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.
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.
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.
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. The decline stopped, and life expectancy rose slightly in 2019, but then fell sharply in the first two years of the covid-19 pandemic. Covid mortality was higher among socioeconomically disadvantaged communities and black people. 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.
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. 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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