The poorer you are, the more likely you are to fall ill, and the harder it becomes to recover. This stark warning was underscored this week at the launch of a groundbreaking report by the Global Council on Inequality, Aids and Pandemics, titled Breaking the Inequality Pandemic Cycle: Building True Health Security in a Global Age.
The report, supported by UNAIDS, exposes how poverty, gender inequality and social exclusion continue to drive pandemics such as HIV, tuberculosis and MPOX, while leaving the world dangerously unprepared for future outbreaks.
It highlights the social determinants of pandemics and calls for urgent multi-sectoral action, from equitable access to medicines and economic reform to stronger community-led health systems and governance.
According to UNAIDS, the report provides a roadmap to tackle not only new and emerging health threats, but also to end existing crises such as HIV and TB, which continue to claim millions of lives each year.
The findings come as G20 health ministers prepare to meet amid growing international outbreaks of avian flu and MPOX, and as drug regulators approve new breakthrough HIV prevention medicines, which remain out of reach for many in low-income countries.
Inequality entrenches illness
South Africa, home to the world’s largest HIV epidemic and a stubborn TB burden, remains one of the clearest examples of how inequality shapes health outcomes.
Deputy health minister Dr Joe Phaahla said poverty, poor living conditions and unequal access to health facilities continue to deepen the country’s health crisis.
“HIV/Aids and TB are the driving forces of inequality and limited access to health care in the country. Poverty increases vulnerability, not just in terms of affording medicines, but even in having money for transport to visit clinics. We’re trying to make sure people get medicines delivered closer to their homes,” Phaahla said.
Phaahla said young women and girls are particularly at risk, especially those from poor backgrounds, where sex work becomes a means of survival.
“To avoid TB, you need good ventilation, and that depends on your income. The stigma in low-income areas is also a challenge,” he added.
While progress has been made in strengthening the public health system, he said, reducing inequalities remains key to building lasting resilience against disease.
Nomonde Ngema, an HIV youth activist who was born with HIV in 2003, said pandemics expose and amplify the inequalities that already exist, particularly for young women.
“To be a woman is a big thing, and you can’t be boxed into one policy because inequalities follow us into our day-to-day lives,” Ngema said.
She said when pandemics happen, women, who are the heart of communities, are affected most. They often don’t have enough to survive. Meanwhile, young people are left out of decision making, and the solutions don’t reflect what we’re going through.”
Pandemic inequalities
Winnie Byanyima, executive director of UNAIDS and UN under-secretary-general, said the Global Council was established to understand why pandemics persist despite scientific progress.
We need to deal with the debt crisis that prevents governments from investing in health. And we must address social determinants such as housing and social protection, which build resistance to pandemics
— Winnie Byanyima, executive director of UNAIDS
“There is so much innovation in science, we have complex systems for detecting and tracking outbreaks, yet we have one pandemic after another. We wanted to understand why, despite all this science, we remain vulnerable,” she said.
Byanyima said after two years of research, the council found that inequality, both within and between countries, makes the world more prone to pandemics.
“Between countries, there are inequalities in access to resources and medicines. These are key drivers of pandemics,” she said.
She added that addressing financial barriers, particularly in sub-Saharan Africa, is critical.
“We need to deal with the debt crisis that prevents governments from investing in health. And we must address social determinants such as housing and social protection, which build resistance to pandemics,” Byanyima said.
She said during pandemics, new medicines should be treated as global public goods and be accessible to all.
“And pandemic response must include all sectors, not just health: finance, human rights and communities must be at the centre,” she said.
South Africa as a microcosm
Phaahla said South Africa’s experience illustrates many of the report’s findings. The Covid-19 pandemic, he said, revealed the country’s deep-seated inequities in access to care.
“People died without knowing they had Covid because only private labs initially had testing capacity. We had to quickly build public health labs to ensure access across public facilities,” he said.
He said the World Health Organization (WHO) gave guidance on mitigating Covid’s impact, but many of those measures were easier said than done.
He added that social distancing was nearly impossible in overcrowded informal settlements.
“It might have been easy for someone living in a mansion, but how do you distance when 20 people share a four-room house? The issue of income devastated people who survive from day to day,” Phaahla said.
Debt, resources and the vicious cycle
Joseph Stiglitz, Nobel Prize-winning economist, said pandemics both result from and reinforce inequality.
“If you don’t have resources, you can’t provide the medicines needed to prevent disease spread,” Stiglitz said.
He said, equally important, without resources, you can’t prevent the increase in inequality.
“During Covid-19, the people who suffered most were the poor. It’s a vicious cycle, more poverty means more vulnerability to disease, which then deepens inequality,” he said.
He noted that during Covid-19, countries poured 20–30% of GDP into keeping their economies afloat.
Last year, the Health Justice Initiative reported that South Africa struggled to protect its citizens’ health because it was bullied by big pharmaceutical companies demanding up to three times the price for vaccines compared with other countries.
Stiglitz cautioned against austerity as a response to debt.
When I saw the picture in front of the report, I saw South Africa. This is Alexandra and Sandton. We are not necessarily the poorest country on this continent, but we are certainly the most unequal in the whole world
— Health minister Dr Aaron Motsoaledi
“Governments must not respond with austerity, it worsens inequality and doubles down on the cycle,” he warned.
He said pandemics are not only health crises but an economic crisis that can deepen inequality and lead to the wrong policy choices.
A call for equity and justice
As the world faces new waves of health threats, the report urges governments to act on the lessons of HIV and Covid-19: that science alone cannot end pandemics; only justice and equality can.
South Africa, long at the epicentre of global health inequality, continues to serve as both a warning and a beacon, showing that when the poorest are left behind, everyone remains at risk.
Health minister Dr Aaron Motsoaledi welcomed the report, as he said it talks to South Africa.
“When I saw the picture in front of the report, I saw South Africa. This is Alexandra and Sandton. We are not necessarily the poorest country on this continent, but we are certainly the most unequal in the whole world.
Recommendations
To break the inequality pandemic cycle it is recommended that financial barriers in the global architecture be removed to allow all countries sufficient fiscal capacity to address the inequalities driving pandemics.
- Invest in the social determinants of pandemics
- Build local and regional production alongside a new governance of research and development capable of ensuring the sharing of technology as public goods needed to stop pandemics
- Build greater trust, equality and efficiency in pandemic response by investing in responses that include multiple sectors, ministries and community
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