Still Dying of Something We Already Fixed

Las tasas de cobertura vacunal, que antes de la pandemia ya rondaban el ochenta y cinco por ciento, bajaron durante el COVID y no han recuperado los niveles anteriores en todas las regiones del país.

Vaccination coverage rates, which were already around eighty-five percent before the pandemic, dropped during COVID and haven't recovered previous levels in all regions of the country.

And that eighty-five percent figure matters because measles has one of the highest contagion rates of any disease known.

The R0, the basic reproduction number, is somewhere between twelve and eighteen.

You need about ninety-five percent of a population immune to stop transmission.

Eighty-five percent leaves a real gap.

Doce a dieciocho.

Twelve to eighteen.

Para que la gente lo visualice: si una persona con sarampión entra en una habitación con diez personas no vacunadas, infecta a nueve de ellas.

So people can picture it: if one person with measles enters a room with ten unvaccinated people, they infect nine of them.

No es una hipérbole, es la biología de este virus.

That's not hyperbole, it's the biology of this virus.

Es increíblemente contagioso.

It is incredibly contagious.

Compare that to COVID's original strain, which was around two or three.

Measles makes COVID look timid.

Bueno, y eso tiene una implicación directa para Bangladesh: incluso si vacunas al ochenta y ocho o al noventa por ciento de los niños, no es suficiente para cortar la cadena de transmisión.

Right, and that has a direct implication for Bangladesh: even if you vaccinate eighty-eight or ninety percent of children, it's not enough to cut the chain of transmission.

El umbral de inmunidad colectiva para el sarampión es más alto que para casi cualquier otra enfermedad prevenible.

The herd immunity threshold for measles is higher than for almost any other preventable disease.

Let me ask you something, because this comes up whenever I talk to public health people.

How much of this is a logistics problem versus a trust problem?

Vaccine hesitancy isn't just a Western phenomenon.

Es una mezcla, y sería deshonesto presentarlo de otra manera.

It's a mixture, and it would be dishonest to present it otherwise.

En Bangladesh hay zonas rurales donde el acceso a los centros de salud es genuinamente difícil.

In Bangladesh there are rural areas where access to health centers is genuinely difficult.

Pero también hay desconfianza, especialmente en comunidades donde la desinformación sobre vacunas ha calado a través de las redes sociales.

But there is also distrust, especially in communities where vaccine misinformation has taken hold through social media.

Eso ya no es un problema exclusivo de Europa o Estados Unidos.

That is no longer an exclusively European or American problem.

That's something I've thought about a lot.

I spent time in Jakarta years ago and even then you could see how quickly bad health information spread through WhatsApp communities in ways that were almost impossible to counter.

By the time an official correction came out, the rumor had been shared ten thousand times.

Mira, la desinformación sanitaria en contextos de bajos recursos es especialmente peligrosa porque la gente no tiene otras fuentes fiables a las que acudir.

Look, health misinformation in low-resource contexts is especially dangerous because people don't have other reliable sources to turn to.

Si tu experiencia con el sistema de salud es escasa o negativa, y alguien de confianza en tu comunidad te dice que la vacuna es dañina, ¿por qué ibas a creer al ministerio antes que a esa persona?

If your experience with the health system is limited or negative, and someone you trust in your community tells you the vaccine is harmful, why would you believe the ministry over that person?

Trust is built over generations.

It gets torn down in a single bad encounter.

And in countries with historically underfunded public health systems, bad encounters aren't rare.

Dicho esto, la desconfianza no explica todo el problema en Bangladesh.

That said, distrust doesn't explain the whole problem in Bangladesh.

Hay que hablar también de los rohingyas.

We also need to talk about the Rohingya.

Bangladesh acoge aproximadamente un millón de refugiados rohingyas en el distrito de Cox's Bazar, en condiciones de hacinamiento extremo, con acceso muy limitado a servicios de salud formales.

Bangladesh hosts approximately one million Rohingya refugees in the Cox's Bazar district, in conditions of extreme overcrowding, with very limited access to formal health services.

Los brotes en campos de refugiados se propagan con una velocidad que es casi imposible de contener.

Outbreaks in refugee camps spread at a speed that is almost impossible to contain.

