H5N1

Marmot: Studying health inequalities has been my life’s work. What’s about to happen in the UK is unprecedented

Via The Guardian, Sir Michael Marmot writes: Studying health inequalities has been my life’s work. What’s about to happen in the UK is unprecedented. Excerpt:

Dignity. It is fundamental to who we are and our place in society. One way to deprive people of the opportunity to lead dignified lives is to take away the means to meet their material needs. It is undignified to have to resort to food banks to feed your children; to wear two coats indoors against the cold; to plead against eviction because of an inability to pay the rent; to deny children a birthday party because of cost.  

The poorest people in the UK are about to experience a fresh wave of such indignities. These psycho-social assaults will be joined by the physical ill-effects of poverty.  

My life’s work has been studying the relationship between social conditions and inequalities in health. In the UK, a decade of austerity damaged public health and made health equity worse. But the cost of living crisis – and the chancellor’s failure to deal with it – is unprecedented, with its threats to the health and wellbeing of the nation. A 54% rise in the energy price cap will now mean an average household will pay £1,971 a year for gas and electricity, at the same time that council tax, water bills and car tax are all increasing. In October, a further rise pushing the annual energy bill up to £2,300 is expected.  

The typical working-age household will, according to the Resolution Foundation, experience a 4% fall in income, £1,100, in 2022-23. Surely, one might think, 4% is scarcely noticeable, hardly a matter of life and death? It is if you are on the margins.  

The Resolution Foundation gives the example of a single parent, with one child, working 20 hours a week at a low-to-medium wage. In September 2021, this person might have had an income of £18,265. The precipitate removal of the universal credit boost will have reduced income by £1,040. The cost of living rise to September 2022 will take another £1,198 off income. With the chancellor’s changes to taxes and allowances, and salary increases, this person’s income in September 2022 will be £17,681 – £584 less than it was a year earlier. (By contrast, a couple working full-time, both at the median wage, will see their net income fall by 1%, £392.)  

Inflation of more than 8%, and the government’s failure to deal with the cost of living crisis for the poorest people – an unemployed single person will see a 15% drop in income – will put an extra 1.3 million people, including 500,000 children, below the poverty line.

A new study ties lifespans to wealth gaps in Greater Vancouver

The Tyee has published my latest article: A New Study Ties Lifespans to Wealth Gaps in Greater Vancouver. Excerpt:

We like to think of Greater Vancouver as one of the best places to live in Canada, if not in the world. Yes, it is — especially for those of us living in the most affluent neighbourhoods. Those in the poorest neighbourhoods, however, are dying younger than their rich neighbours, sometimes by many years. And the gap between them was getting wider even before the opioid-overdose crisis and the COVID-19 pandemic became twin health emergencies. 

That’s an easy conclusion to draw from a recent study published in the journal Health & Place. Of course it’s more complicated than that, but it still seems paradoxical that a region as prosperous as Greater Vancouver should see some people die years younger than others living just a few kilometres away.  

The study involved UBC researchers working with the Institute for Health Metrics and Evaluation at the University of Washington and with Imperial College, London. Its ambitious goal was to track life expectancy and major causes of deaths in Greater Vancouver over a quarter-century, from 1990 to 2016. Moreover, they broke the numbers down to the census-tract-level — in effect, neighbourhood by neighbourhood. Overall, the study offers an invaluable portrait of our collective health before the pandemic.  

In some ways, it’s a very flattering portrait. Even the poorest males, in the tenth percentile, had a median life expectancy in 2016 of 77.6; that is, half died before that age and half later. For tenth-percentile females, median life expectancy was 82.5.  

But in the 95th percentile, the richest five per cent of our population, median male life expectancy was 87.1. For females in the 90th percentile, it was 90.8. The poor were paying with almost a decade of their lives for the privilege of living here. 

 The study makes a striking observation: “Between 1991 and 2016, there was a downward trend in the LE [life expectancy] gap, whereby the lowest gap was observed in 2001 (6.9 years for females and 7.9 for males), but this reversed and increased by 1.4-1.6 years between 2001 and 2016.” By a wild coincidence, 2001 was the year the BC Liberals won a huge majority over the NDP and ran the province under Gordon Campbell and then Christy Clark until 2017.  

