI has worked rapidly to raise over $924 million dollars dedicated to the development of a vaccine for the virus. CEPI has its own equitable access policy which states to ensure that LMIC’s will have equal accessibility to vaccinations and treatments created by the company just as developed countries do. Many manufacturers do not see CEPI’s equitable access policy as reliable in competitive business models without guaranteed financial gain or intellectual property rights. In December 2018, however, CEPI revised its philanthropic policy most likely in response to pharmaceutical industries’ unwillingness to collaborate on a partnership. The revised equitable access policy no longer guarantees the promise of affordable vaccine prices and takes zero accountability to investors. Because the profit returns are not large enough to warrant any investment, pharmaceutical companies are not as open or willing to invest in drug manufacturing in developing countries.
Pharmaceutical industries do not endorse rare diseases, or orphan diseases, that affect less than 200,000 people by the US medical standards. Expanding on this definition, the title of orphan diseases is also named for common diseases in developing countries, such as tuberculosis (TB), HIV/AIDS, or malaria, which large pharmaceutical companies neglect to treat and research due to their lack of pervasiveness in developed countries. According to WHO, “tuberculosis, HIV/AIDS, and malaria together account for nearly 18 percent of the disease burden in the poorest countries”, most of which are in Africa, South East Asia, and the Western Pacific. The disheartening fact of the matter is that all of these diseases are preventable and can be combated with existing medicines from developed countries and pharmaceutical industries, especially when granted orphan drug status to treatments and candidate vaccinations.
The emergence of the COVID-19 pandemic, however, has shown that in disaster situations, normal protocols are not being followed. In March 2020, for example, Gilead requested and was subsequently granted orphan drug status by the FDA for Remdesivir, a potential treatment for COVID-19. The Orphan Drug Act of 1983 was signed in order to combat and fund research and development for rare diseases observed by the FDA, such as Lou Gehrig’s Disease or Tourette’s Syndrome. This title would ultimately limit competing manufacturers from developing generic versions of the drug, would guarantee tax credits for development, and ultimately grant Gilead the power to name their own price. COVID-19, however, is in no such way an orphan disease seeing that it has been confirmed to have affected over one million people in the US and nearly four million people globally. After a public uproar, Gilead has since then revoked Remdesivir’s status as an orphan drug. During this emergency basis, it is clear that normal protocols are not being followed. Major pharmaceutical manufacturers may still be profit-hungry, but perhaps COVID-19 will change the status-quo direction of compulsory license options.
COVID-19 may prove whether or not CEPI will follow through with its promises of equal accessibility to deliver a non-patent vaccination, challenging the usual business approaches of Big Pharma. Medical innovation is crucial for the development of a vaccine to COVID-19, however, global accessibility to ensure aid is given to every person in need is even more critical to slow the rapid circulation of the virus that has reached every corner of the globe.