The poorest people and countries suffer the most during pandemics, setting in motion a “vicious cycle” of inequality where those who suffer the most are least equipped to address disease outbreaks, according to the Global Council on Inequality, AIDS and Pandemics in a report released on Monday (3 November).

The COVID-19 pandemic pushed 165 million people into poverty, with women, informal workers, and ethnic minority groups experiencing the worst income shocks.

The pandemic also raised the debt of developing countries to $3 trillion, and more than half of low-income countries are either in debt distress or at high risk of it. 

In comparison, the world’s richest people increased their wealth by 25%.

“The rich had a very good pandemic. There was an increase in billionaires and an increase in their wealth, while poorer people got poorer,” said Professor Michael Marmot, director of the Institute of Health Equity at University College London.

“The pandemic increased social and economic inequality, which means that we’re less well prepared for the next pandemic unless we act on the conditions in which people are born, grow, live, work and age, and the fundamental drivers of those inequalities,” added Marmot, co-chair of the council, addressing the report launch in Johannesburg.

“If we reduce inequalities – including through decent housing, fair work, quality education and social protection – we reduce pandemic risk at its roots. Actions to tackle inequality are not ‘nice to have’; they are essential to pandemic preparedness and response.”

‘Diseases fester and stay’

“Where these inequalities are biggest, where the most unequal are, within their countries and between countries, that is where we see diseases festering and staying,” UNAIDS director Winnie Bwanyima told the launch.

“These inequalities drive pandemics, prolong them, make them more deadly and make them more economically disruptive. And when that happens, we see inequality continuing to increase. That is a cycle.”

More unequal countries had significantly higher COVID-19 mortality, HIV infection, and AIDS mortality, according to the report, which was compiled over two years.

Epidemics of H1N1 influenza, SARS, MERS, Ebola, and Zika have led to “a persistent increase in inequality that peaked about five years later”.

Debt relief

“Pandemics are not only health crises. They are economic crises that can deepen inequality if leaders make the wrong policy choices,” said Prof Joseph Stiglitz, council co-chair and Nobel Laureate in Economics.

“When efforts to stabilise pandemic-hit economies are paid for through high interest on debts and through austerity measures, they starve health, education and social protection systems,” he added.

“Around 60% of tax revenue in sub-Saharan Africa goes to servicing the debt, and that means less money is left over to provide medicines to address the disease directly, but also to stop the growth of inequality. Societies then become less resilient and more vulnerable to disease outbreaks.”

Stiglitz added that breaking this cycle means “enabling all countries to have the fiscal space to invest in health security.”

One of the report’s key recommendations to address inequality is through debt relief for developing countries to alleviate long-term economic harm and stop the cycle of disease outbreaks deepening inequality.

Debt repayments “crowd out spending on today’s pandemics and preparation for tomorrow’s,” the report notes.

The council is “deeply worrying that AIDS remains a pandemic”, and that, with tuberculosis and malaria, “it continues to cause millions of deaths, disproportionately in low- and middle-income countries and among marginalised groups in high-income countries”. 

Aside from debt relief for countries affected by HIV from now until 2030, the report also proposes that affected countries have access to the  International Monetary Fund’s (IMF) Special Drawing Rights.

It also wants international financial institutions to stop financial assistance that encourages “pro-cyclical austerity policies” and to rather address the “structural flaws that lead to insufficient fiscal space to reverse inequalities and to stop pandemics”.

Stiglitz also called for a “reserve fund” that countries can access “the moment that the World Health Organization says there’s a pandemic”.

By the end of 2024, new HIV infections fell to their lowest level since 1980, but this year’s “rapid donor withdrawal threatens gains and leaves the most vulnerable behind.”

Local medicine production

The third co-chair of the council, Monica Geingos, addressed the lack of local production of vaccines and medicines, which affects access to medicines.

The tragedy is that breakthroughs in medicines and technologies for HIV, COVID-19 and other diseases are not reaching the vulnerable populations quickly enough, and this prolongs inequities in access to optimal care and prevention,” said Geingos, former First Lady of Namibia.

“Six months after COVID-19 the vaccines had received approvals, high-income countries had 90% of what they needed to cover priority populations, while low-income countries received only enough to cover 12% of the priority populations,” said Geingos.

“We’re at an awkward place where breakthroughs in science and technology have still been met by a failure to share technology across borders in pandemics,” she noted.

“The intellectual property barriers and the insufficient manufacturing capacity together mean that the supply of pandemic technologies continues to be insufficient to the needs of those who need them the most. 

“World leaders need to look at increasing global funding for regional production and create a pool mechanism for technology transfer. Brazil has already proposed a global coalition that we support, and the international financial institutions, like the World Bank, should support and enable that coalition to address the pandemics of today, like AIDS and TB, so that we prepare for those of tomorrow.”