British researchers noticed a very similar effect during Margaret Thatcher’s years in power: Around 1980, British and Japanese life expectancy were about the same, but then, as the U.K. income gap widened, British lives grew shorter. In Japan, with a much narrower income gap, life expectancy rose to among the highest on the planet.  

What we’re dying of  

And what have Greater Vancouver residents been dying of? Between 1990 and 2016, deaths from cardiovascular diseases, neoplasms (cancers) and unintentional injuries dropped sharply. Clearly, we’ve been exercising more, smoking less, and taking care of ourselves, at least up to a point.  

But we’ve also seen a 10 per cent increase in neurological disorders, a catch-all term that can include everything from Alzheimer’s to eating disorders to meningitis. Other noncommunicable diseases like diabetes mellitus and kidney disease rose by almost four per cent.  

And while the richest of us had little to fear from infectious diseases in 1991, the poorest were already contending with (and dying from) HIV-AIDS and sexually transmitted infections at 12 times the rate as the richest. The poorest faced seven times the rate of maternal and neonatal disorders. They died of neoplasms at over four times the rate of the richest.

The police as public health crisis

Via The Lancet: Fatal police violence by race and state in the USA, 1980–2019: a network meta-regression. The summary and then a comment:

Background  

The burden of fatal police violence is an urgent public health crisis in the USA. Mounting evidence shows that deaths at the hands of the police disproportionately impact people of certain races and ethnicities, pointing to systemic racism in policing. Recent high-profile killings by police in the USA have prompted calls for more extensive and public data reporting on police violence. 

This study examines the presence and extent of under-reporting of police violence in US Government-run vital registration data, offers a method for correcting under-reporting in these datasets, and presents revised estimates of deaths due to police violence in the USA.  

Methods  

We compared data from the USA National Vital Statistics System (NVSS) to three non-governmental, open-source databases on police violence: Fatal Encounters, Mapping Police Violence, and The Counted. We extracted and standardised the age, sex, US state of death registration, year of death, and race and ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic of other races, and Hispanic of any race) of each decedent for all data sources and used a network meta-regression to quantify the rate of under-reporting within the NVSS. Using these rates to inform correction factors, we provide adjusted estimates of deaths due to police violence for all states, ages, sexes, and racial and ethnic groups from 1980 to 2019 across the USA.  

Findings  

Across all races and states in the USA, we estimate 30 800 deaths (95% uncertainty interval [UI] 30 300–31 300) from police violence between 1980 and 2018; this represents 17 100 more deaths (16 600–17 600) than reported by the NVSS. Over this time period, the age-standardised mortality rate due to police violence was highest in non-Hispanic Black people (0·69 [95% UI 0·67–0·71] per 100 000), followed by Hispanic people of any race (0·35 [0·34–0·36]), non-Hispanic White people (0·20 [0·19–0·20]), and non-Hispanic people of other races (0·15 [0·14– 0·16]). This variation is further affected by the decedent's sex and shows large discrepancies between states. Between 1980 and 2018, the NVSS did not report 55·5% (54·8–56·2) of all deaths attributable to police violence. When aggregating all races, the age-standardised mortality rate due to police violence was 0·25 (0·24–0·26) per 100 000 in the 1980s and 0·34 (0·34–0·35) per 100 000 in the 2010s, an increase of 38·4% (32·4–45·1) over the period of study.  

Interpretation  

We found that more than half of all deaths due to police violence that we estimated in the USA from 1980 to 2018 were unreported in the NVSS. Compounding this, we found substantial differences in the age-standardised mortality rate due to police violence over time and by racial and ethnic groups within the USA. Proven public health intervention strategies are needed to address these systematic biases. State-level estimates allow for appropriate targeting of these strategies to address police violence and improve its reporting.

Canada is not much different. We have used our police, including the well-marketed Royal Canadian Mounted Police, to suppress Indigenous and other minority peoples, with increasingly poor results. I suggested a solution back in 2007: Disband the RCMP. 

Covid is killing rural Americans at twice the rate of people in urban areas

Via NBC News, a report by Lauren Weber of Kaiser Health News: Covid Is killing rural Americans at twice the rate of people in urban areas. Excerpt:

Rural Americans are dying of Covid at more than twice the rate of their urban counterparts — a divide that health experts say is likely to widen as access to medical care shrinks for a population that tends to be older, sicker, heavier, poorer and less vaccinated.  

