Pandemics and the social and economic crises they cause are not inevitable, says Winnie Byanyima (United Nations). The lessons learnt from fighting AIDS, TB and now COVID can help us tackle the next outbreak.

COVID has killed at least six million people. Whilst some in the West are already claiming victory over the virus, in Africa only one in 11 people are double-jabbed. The virus, and the crisis, are not over. Meanwhile, other infectious diseases continue to take a toll. Scientists in the Netherlands recently discovered a new and damaging HIV variant. One and half million people died of tuberculosis (TB) in 2020, and antibiotic-resistant infections continue to rise.

Each pandemic worsens the impact of other pandemics: COVID has disrupted HIV testing and prevention services, including tackling vertical transmission from mother to child, voluntary male circumcision, and PREP. Progress in fighting AIDS was already off-track before COVID. Now it is under even greater strain. Deaths from TB have risen for the first time in a decade.

The damage done by pandemics goes beyond deaths. They disrupt the functioning of essential public services, and damage the economy in ways that hit the most vulnerable hardest, heightening social tensions and widening inequalities.

Ten million girls may never return to school

In the 1980s, the impact of AIDS on social and economic development contributed to what has become known as Africa’s lost decade. Today, one estimate has put the cost of delays to access to COVID vaccines in developing countries at nine trillion dollars. The COVID crisis has caused an increase in extreme poverty for the first time in 20 years. Eighty million people have gone into extreme poverty; another 160 million have gone hungry; and 250 million have lost their jobs, and many more their livelihoods.

Over 168 million children lost access to school for at least a year. Ten million girls may never return to school. Meanwhile, in 2020 workers lost 3.7 trillion dollars, while billionaires at the top gained 3.9 trillion dollars. According to Oxfam, the world’s ten richest men doubled their fortunes during COVID while the incomes of 99 percent of humanity have fallen.

Surges have been reported in gender-based violence, forced child marriages, and teenage pregnancies. In a UN Women Survey, 7 in 10 women said they think the COVID-19 pandemic has increased domestic violence. Almost 1 in 2 women reported that they or a woman they know experienced violence since the COVID-19 pandemic. Calls to helplines have increased five-fold in some countries during the pandemic. Violence against and harassment of LGBTIQ+ people has increased, as has stigma and discrimination against marginalised communities.

The World Health Organisation has warned “the next pandemic may be more severe.” The damage wrought by pandemics is so deep and so broad, and the risks from future pandemics so grave, that we can’t afford not to protect ourselves.

While AIDS, TB and COVID each spread in unique ways, many of the drivers of our collective vulnerability are common to all of them. A viral outbreak does not automatically become a global pandemic. It does need to become an economic, social, and political crisis like COVID. The world’s failure to address marginalisation and unequal power is leaving us unprepared.

What we need to do is not a mystery. We know it – not from theory, but from what we’ve repeatedly seen succeed across contexts. We have the lessons, rooted in ongoing experience from progress and challenges in the AIDS response and other pandemics, echoed again in the COVID crisis.

End inequalities in access to health technologies

 Some people want us to believe that vaccine hesitancy is stopping people getting jabbed in low-income countries. It is not true. Hesitancy is everywhere, but there is not enough supply. Inequality is built into the global system. Our rules permit — and even endorse — greed. A handful of people can own a life-saving technology and make billions as people die.

Mass use of antiretrovirals to prevent AIDS came only when middle- and low-income countries defied pressure and triggered generic competition

Health apartheid is not unique to COVID. We are witnessing the same deadly mistakes today as were made when treatment for HIV became available. Then, ARV monopolies meant the price charged by suppliers was $10,000 per person per year, a price far out of reach for the millions of people living with HIV in the global south, and in consequence 12 million Africans died. Mass use of antiretrovirals to prevent AIDS came only when middle- and low-income countries defied pressure and triggered generic competition, and when global civil society pressured Western governments and companies to stop working to block them.

Some of the same big companies and governments who held up progress on anti-retrovirals then are doing so again on COVID vaccines, and even using the same discredited talking points.