I should have brought that up myself.

Cox's Bazar is one of the most densely populated places on Earth when you factor in the camps.

You have over a million people in an area without the infrastructure to support a tenth of that number.

Y los rohingyas llevan años en una situación de limbo legal que complica incluso los programas de vacunación.

And the Rohingya have been in a legal limbo for years that complicates even vaccination programs.

Organizaciones como UNICEF y Médicos Sin Fronteras trabajan allí, pero los recursos nunca son suficientes para la escala del problema.

Organizations like UNICEF and Doctors Without Borders work there, but the resources are never sufficient for the scale of the problem.

Eso crea exactamente el tipo de bolsa de población no inmunizada que permite que el sarampión se propague.

That creates exactly the kind of pocket of unimmunized population that allows measles to spread.

Let's zoom out a bit.

The WHO set a goal years ago of eliminating measles in at least five of its six world regions by 2020.

That deadline passed.

Then they pushed it.

Measles is one of those elimination targets the global health community keeps revising, and it never quite gets there.

Es que la eliminación del sarampión es increíblemente difícil de sostener políticamente.

Measles elimination is incredibly difficult to sustain politically.

No tiene el dramatismo del ébola o el impacto económico visible del COVID.

It doesn't have the drama of Ebola or the visible economic impact of COVID.

Es una muerte de niño en un pueblo de Bangladesh, y no genera la presión mediática ni la voluntad política que se necesitan para mantener programas de vacunación robustos durante décadas.

It's a child's death in a village in Bangladesh, and it doesn't generate the media pressure or political will needed to maintain robust vaccination programs for decades.

That invisibility is its own kind of tragedy.

Polio got eradicated almost everywhere partly because it visibly paralyzed children in wealthy countries first.

That drove the funding.

Measles mostly kills the children that global health funding reaches last.

Hay algo moralmente perturbador en eso.

There is something morally disturbing about that.

La facilidad con la que se puede prevenir una enfermedad no garantiza que se prevenga.

The ease with which a disease can be prevented does not guarantee it will be prevented.

Lo que garantiza que se prevenga es que muera suficiente gente importante, es decir, gente cuya muerte genera consecuencias políticas y económicas para los poderosos.

What guarantees it will be prevented is enough important people dying, meaning people whose deaths generate political and economic consequences for the powerful.

You've just described the entire history of tropical medicine in a sentence.

That's essentially the argument Paul Farmer was making his whole career.

Exactamente.

Exactly.

Y ahora mismo hay otro factor que complica la situación: los recortes en la ayuda internacional al desarrollo.

And right now there is another factor complicating the situation: cuts to international development aid.

Varias agencias de salud global han visto sus presupuestos reducidos en los últimos dos años.

Several global health agencies have seen their budgets reduced in the last two years.

Gavi, la alianza para las vacunas, depende en parte de donaciones de gobiernos que ahora están mirando más hacia adentro.

Gavi, the vaccine alliance, depends in part on donations from governments that are now looking more inward.

Eso tiene consecuencias directas sobre el terreno.

That has direct consequences on the ground.

I'll be direct about this: the US has pulled back significantly from global health funding commitments under the current administration.

USAID, which had been one of the largest funders of vaccination programs in South Asia, has been gutted.

That has a name.

It has a consequence.

And it's playing out right now in Bangladesh.

No solo Estados Unidos, aunque Estados Unidos es el caso más visible.

Not only the United States, although the United States is the most visible case.

El Reino Unido redujo su presupuesto de ayuda al desarrollo hace unos años, y otros países europeos también han ido recortando.

The UK reduced its development aid budget a few years ago, and other European countries have also been cutting.

El resultado es que organizaciones como la OMS y UNICEF están intentando cubrir los mismos problemas con menos recursos, justo cuando los efectos retardados de la pandemia en la cobertura vacunal se están materializando.

The result is that organizations like WHO and UNICEF are trying to cover the same problems with fewer resources, exactly when the delayed effects of the pandemic on vaccination coverage are materializing.

And here's what gets me about the math on this.

The cost of treating a child with severe measles complications, hospitalization, potential long-term care, is orders of magnitude higher than the cost of vaccination.

From a purely economic standpoint, cutting vaccination funding is not even saving money.