While the initial surge of Covid-19 deaths skipped over much of rural America, where roughly 15 percent of Americans live, nonmetropolitan mortality rates quickly started to outpace those of metropolitan areas as the virus spread nationwide before vaccinations became available, according to data from the Rural Policy Research Institute.  

Since the pandemic began, about 1 in 434 rural Americans have died from Covid, compared with roughly 1 in 513 urban Americans, the institute’s data shows. And though vaccines have reduced overall Covid death rates since the winter peak, rural mortality rates are now more than double that of urban ones — and accelerating quickly.  

In rural northeastern Texas, Titus Regional Medical Center CEO Terry Scoggin is grappling with a 39 percent vaccination rate in his community. Eleven patients died of Covid in the first half of September at his hospital in Mount Pleasant, population 16,000. Typically, three or four nonhospice patients die there in a whole month.  

“We don’t see death like that,” Scoggin said. “You usually don’t see your friends and neighbors die.”

Part of the problem is that Covid incidence rates in September were roughly 54 percent higher in rural areas than elsewhere, said Fred Ullrich, a University of Iowa College of Public Health research analyst who co-wrote the institute’s report. He said the analysis compared the rates between nonmetropolitan, or rural, areas and metropolitan, or urban, areas. In 39 states, he added, rural counties had higher rates of Covid than their urban counterparts.  

“There is a national disconnect between perception and reality when it comes to Covid in rural America,” said Alan Morgan, head of the National Rural Health Association. “We’ve turned many rural communities into kill boxes. And there's no movement towards addressing what we're seeing in many of these communities, either among the public, or among governing officials.”  

Still, the high incidence of cases and low vaccination rates don’t fully capture why mortality rates are so much higher in rural areas than elsewhere. Academics and officials alike describe rural Americans’ greater rates of poor health and their limited options for medical care as a deadly combination. The pressures of the pandemic have compounded the problem by deepening staffing shortages at hospitals, creating a cycle of worsening access to care.  

It's the latest example of the deadly coronavirus wreaking more havoc in some communities than others. Covid has also killed Native American, Black or Hispanic people at disproportionately high rates.  

Vaccinations are the most effective way to prevent Covid infections from turning deadly. Roughly 41 percent of rural America was vaccinated as of Sept. 23, compared with about 53 percent of urban America, according to an analysis by The Daily Yonder, a newsroom covering rural America. Limited supplies and low access made shots hard to get in the far-flung regions at first, but officials and academics now blame vaccine hesitancy, misinformation and politics for the low vaccination rates.

How the US vaccine effort derailed and why we shouldn’t be surprised

Via The Guardian: How the US vaccine effort derailed and why we shouldn’t be surprise. Excerpt:

There are very specific, well-documented reasons that Americans are hesitant to take vaccines. They vary from the troubling way the medical system treats people of color, to vaccine misinformation campaigns overwhelmingly popular in conservative circles, to logistical challenges.  

But population health researchers, whose work considers how society as a whole is fairing, said low vaccine uptake may be looked at another way: as the predictable outcome of a campaign subject to entrenched social forces that have diminished American health and life expectancy since the 1980s.  

“When I look at this I do see a very familiar pattern,” said Dr Steven Woolf, a prominent population health researcher at Virginia Commonwealth University. “When Operation Warp Speed came out I thought I was just seeing a modern example of this old problem where the scientific community developed the vaccine at ‘warp speed,’ but the implementation system for getting it out into the community was inadequate”.  

Woolf calls this “breakthrough without follow-through”. In that light, the plodding vaccination campaign could be seen as one more aspect of the American “health disadvantage”.  

The phrase describes a paradox: the US houses among the most advanced medical and research centers in the world, but performs poorly in basic health metrics such as maternal mortality and infant mortality; accidental injury, death and disability; and chronic and infectious disease.

"So much of the whole issue of social determinants of health and the US ‘health disadvantage’ is rooted in a lack of trust and a lack of trustworthiness in many parts of our society,” said Laudan Y Aron, a senior fellow at the Urban Institute’s health policy center. 

A key piece of research in this area is a 2013 report by a panel chaired by Woolf, directed by Aron, and funded by the National Institutes of Health. Called US Health in International Perspective: Shorter Lives, Poorer Health, the report describes how Americans spend more than double per person on healthcare compared to 17 peer nations, but rank near the bottom in health outcomes.  

