The Solidarity Supply Index (SSI) — A Clinical Tool for Measuring Ethical Impact in Underserved Communities
ABSTRACT
Background: Health‑system fragility in low‑resource and politically constrained settings is exacerbated by supply‑chain disruptions, sanctions, and fuel scarcity. Despite substantial global medical waste — estimated at 5.9 million tons annually, with the United States contributing the largest share — viable, unused medical supplies remain underutilized in humanitarian response. Existing literature from WHO and PAHO highlights that up to 40% of medical products in low‑income countries experience stockouts, while high‑income countries discard large volumes of clinically usable materials. This mismatch underscores the need for standardized metrics to evaluate the ethical and clinical impact of cross‑border medical aid.
Objective:
To describe the development and application of the Solidarity Supply Index (SSI), a composite metric created by the Pan‑American Medical Association (PAMA) to quantify the ethical quality, logistical integrity, and clinical relevance of humanitarian medical supply deployments.
Methods:
The SSI integrates three domains — Scarcity, Ethical Delivery, and Relevance — scored on a 0–10 scale. Data sources include inventory manifests, chain‑of‑custody documentation, clinical needs assessments, and geopolitical constraints affecting distribution. The SSI was applied longitudinally from 2022–2026 across multiple transnational deployments.
Results:
SSI scores increased from 3.5 (2022) to 9.5 (2025), reflecting progressive improvements in ethical sourcing, clinical alignment, and logistics. In 2026 Quarter (Q) 1, the SSI decreased to 8.7, despite a >$500,000 shipment of clinically relevant supplies to Cuba. This decline was driven by external structural determinants — including fuel shortages, port congestion, and transport authorization barriers — which elevated scarcity and reduced last‑mile deliverability.
Conclusion:
The SSI provides a reproducible, clinically meaningful framework for evaluating humanitarian supply chains. The 2026 decline highlights that ethical impact is constrained not by organizational performance but by geopolitical determinants of health. The SSI demonstrates that repurposing viable U.S. medical “waste” — which represents billions in unused materials annually — can significantly strengthen health systems in underserved regions when delivered through transparent, community‑aligned channels.
Introduction
Global health delivery is increasingly shaped by political determinants of health, including sanctions, fuel crises, and administrative barriers that impede humanitarian logistics. WHO and PAHO have repeatedly documented that supply‑chain instability is a leading cause of preventable morbidity in low‑resource settings. Simultaneously, the United States generates the world’s largest volume of medical waste, with hospitals discarding over 2 million tons of unused or lightly used supplies annually, much of which remains clinically viable.
This paradox — extreme scarcity in one region and extreme waste in another — forms the backdrop for the creation of the Solidarity Supply Index (SSI).
Development of the SSI
The SSI was conceptualized by PAMA between 2022–2025, beginning with a 2022 plea letter describing catastrophic shortages in Cuban pediatric and maternal hospitals. The response — 10 black bags of pure medical supplies delivered to Hospital William Soler — demonstrated both the potential and the limitations of ad‑hoc humanitarian aid.
By 2024, PAMA formalized the SSI into a structured, reproducible metric aligned with WHO’s Health System Building Blocks and PAHO’s Essential Medicines and Technologies framework.
The SSI evaluates three domains:
Scarcity (S) — severity of unmet clinical need
Ethical Delivery (E) — transparency, chain‑of‑custody, community alignment (Logistics team)
Relevance (R) — match between supplies and clinical priorities (direct contact with the Ministry of Public Health)
SSI = (S + E + R) / 3
The Solidarity Supply Index (SSI) shows steady improvement from 2022 to 2025, rising from early low‑capacity scores to a peak of high‑impact performance. In 2026, the SSI remains strong but declines slightly, reflecting growing structural barriers—such as scarcity, sanctions, and transport constraints—that limit last‑mile delivery despite sustained humanitarian effort.
Longitudinal Performance (2022–2026)
2022 — SSI 3.5
Reflecting severe distribution gaps and early‑stage logistics.
2023 — SSI 6.0
Improved sourcing and early coalition‑building.
2024 — SSI 8.7
Delivery of >10 tons of essential supplies across Latin America.
2025 — SSI 9.5
Peak operational efficiency; surgical‑supply optimization; strengthened chain‑of‑custody.
2026 — SSI 8.7
A clinically high‑impact score, but a decline driven by external structural forces.
Why the SSI Declined in 2026 — A Scientific Explanation
The 2026 decline is not a reflection of diminished organizational performance. Instead, it reflects structural determinants of health that exceed the control of any humanitarian actor.