It's deferred spending with interest.

Los economistas de salud llevan décadas demostrando exactamente eso.

Health economists have been demonstrating exactly that for decades.

Cada dólar invertido en vacunación devuelve algo entre dieciséis y cuarenta y cuatro dólares en beneficios económicos, dependiendo del estudio.

Every dollar invested in vaccination returns somewhere between sixteen and forty-four dollars in economic benefits, depending on the study.

Pero la política tiene sus propios ritmos, y el coste de no vacunar hoy no aparece en el presupuesto de este año sino en los hospitales de dentro de tres años.

But politics has its own rhythms, and the cost of not vaccinating today doesn't appear in this year's budget but in hospitals three years from now.

Short-termism in public health policy is a story I've watched play out in country after country for thirty years.

The pattern is almost invariant: cuts happen, outbreak follows, emergency response costs triple what prevention would have cost, and then everyone acts surprised.

Siempre sorprendidos.

Always surprised.

Aunque lo que está pasando en Bangladesh no es sorprendente en absoluto.

Although what is happening in Bangladesh is not surprising at all.

Lo que debería sorprendernos es que sigamos sin aprender.

What should surprise us is that we still haven't learned.

Hay una pregunta que me parece fundamental: ¿cuántos niños tienen que morir de una enfermedad que ya sabemos cómo prevenir antes de que esto se trate como la emergencia que es?

There is a question that seems fundamental to me: how many children have to die from a disease we already know how to prevent before this is treated as the emergency it is?

No good answer to that.

There really isn't.

What I will say is that the Bangladesh outbreak is almost certainly not going to stay in Bangladesh's headlines for long, and that's exactly the problem.

The global health community will manage it, partially.

The children who died will not be remembered by name.

And the underlying conditions will remain.

Oye, había una frase que usaste antes, "en la práctica", cuando hablabas de las agencias internacionales.

Hey, there was a phrase you used earlier, "in practice", when you were talking about international agencies.

Me gusta cómo lo dijiste, pero quiero retomar algo que mencioné yo mismo hace un momento, porque creo que los oyentes quizás se quedaron con algo.

I like how you said it, but I want to pick up on something I myself mentioned a moment ago, because I think listeners may have noticed it.

Dije "a no ser que esto se trate como una emergencia." ¿Te diste cuenta de esa construcción?

I said 'a no ser que esto se trate como una emergencia.' Did you catch that construction?

I did, actually.

"A no ser que." I know "unless" is a construction that trips up Spanish learners, myself included.

What's happening grammatically there, because I feel like I would instinctively reach for something wrong.

"A no ser que" siempre va con subjuntivo.

"A no ser que" always takes the subjunctive.

Siempre, sin excepción.

Always, without exception.

Igual que "a menos que", que es su sinónimo.

The same as "a menos que", which is its synonym.

La razón es que estás introduciendo una condición hipotética que todavía no ha ocurrido.

The reason is that you are introducing a hypothetical condition that hasn't happened yet.

"A no ser que esto se trate como una emergencia" implica que en este momento no se está tratando así.

"A no ser que esto se trate como una emergencia" implies that at this moment it is not being treated that way.

El subjuntivo señala esa realidad pendiente, algo que podría ocurrir pero aún no ocurre.

The subjunctive marks that pending reality, something that could happen but hasn't yet.

So it's the subjunctive because the thing hasn't happened yet, you're gesturing at a possibility rather than a fact.

"Unless this gets treated as an emergency", and the subtext is that it isn't being treated as one.

The grammar is doing the pessimism for you.

"La gramática hace el pesimismo por ti." Me gusta.

"The grammar does the pessimism for you." I like that.

Sí, exactamente.

Yes, exactly.

Y mira, el error clásico es decir "a no ser que esto se trata", con indicativo, como si fuera un hecho.

And look, the classic mistake is to say "a no ser que esto se trata", with the indicative, as if it were a fact.

Eso suena extraño en español, como si dijeras "unless this is a fact".

That sounds strange in Spanish, as if you were saying "unless this is a fact".

El indicativo quitaría esa carga de incertidumbre que es precisamente el punto.

The indicative would remove that weight of uncertainty which is precisely the point.