The phenomenon is described as “pervasive”, impacting all age groups up to 75, with life expectancy declining especially for women. In just a few examples, Americans have the highest infant mortality, children are less likely to live to age five, and the US has the worst rates of Aids among peer nations.  

The US also has the highest or among the highest rates of cardiovascular disease, obesity, chronic lung disease and disability. Together, these risk factors culminate in Americans having the worst or second worst probability of living to age 50.  

Americans know intuitively that their healthcare is expensive, frustrating and often unfair. Remarkably, even amid the pandemic, roughly 30 million Americans went without health insurance, exposing them to potentially ruinous medical debt.  

“It’s also really interesting how often the messaging is: talk to your doctor, talk to someone you trust,” said Aron. “Yet, we don’t really acknowledge how many people don’t have a doctor, or a doctor they have a trust-based relationship with them”.

New findings on pandemic kids. And what they really tell us

The Tyee has published my article: New Findings on Pandemic Kids. And What They Really Tell Us. Excerpt:

A new report by Children First Canada takes a long and detailed look at the state of our kids in this second year of pandemic. Even if you don’t have children, but hope for a decent and dignified old age, you’d better take note the findings of Raising Canada 2021 — and take appropriate action in this and future elections. 

The report finds that COVID-19 has aggravated ten major threats to our children. Those threats have been still more aggravated by “cross-cutting themes”: access to education and child care, access to health care and social services, inequity and inequality, and climate change. 

The report points to a host of threats to children that are also threats to us all. And those threats are unlikely to be blunted short of the kind of social transformation we usually call a revolution. 

Let’s look at the threats first. Some are simply intensified forms of the pre-pandemic status quo. Kids are coming into emergency departments with opioid and other poisonings, and cannabis ingestions. Their parents’ attempts to cope with stress don’t work with the kids either. 

Pre-pandemic Canada was stressful enough, but the report finds that “the effects of school closures have accelerated this threat,” leading to more eating disorders, substance misuse and suicide attempts among adolescents.

Systemic racism and discrimination stress racialized families, and the pandemic has only stressed them more. So it should be no surprise that “status First Nations, Métis, Inuit and Black children are disproportionately overrepresented in the child welfare system.” 

So stressed parents with no support are taking it out on their kids: “In some jurisdictions, clinicians have seen twice as many infants for maltreatment-related concerns, specifically fractures and head trauma.” 

More work for the health-care system 

Meanwhile, even less-stressed parents have skipped routine childhood vaccinations, ensuring more work for our health-care system when kids start coming down with measles and other preventable diseases. While many Canadian and U.S. states try to vaccinate their kids from age 12 and up, the report says, for those under 12 “vaccines may not be available until 2022.” Cuba is already testing its homegrown vaccines on kids as young as three. 

The pandemic has worsened childhood poverty, notably in a third of female lone-parent families, and “households with children are more likely to face food insecurity compared to households without children.” In other words, kids aren’t getting enough to eat. We are “ranked 37th out of 41 countries when it comes to providing healthy food for children.” Failing to nourish our children today will have consequences for the rest of the century. 

Well, not for those who die in infancy. The report says, “Canada’s infant mortality rate has increased. It is now the second highest among 17 OECD countries, at approximately 4.4 infant deaths per 1,000 live births. This is a marked change from 1960, when Canada ranked fifth lowest.”

Postoperative outcomes for Indigenous Peoples in Canada: A systematic review

Via CMAJ: Postoperative outcomes for Indigenous Peoples in Canada: a systematic review. The abstract:

Background: Substantial health inequities exist for Indigenous Peoples in Canada. The remote and distributed population of Canada presents unique challenges for access to and use of surgery. To date, the surgical outcome data for Indigenous Peoples in Canada have not been synthesized. 

Methods: We searched 4 databases to identify studies comparing surgical outcomes and utilization rates of adults of First Nations, Inuit or Métis identity with non-Indigenous people in Canada. Independent reviewers completed all stages in duplicate. Our primary outcome was mortality; secondary outcomes included utilization rates of surgical procedures, complications and hospital length of stay. We performed meta-analysis of the primary outcome using random effects models. We assessed risk of bias using the ROBINS-I tool. 

