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The Front Lines of Health Inequities

A Conversation with Dr. Megan Huchko and Dr. Diana Silimperi



Last week, GWHT staff member, Keny Murillo, spoke with Dr. Megan Huchko and Dr. Diana Silimperi about the effects of the COVID-19 pandemic on sexual and reproductive health inequities.


Dr. Huchko (MH) is the director of the Center for Global Reproductive Health at Duke and Associate Professor of Obstetrics & Gynecology and Global Health at the Duke University School of Medicine.


Dr. Silimperi (DS) is a Visiting Professor of the Practice of Global Health at Duke Global Institute and specializes in public pediatric and global health.


Here, we have condensed the interview and provided key answers to our questions.


DS:

“There is already this enormous backdrop of inequities in terms of access to health, healthcare and health practices that was largely but not exclusively based on income, on wealth disparities…”


“Probably over 2 billion people in the world today lack access to that kind of readily available water. So in the construct of low and middle income countries or even the low income in more developed countries, in fact, access to water in order to wash their hands, much less soap, is a major issue that is having a disproportionate impact, obviously on their ability to prevent the spread of this infection.”


“If, in fact, you are living in a refugee camp or you’re living in an urban slum or you’re living in a tenement with multiple generations in one room … literally it’s impossible to practice physical distancing.”


“So, our two most powerful interventions globally, in fact, are not going to be possible in the most disadvantaged, the most vulnerable populations and so the inequity in even protecting yourself from the pandemic is enormous.”


MH:

“For many people in this country, looking at the soaring unemployment rate has illustrated how many people don’t have the ‘luxury’ of staying at home that many of us are complaining about.”


“Many people have thought of Global Health as something that happens ‘there’ and then we have what happens ‘here’ in the United States … we have very strong inequities that are leading to poor health outcomes for the entire society in the United States. We have them here as well demarcated as they are in many low- and middle-income countries.”


DS:

“These are effects that are going to continue, whether you’re talking about nutrition or a lack of learning … these are going to continue beyond the pandemic, we don’t simply wake up and make up for those loses that are occurring now over a period of time.”


MH:

“We want to make sure that women aren’t afraid to come into the hospital or to get their antenatal care because they’re afraid of COVID. So I think one of the best things we’ve done is create an educational pamphlet for women visiting our clinics whether they’re pregnant or not pregnant: what to expect when they come in, what safety precautions we’ve taken, and what women can do to protect themselves. Then over the next few weeks, we’ll be starting to open the clinic to get women in for the non-urgent but important visits like preventative care and the screenings and physical exams.”


“… unfortunately really quickly it has become evident that access to women’s healthcare and reproductive healthcare seem like they have been either politicized or disproportionately negatively impacted by some of the restrictions on COVID … It is time to really ensure that theses services can continue in the setting of major societal shifts.”


DS:

“I think linked with the infectious pandemic, if you will, is a second pandemic that’s already happening, … that is the mental health pandemic … both women potentially in postpartum depressions, not necessarily being able to access care but also in the context of domestic violence and the stressors that come with the loss of income, family structure changes.”


“Fortunately, as you’re probably aware, right now at least the evidence is that there is less of a direct impact of the virus on children and adolescents …”


“It is the indirect effect from the pandemic, that will in fact add up to the excess mortality in children … That it’s the indirect effects and by that I mean the breakdown in medical supply chains, the lack of providers … and, obviously, the whole infrastructure of primary healthcare, much less hospitals is threatened. The tertiary side of that is that people fear to go to the facility … it keeps people and in particular people with sick children from taking what they already want to protect, which is their sick child, into what they see as a facility that in their eyes could in fact cause death.”


“… the excess mortality in malaria and diarrheal disease, for example, in children is enormous. We’ve seen it in the past, and we’re seeing it again now.”


“The final piece … is the psychosocial trauma and the mental health issues. And these affect children just as greatly as they do adults and we’re woefully unprepared to address those sorts of things in this country as well as internationally.”


DS:

“Globally, the hardest hit is the informal sector. Informal sector supplies the well being and income for probably the majority of people in middle income countries. And yet that sector is totally being decimated by some of the broader political decisions- some of them based on evidence….when you restrict borders and movement obviously it effects informal sector.”


“One of the things to me that is really positive about the WISH team and WISH efforts is that we are really focusing on increasing the voices, increasing the accountability and empowerment of women. That is really important as we look at how policy on a national or global level influences communities. The voice of women and understanding of those facts and how to protect their health and their families- is what the WISH Revolution is about. But I think it has a very important role, particularly now during this time of the pandemic.”


MH:

“We’ve seen local leaders who have the capacity to understand or the willingness to learn some of the public health practices… centuries old of basic public health.”


“The decisions that people are making on an individual or family level are heroic on a day to day basis.”


“They are coming to leadership that they trust … We are seeing governors stand up and make the hard decisions. We are seeing the private sector, employers..leadership at Duke for instance has made some really quick and hard decisions about closing campus early and putting restrictions on the hospital, to make workplaces safe while ensuring that people have the tools to do their job and keep their job.”


“There are things that can be put in place effectively in the absence of an effective treatment or effective vaccine.”


MH:

“Medically they do not think that COVID is more severe for pregnant women. We do not think that there is perinatal transmission and we are in a field of changing information, but those two things have stayed pretty consistent”


“I think as the understanding of the psychological effect of having to labor alone outweighed the potential risk of transmission with the partner or support person, so that has changed in many settings.”


“Because a lot of settings are testing women as soon as they come in, we know that the labor floor is actually a very safe place to be. We know that it is not going to be like when you walk around in the streets or grocery store and don’t know everyone’s status. Here everyone is wearing masks, when women are in labor, we know that they are negative.”


DS: “On a macro level: there is global scientific collaboration more than I have ever seen in my 30+ years of practicing … It won’t happen in one week, but still i have a lot of confidence and the degree and width of the collaboration is really impressive.” “In the short term, the primary health care system might be weakened…overall the pandemic will strengthen primary healthcare in this country and overseas.”

“This shifting of work to community health workers, such as what we are doing with WISH and building engagement and accountability and sense of ownership for women’s health and their families health will be strengthened. Out of this adversity, these are some positive things that are coming as well as obvious extension and expansion of telemed.” Watch the whole interview here:


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