Wednesday, September 27, 2023

The global community needs to do more to tackle the inequality crisis

Progress on health inequalities is now at risk, argue Michael Marmot and colleagues, the chairs of a new Global Council on Inequality, AIDS, and Pandemics

The climate emergency and the global rise in inequalities are putting us all at risk. Both will damage health. The global community, with successive climate change conferences (COPs), is taking faltering steps to tackle the climate emergency but is doing little about the inequality crisis. In some countries, political and economic forces are increasing social and economic inequalities, with potentially dire consequences for health inequalities and for people’s vulnerability to pandemics. Unfair distribution of power, money, and resources are driving inequalities in health.1

We’ve been through a good period. Global progress in improving health has been impressive throughout the 20th and early 21st centuries, and health inequalities between countries have diminished. Within countries, too, absolute inequalities in health have lessened, although that picture is more mixed.

But this progress is now at risk. If the AIDS and covid-19 pandemics did nothing else, they showed how fragile these health improvements are. These pandemics have, to some extent, been driven by social and economic inequalities, and their effects have been to expose and exacerbate health inequalities. The effects of the pandemics have also been disproportionate in some communities and related to socioeconomic circumstances, gender, LGBTQ+ identities, and race and ethnicity.

To deal with the effects of inequalities on pandemics and of pandemics on health inequalities, the Joint United Nations Programme on HIV/AIDS (UNAIDS) has convened the Global Council on Inequality, AIDS, and Pandemics. We are the co-chairs of this global council. The announcement of the new council was made in Brazil at a meeting hosted by the Brazilian Ministry of Health. Our backgrounds as co-chairs are highly relevant to the council’s mission. We seek to bring the perspectives of international and national economic arrangements, social determinants of health, and human rights to bear on our central questions. The need is great as the following examples show.

Analyses indicate that countries with greater income inequality have higher rates of HIV infection and of death from AIDS and covid-19.2 In most, but not all, African cities the urban poor are much more likely to have with HIV than those from higher socioeconomic groups.3

HIV and AIDS have also exposed gender inequalities. In the west African countries of Cote d’Ivoire, Ghana, and Liberia, HIV prevalence in people aged 20-24 was five times higher in women than in men.4

The unequal effect of the AIDS pandemic on men who have sex with men is a political choice. In Thailand, for example, where identifying as LGBTQ+ is not criminalised, the prevalence of HIV is 12 times higher among men who have sex with men than among other adults. In Malaysia, where identifying as LGBTQ+ is criminalised and subject to arrest, the HIV prevalence rate among men who have sex with men is more than 70 times higher than among other adults.456

In Brazil, where racial inequalities were not openly acknowledged for a long time, the evidence of the effects of this on health inequalities is stark. Rates of new HIV infections have been falling among white people, while rising among black people.7

The United States provides an important case study of the role of socioeconomic influences and racism on health, including during the covid-19 pandemic. Life expectancy had been falling in the years 2016-18, in part owing to deaths of despair, which show a social gradient—the fewer the years of education, the bigger the effect.8 The decline stopped, and life expectancy rose slightly in 2019, but then fell sharply in the first two years of the covid-19 pandemic.9 Covid mortality was higher among socioeconomically disadvantaged communities and black people.10 In New York City, in the first year of the pandemic, life expectancy fell by three years among white residents, 5.5 years among black residents, and six years among Hispanic residents.11

The AIDS and covid-19 pandemics send two clear messages, and hopefully the global community is open to receiving them. The first is that inequalities drive the likelihood and consequences of pandemics, and pandemics amplify health inequalities. This is the problem that this global council is set up to tackle.

The second is that medical and technical responses are crucial but are only part of the story. Inequities in access to care are needless, harmful, and immoral, and should be relatively easy to solve. Could there have been a global rollout of covid vaccines, entailing higher levels of production? Most certainly. Technically, it should be possible in future pandemics to have the capacity to vaccinate the world as needed. The money is certainly there. In the first year of the covid-19 pandemic, the rich world found $18tn to protect the economies of high income countries.12 Against this amount, $25bn for a global rollout of the vaccine is coffee money. And the technology that would have made it even easier to rollout the vaccine more widely wasn’t shared, even though governments had put up the vast majority of funds for vaccine development. As the old saying has it, this was penny wise but pound foolish because everyone would have benefited from dampening down covid-19 globally.

The effects of transnational economic inequalities are striking. During the covid-19 pandemic, high income countries put trillions into health and social spending to fight the pandemic’s effects, including supporting their economies, but low and middle income countries lacked the fiscal resources to make this choice. In 2021, almost half of all low and middle income countries cut healthcare spending, and about 70% cut spending on education.

The clear lessons from pandemics are that paying attention to the social determinants of health, respecting human rights, and involving communities are critical. Inequalities in health this vast are not inevitable. They are the result of policies—both what we do and what we fail to do. To achieve a world with better health and fewer health inequalities we need knowledge, resources, and political will. One of the tasks of the Global Council on Inequality, AIDS, and Pandemics is to synthesise the knowledge we already have. As the example of the money found by high income countries to protect their economies shows, “we”—the global community—also have the resources. The problem is the skewed distribution of financial and other resources. Political will is the great challenge. The global council will work with partners in governments, agencies, and communities to build the political will and public demand for change. Social justice requires it.

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