Results: Twenty-eight studies were reviewed involving 1 976 258 participants (10.2% Indigenous). No studies specifically addressed Inuit or Métis populations. Four studies, including 7 cohorts, contributed adjusted mortality data for 7135 participants (5.2% Indigenous); Indigenous Peoples had a 30% higher rate of death after surgery than non-Indigenous patients (pooled hazard ratio 1.30, 95% CI 1.09–1.54; I2 = 81%). Complications were also higher for Indigenous Peoples, including infectious complications (adjusted OR 1.63, 95% CI 1.13–2.34) and pneumonia (OR 2.24, 95% CI 1.58–3.19). Rates of various surgical procedures were lower, including rates of renal transplant, joint replacement, cardiac surgery and cesarean delivery. 

Interpretation: The currently available data on postoperative outcomes and surgery utilization rates for Indigenous Peoples in Canada are limited and of poor quality. Available data suggest that Indigenous Peoples have higher rates of death and adverse events after surgery, while also encountering barriers accessing surgical procedures. These findings suggest a need for substantial re-evaluation of surgical care for Indigenous Peoples in Canada to ensure equitable access and to improve outcomes.

Rich countries close their eyes to the global Covid surge at their own peril

Via The Guardian, an op-ed by Laura Spinney: Rich countries close their eyes to the global Covid surge at their own peril. Excerpt:

Is there one pandemic, or two? That was a question being asked a year ago, when wealthy countries accounting for only 15% of the global population had 80% of the Covid deaths. Could it be that the rich world was more vulnerable, somehow, because its populations were older, or more individualistic, or had forgotten to be scared of infectious disease? 

Even then, some were warning that the worst was yet to come, once the disease took hold in poorer countries. World Bank analysts Philip Schellekens and Diego Sourrouille, for example, predicted a “massive shift” in disease burden to the developing world. Just in terms of demography, they said, you’d expect those countries to account for around 70% of deaths. As things stand they account for a little over half of it, which is probably an underestimate due to variations in data quality – and the pandemic is far from over. 

Last week saw more than 5.8 million new cases of Covid globally, the highest number yet. More than 3 million people have now died from Covid, according to the World Health Organization (WHO), which also reports that infections and hospitalisations in those aged 25 to 59 are increasing at an alarming rate. “It took nine months to reach 1 million deaths, four months to reach 2 million, and three months to reach 3 million,” WHO director general, Tedros Adhanom Ghebreyesus, said last week. 

The sharpest upticks in recent weeks have been seen in south-east Asia – driven in large part by India – and the eastern Mediterranean and western Pacific regions, but the situation is also very bad in Latin America. People who migrated to Brazil in search of work are now reported to be fleeing the humanitarian catastrophe that is unfolding there. 

Infection rates are still high in many wealthy countries – including the US and much of Europe – but the mood is more upbeat: as vaccines roll out, many people feel the worst is behind them. Some US states have rashly lifted their mask mandates. The British government gave the most optimistic signal it could think of earlier this month, when it reopened pubs. 

And Covid-19 is slipping down the headlines, reflecting not just fatigue at having to respect the rules, but fatigue at the very mention of the disease. Fear concentrates the mind, but fear is dissipating; we’d rather read about Tory sleaze, or the doomed European Super League. 

Again, you could be forgiven for asking, is there one pandemic or two? Only now the question has an entirely different meaning. The tables have turned. 

In reality, there was only ever one pandemic. We tend to think of it in terms of national impacts and responses, at best regional ones, but for it to make sense you have to stand back and look at it globally. For all its idiosyncrasies, Covid will stay true to type in at least one way: like pandemics throughout history, it will hammer the poorest hardest.

Effect of socioeconomic inequalities and vulnerabilities on health-system preparedness and response to COVID-19 in Brazil: A comprehensive analysis

Via The Lancet Global Health: Effect of socioeconomic inequalities and vulnerabilities on health-system preparedness and response to COVID-19 in Brazil: a comprehensive analysis. The summary:

Background 

COVID-19 spread rapidly in Brazil despite the country's well established health and social protection systems. Understanding the relationships between health-system preparedness, responses to COVID-19, and the pattern of spread of the epidemic is particularly important in a country marked by wide inequalities in socioeconomic characteristics (eg, housing and employment status) and other health risks (age structure and burden of chronic disease). 