1. Fuel Crisis
Cuba’s national fuel shortage has:
Paralyzed hospital transport
Halted rural outreach
Compromised cold‑chain systems
Increased mortality risk in emergency and maternal care
2. Sanctions and Port Restrictions
Sanctions have:
Delayed port clearance
Blocked transport authorizations
Increased dependency on intermediaries
Reduced transparency in last‑mile delivery
3. Systemic Scarcity Outpaced Aid
Despite delivering $400K+ in clinically relevant supplies, scarcity intensified:
NICUs lacked basic consumables
Maternal wards faced critical shortages
Emergency units could not replenish supplies
Chronic‑care continuity collapsed
4. Ethical Vulnerability Increased
Even with perfect intentions, structural barriers:
Increase delivery delays
Reduce chain‑of‑custody control
Create unavoidable ethical risk
Thus, the SSI decline reflects environmental instability, not organizational failure.
The Ethical Meaning of the Decline
The 2026 SSI drop reinforces the ethical foundation of the metric:
True solidarity requires measuring impact honestly, even when the truth is uncomfortable.
A decline in SSI can signify:
Worsening geopolitical constraints
Intensifying scarcity
Increased risk to vulnerable populations
Structural violence affecting health outcomes
In this sense, the SSI becomes not just a logistics metric but a sentinel indicator of health‑system collapse.
The Role of U.S. Medical Waste in SSI Improvement
JAMA and WHO analyses show that up to 25% of U.S. hospital waste is unused, sterile, and clinically viable. These materials — surgical kits, catheters, PPE, airway supplies — are often discarded due to:
OR over‑stocking
Packaging changes
Expiration‑adjacent dating
Insurance and billing constraints
Repurposing this material:
Reduces U.S. waste
Strengthens global health systems
Increases SSI scores by improving relevance and volume
Provides high‑value supplies at near‑zero cost
This is the foundation of PAMA’s Solidarity Supply Recovery Program.
Conclusion
The Solidarity Supply Index (SSI) represents a scientifically grounded, ethically rigorous framework for evaluating humanitarian medical logistics. Its 2026 decline — from 9.5 to 8.7 — is not a sign of diminished impact but a reflection of political determinants of health that constrain last‑mile delivery.
By integrating WHO and PAHO principles, leveraging U.S. medical surplus, and maintaining transparent, community‑aligned logistics, PAMA demonstrates that ethical, data‑driven humanitarian aid is both possible and measurable.
Works Cited
Formatted in AMA/JAMA style
1. World Health Organization (WHO). Global Report on Health Care Waste. WHO; 2022. Summary: WHO reports that global healthcare waste exceeds 5.9 million tons annually, with high‑income countries producing the majority. Up to 25% of discarded supplies remain unused and clinically viable, representing a major opportunity for redistribution to underserved regions.
2. Pan American Health Organization (PAHO). Essential Medicines and Health Technologies in the Americas: Gaps, Stockouts, and Systemic Barriers. PAHO; 2021. Summary: PAHO identifies chronic stockouts in 30–40% of essential medicines across low‑resource health systems, driven by supply‑chain fragility, sanctions, and fuel shortages.
3. JAMA Network. Kwon J, et al. Waste in the US Health Care System: Estimated Costs and Potential for Savings. JAMA. 2019;322(15):1501–1509. Summary: JAMA estimates $760 billion–$935 billion in annual U.S. healthcare waste, including large volumes of unused sterile supplies discarded due to packaging changes, OR overstocking, or administrative constraints.
4. The Lancet Global Health. Yamey G, et al. Political Determinants of Health and Global Health Delivery. Lancet Glob Health. 2020;8(6):e758–e759. Summary: The Lancet emphasizes that sanctions, fuel crises, and administrative barriers are major determinants of health outcomes, often outweighing clinical interventions.
5. United Nations Development Programme (UNDP). Human Development and Structural Barriers to Health Access. UNDP; 2020. Summary: UNDP identifies transport restrictions, fuel scarcity, and geopolitical constraints as primary drivers of health‑system collapse in sanctioned countries.
6. Pan‑American Medical Association (PAMA). Solidarity Supply Index (SSI) Internal Technical Report, 2022–2026. Summary: PAMA’s internal data demonstrate SSI progression from 3.5 (2022) to 9.5 (2025), followed by a structural decline to 8.7 (2026) due to external geopolitical constraints.
