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In a recent article in JAMA Psychiatry, Warren et al1 propose that people with severe mental disorders (SMD) should be prioritized for the COVID-19 vaccine. They indicate that people with SMD are at higher risk of being infected by SARS-CoV-2, have increased COVID-19–associated morbidity and mortality rates, and face individual and structural barriers to participation in vaccination programs. From a global mental health perspective, we underscore that across the globe, people with SMD were typically poor, socially excluded, and in poor health even before the pandemic struck. Indeed, within almost all countries, people with SMD are among the most disadvantaged groups of all. They have been recognized by the United Nations as a vulnerable population entitled to special consideration to ensure that they benefit from socioeconomic and health development, including vaccines.2 As vaccines for COVID-19 roll out, however, most countries have not yet prioritized this group. Furthermore, the pandemic has reduced mental health services for this population in the face of increasing demand, especially in low- and middle-income countries (LMICs), where services are already minimal relative to need (eg, Latin America).3 Although we focus here on people with SMD, including those with psychotic disorders as well as bipolar disorder and major depression without psychosis, we believe that a similar argument could be made for people with other psychosocial disabilities (eg, developmental disabilities).
It is not yet clear that the COVID-19 pandemic can be suppressed in LMICs. High-income countries (HICs) and pharmaceutical companies have yet to implement policies, such as those adopted for HIV and AIDS, that would enable LMICs to acquire or manufacture enough vaccines for this purpose. The reluctance to do so seems shortsighted, because it is hard to envision how a global pandemic can be controlled even in HICs (and China) while it persists in many other countries. New SARS-CoV-2 variants that diminish vaccine efficacy have surfaced, and more will emerge. Some of these variants have already spread to HICs.4
We focus on Latin America, one of the most affected regions in terms of cases and deaths per capita. By December 2020, the Latin American region accounted for one-third of all COVID-19 cases globally and 34% of COVID-19–associated deaths,5 and this was before the current, devastating wave in Latin America. The COVID-19 pandemic has seriously affected the provision of mental health care for people with SMD in Latin America, including partial or total disruptions of medication, psychotherapy, and counseling services.3 Furthermore, a large number of people with SMD have been infected in psychiatric hospitals throughout the region.
Latin America is characterized not only by high rates of COVID-19, but also by fragmented and often ineffective public health responses to the pandemic, exacerbated now by the scarcity of vaccine supplies and well-developed plans for distribution. At a regional level, the public health response has been even weaker than in lower-income regions. For example, the Africa Centres for Disease Control and Prevention have developed a unified approach informed by previous experiences with Ebola, HIV, and other infections.6 This is not occurring in Latin America. This weak response cannot be simply attributed to civil conflicts, political instability, and scarce resources, since these factors are also present in other regions, notably Africa. It is at least in part because of a failure of political leadership in some Latin American countries with large populations, especially Brazil and Mexico, which together constitute almost half of the total population of Latin America. The presidents of these and some other Latin American countries have misunderstood and publicly denied the severity of COVID-19, followed the HIC playbook by imposing blanket lockdowns that are often infeasible in LMICs, and/or implemented poor and fragmented policies to alleviate the manifold consequences of the pandemic. Instead, Latin American countries should promote and implement health measures that are feasible and useful within a given country, such as universal mask wearing, physical distancing to the degree feasible (at a minimum, banning large gatherings, such as festivals and campaign rallies), community engagement in preventive measures, and rapid testing and contact tracing combined with specifically targeted and adapted lockdowns where new outbreaks are identified. These public health measures have already suppressed the epidemic in several LMICs.
We use vaccines to illustrate the challenges posed by the pandemic in Latin America. We contend that the US has a special obligation to Latin America in mobilizing support for COVID-19 vaccines for historical reasons (eg, political interventionism), as well as to the Pan-American Health Organization, which has a major public health role in Latin America and is headquartered in Washington, DC. Latin American countries have had to negotiate bilateral secretive deals with pharmaceutical companies alongside inadequate supplies from global agencies to acquire vaccines even for high-priority populations, such as frontline health care workers and older individuals. Most Latin American countries will likely have a small stock of vaccines in 2021, making it difficult to select groups for inoculation. High-income countries have already preordered most vaccines with the highest efficacy (eg, mRNA vaccines) and have not been forthcoming in supporting initiatives to widely disseminate these vaccines in Latin America or elsewhere. Although some Latin American countries (eg, Argentina, Brazil) participated in large trials of some of these vaccines (eg, Pfizer), they will not be receiving enough to inoculate their entire populations anytime soon.7 In fact, if they were to wait for their turn under current plans for distribution of vaccines being used in the US and Europe, most Latin American countries would not be able to fully vaccinate their populations for several years. In this context, some countries (eg, Argentina, Bolivia, Venezuela) are using vaccines that are more accessible and may be efficacious but have less transparent data (eg, Coronavac, Sputnik). New vaccines are rapidly emerging, and the best choice may change over time. Nonetheless, even with new vaccines, supply will not be sufficient before the end of this year.
Moreover, the distribution of vaccines in Latin America will have to deal with a large variety of longstanding social, economic, health, and racial/ethnic inequalities. Latin America is the most unequal region in the world, with major differences in living conditions and access to services across and within countries. We contend that the aforementioned inequalities will act in tandem with the vulnerabilities of people with SMD to diminish the reach of a COVID-19 vaccine program for this population. For instance, many people with SMD in Latin America have limited income, are socially marginalized, have very limited access to health and social services, and live in crowded and impoverished urban areas. The highest rates of infection and lethality due to COVID-19 in Latin America have been reported for these groups, and their participation in other vaccination programs has often been low. Therefore, special efforts by local stakeholders to ensure community engagement and accessibility will be required to vaccinate these groups, alongside specific outreach to people with SMD among them. This specific outreach should include learning from the lived experience of people with SMD and giving them a role as leaders and messengers. Progress toward vaccination of people with SMD against COVID-19 will face serious obstacles in Latin America. These obstacles include lack of support from HIC governments and pharmaceutical companies to ensure effective and safe vaccines; unreliable governments and public health authorities; pervasive social and economic inequalities; and systematic discrimination against people with SMD, including in accessing health care. The US, as a leading HIC in the production and distribution of COVID-19 vaccines, has a historic and moral duty to help Latin American countries acquire and distribute vaccines and encourage the prioritization of people with SMD as a vulnerable population.
Corresponding Author: Ezra Susser, MD, DrPH, Department of Epidemiology, Mailman School of Public Health, Columbia University, 722 W 168 St, New York, NY 10032 (firstname.lastname@example.org).
Published Online: May 28, 2021. doi:10.1001/jamapsychiatry.2021.1416
Conflict of Interest Disclosures: None reported.
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Mascayano F, Bruni A, Susser E. Implications of Global and Local Inequalities in COVID-19 Vaccine Distribution for People With Severe Mental Disorders in Latin America. JAMA Psychiatry. 2021;78(9):945–946. doi:10.1001/jamapsychiatry.2021.1416
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