Methods 

From several publicly available sources in Brazil, we obtained data on health risk factors for severe COVID-19 (proportion of the population with chronic disease and proportion aged ≥60 years), socioeconomic vulnerability (proportions of the population with housing vulnerability or without formal work), health-system capacity (numbers of intensive care unit beds and physicians), coverage of health and social assistance, deaths from COVID-19, and state-level responses of government in terms of physical distancing policies. We also obtained data on the proportion of the population staying at home, based on locational data, as a measure of physical distancing adherence. 

We developed a socioeconomic vulnerability index (SVI) based on household characteristics and the Human Development Index. Data were analysed at the state and municipal levels. Descriptive statistics and correlations between state-level indicators were used to characterise the relationship between the availability of health-care resources and socioeconomic characteristics and the spread of the epidemic and the response of governments and populations in terms of new investments, legislation, and physical distancing. We used linear regressions on a municipality-by-month dataset from February to October, 2020, to characterise the dynamics of COVID-19 deaths and response to the epidemic across municipalities. 

Findings 

The initial spread of COVID-19 was mostly affected by patterns of socioeconomic vulnerability as measured by the SVI rather than population age structure and prevalence of health risk factors. The states with a high (greater than median) SVI were able to expand hospital capacity, to enact stringent COVID-19-related legislation, and to increase physical distancing adherence in the population, although not sufficiently to prevent higher COVID-19 mortality during the initial phase of the epidemic compared with states with a low SVI. 

Death rates accelerated until June, 2020, particularly in municipalities with the highest socioeconomic vulnerability. Throughout the following months, however, differences in policy response converged in municipalities with lower and higher SVIs, while physical distancing remained relatively higher and death rates became relatively lower in the municipalities with the highest SVIs compared with those with lower SVIs. 

Interpretation 

In Brazil, existing socioeconomic inequalities, rather than age, health status, and other risk factors for COVID-19, have affected the course of the epidemic, with a disproportionate adverse burden on states and municipalities with high socioeconomic vulnerability. Local government responses and population behaviour in the states and municipalities with higher socioeconomic vulnerability have helped to contain the effects of the epidemic. 

Targeted policies and actions are needed to protect those with the greatest socioeconomic vulnerability. This experience could be relevant in other low-income and middle-income countries where socioeconomic vulnerability varies greatly.

To end covid-19, we must end discrimination and inequality

An opinion piece in The BMJ: To end covid-19, we must end discrimination and inequality.

Inequalities, fueled by stigma and discrimination, have for decades obstructed proven solutions in HIV prevention and treatment. For example, at least 92 countries still criminalize HIV transmission, exposure, or nondisclosure, and at least 68 countries and territories criminalize consensual same-sex sexual relations, exacerbating stigma in such a way that hinders key populations’ access to prevention and care. 

Research shows that punitive laws and discriminatory policies fuel HIV transmission among key populations, which includes people living with HIV, gay men and other men who have sex with men, sex workers, transgender people, people who use drugs, and people in prisons and other closed settings. 

The covid-19 pandemic and accompanying response measures are also compounding inequities for marginalized groups, particularly in LMICs, disrupting access to HIV and other services and threatening decades of progress. Women and key populations, for example, are reporting an elevated risk of domestic and family violence, increased social isolation, and difficulties accessing HIV and health services. 

Typically, marginalized communities in high income nations have not been spared either: a new report from the US Centers for Disease Control and Prevention confirms that gay, lesbian, and bisexual people experience stigma and discrimination in their lives that “can increase vulnerabilities to illness and limit the means to achieving optimal health and wellbeing,” leading to higher covid-19 risks overall. 

We need global solidarity to support strong systems for health, for everyone 

Ensuring that discriminatory laws, policies, practices, and inequalities do not hinder lifesaving tools from reaching all who need them requires strong systems for health and inclusive governance built on trust. As with HIV, covid-19 responses should be grounded in data, evidence, and human rights, and communities are central to ensure people have continued access to the services they need to survive. 

That is why in July 2020 the United Nations Development Programme (UNDP), World Health Organization, UNAIDS, and the O’Neill Institute launched the COVID-19 Law Lab to support evidence and rights based legal frameworks for covid-19 responses. It is also why UNDP and the Global Fund work with community led organizations, such as those in Panama, to ensure marginalized groups have access to HIV services during covid-19. 

But there is still much more to be done—we need to walk the talk on global solidarity to prevent millions more deaths. It is critical that countries increase funding and support for international cooperation. We must marshal the full strength and capacity of the multilateral system to deliver equity—now.