Who lives and who dies in the world’s next pandemic should not depend on where they live | Michael Marmot

The Covid pandemic was an equivocator with global unity – to misquote the porter in Macbeth. We were united in being affected by the pandemic but both its effects and the responses to it were grossly unequal. More, inequality worsens pandemics, not only current pandemics such as Aids and Covid but those yet to come.

Governments are looking to address one side of this equivocation through their negotiations on a pandemic accord that will be discussed during the UN general assembly in New York this month. Such a development is welcome and much needed. It is the other side, inequality, that is missing from the draft pandemic treaty and from governments’ pandemic preparedness plans. If lessons are learned, the next pandemic can be made less tragic in its effects.

It is to bring the lessons from the Aids response and other pandemics that UNAids took the initiative to convene a Global Council on Inequality, Aids and Pandemics. I am co-chairing it with Monica Geingos, first lady of Namibia, and Joseph Stiglitz, the economist and a professor at Columbia University in New York, with a diverse group of leaders from civil society, academia, government and international organisations, to review the evidence and propose new action.

The global council will seek to influence pandemic preparedness efforts by showing the evidence of three ways in which inequality can be considered: how it drives pandemics; in access to diagnostics, vaccines and treatments; and exclusion of marginalised communities from engagement in designing their own welfare. Solutions must be found to all three.

Say the word “health” in the context of action and a common reaction is to think of the healthcare system. But social determinants are crucial in driving health inequalities. A new paper, led by John Ele-Ojo Ataguba, executive director of the African Health Economics and Policy Association, building on work on income inequalities and health, examined the relation between income disparities and HIV incidence and Aids mortality in 217 countries, and excess deaths linked to Covid in 151 countries.

In Africa, where HIV prevalence and Aids deaths are particularly high, and in the rest of the world, there was a link between income inequality and health: the greater the inequality within a country, the higher the HIV incidence, Aids mortality and Covid excess deaths. It is important to understand how this link comes about. One possibility is that the greater the inequality, the greater the deprivation, covering the spectrum from nutrition to education to life chances. Second, greater inequality is linked to lower social cohesion and trust, which make social action to deal with pandemics much more difficult. Third, inequality is linked to a politics that serves special interests against the interests of the whole population, especially marginalised communities.

More generally, we want the treaty to address the social determinants of health. Countries that are taking the social actions necessary to reduce health inequalities are likely to be those that are better prepared to handle the pandemic. In the US and the UK, for example, Covid mortality was higher in subgroups of the population that already had higher risk of ill health. Covid amplified these pre-existing inequalities.

A second major strategy to address inequality between countries is to make commitments to fix the vastly unequal supply of treatments and vaccines available globally. Among the most important of these commitments would be for the governments of the powerful states to attach conditions to the public financing they give pharmaceutical companies for research and development so the resulting technology can be shared around the world. Without these conditions, we are likely to repeat history: a situation in which a government invests more than $10bn in Covid vaccine research, resulting in the development of vaccines that are the private monopolies of pharmaceutical corporations, which are then neither shared with the world, nor even priced fairly for those who paid for them. Actions by governments to limit pharmaceutical monopolies have saved millions of lives in the Aids pandemic by requiring that technology and generic medicines be shared around the world. Following this model could ensure that it is not the geographical location or the fiscal capacity of a state that determines who lives and dies in a pandemic.

Financing pandemic preparedness and response is a key factor in a world where countries have highly unequal resources, whether for buying tests and vaccines or for the upgrades in health infrastructure that can deliver them to people. We are in a world in which lower-income countries, already in deep economic crisis from the pandemic, could be even less prepared for the next, with no plan to address their levels of debt, let alone access more funds to strengthen their health systems and tackle Aids and tuberculosis. Two serious efforts are needed: a clear commitment to a pandemic response fund that would be triggered when a pandemic is declared; and a major effort to address unequal access to financing – in the short term to remove the massive debt burden hampering many countries’ ability to invest in preparedness and in the long term so that lower-income countries have equal access to affordable credit in times of crisis.

A third part of a strategy to deal with inequalities is to learn from the Aids pandemic the importance of including marginalised communities in responses; and to engage everyone in decision-making. It is important to fund community-led services to reach populations that the state cannot. Key commitments should include ending punitive laws including criminalisation of marginalised groups and developing strategies for greater equity related to gender, disability and sexual orientation.

We have a real challenge to global cooperation. High-income countries may be reluctant to make the financial guarantees necessary and their pharmaceutical industries reluctant to do what is needed. In the absence of such commitments, low- and middle-income countries may be reluctant to cooperate in sharing vital data that is necessary for managing a global pandemic. Addressing inequality is an opportunity to make real progress. This pandemic treaty is an opportunity for tangible steps towards a fairer world, with potential benefits for the health of people everywhere.

Michael Marmot is professor of epidemiology at University College London, director of the UCL Institute of Health Equity, and past president of the World Medical Association

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