Indeed, we are on course to repeat the story even with new HIV medicines. Opening up of production is needed to ensure that the new long-acting antiretrovirals reach people not only in New York and London but in Manila, Freetown, Maputo, Sao Paolo and Port-au-Prince. Unless the system of monopolies is tackled, and sky-high prices of final products brought down, innovative health technologies, like long-acting antiretrovirals, are not set to be made available for people in most of the Global South. Opening up production to ensure that all HIV medicines are manufactured affordably by multiple producers, especially in the global South where the disease is concentrated, will be key to ensuring equitable access and to ending AIDS. It will be not only a moral outrage but also a huge lost opportunity for global public health if we allow the deadly inequality in access to HIV medicines that scarred the past to unfold again today.

Breaking open powerful monopolies requires a social movement. Thankfully, that movement is growing. Through the People’s Vaccine Alliance, pressure from civil society is rising.

As an African woman, I feel insulted when we are asked to believe that donations of unwanted extra doses from rich countries will solve the global supply issue

Over 120 countries have pledged support for a TRIPS waiver for COVID – a temporary exception to the enforcement of intellectual property rights to help facilitate trade and production by manufacturers across the world of COVID tools. But the shift can’t end there. We need to invest in all health innovations as global public goods. Systems must be organised around the idea that health is not a commodity, but a right, and that everyone’s health is interdependent.

Whether the pandemic is COVID, AIDS, or the ones we may face in the future, the answer is never only just sharing doses. As an African woman, I feel insulted when we are asked to believe that donations of unwanted extra doses from rich countries will solve the global supply issue. The real answer is to share data and intellectual property rights, and support local production, so that millions more doses can be made and delivered where they are most needed.

The world cannot rely on a handful of companies. We have seen the consequence of allowing companies like Pfizer to decide the pace and location of a global vaccine rollout. It was inevitable that they would make decisions based on the short-term interests of their shareholders. We need to invest now in building health production capacity around the world so that all regions can develop and produce medicines, tests, and vaccines. That means prioritising investment in universities and other institutions. The development of regional institutions, including the Africa Medicines Agency and the Partnership for Vaccine Production in Africa, and the production centres set up in emerging new hubs, can pave the path to creating viably strong biomedical manufacturing across the world. But we need to ensure that this is full manufacturing production, not only fill and finish. For example, African countries have set themselves a goal of scaling up production this year, and moving by 2040, from 1% to 60% production in Africa – success requires multiplying current levels of investment through continental and international cooperation.

Deliver and guarantee health services, education, and social protection for everyone

 We need to end inequalities in access to essential services by delivering on guaranteed health and education for everyone, as rights; with no user fees or other financial barriers; through public systems which integrate community-provided services and reach out to the most marginalised; and by respecting, protecting, and rewarding with fair pay and conditions all the workers on whom services depend.

In more than 40 African countries, ordinary people cannot access healthcare because they cannot afford it. Cameroon’s decision in 2020 to remove user fees at all public health facilities is an example that lights the way. But despite the commitment African governments made in 2001 in Abuja to allocate 15 percent of their budgets to health, the average today is only seven percent. With COVID, that shortfall has increased as fiscal constraints have grown. Debt repayments are a huge threat for many African countries. In a gross irony, most developing countries are poised to cut spending on healthcare in response to a crisis caused by a pandemic.

Six in seven of newly-acquired HIV cases in sub-Saharan Africa among adolescents aged 15-19 years are among girls. A girl’s risk of acquiring HIV can reduce by half by staying in secondary education. This can be reduced even further with comprehensive sexuality education, sexual and reproductive health services and rights, action to tackle gender-based violence and support for school to work transitions. It is vital that all children, including those who dropped out of school during COVID or were absent before it, get to complete a full round of basic education. Yet countries are cutting education spending, and the International Monetary Fund lacks a way to bring debtors and creditors together to work out a way to cut repayments. It is time for a legally-binding agreement that will not only suspend debt repayments for the duration of the crisis, but also provide for a comprehensive debt reconstruction and resolution mechanism. We need also to strengthen resource mobilisation by ensuring that multinational companies cannot hide their revenues from places where profits are made. If we do not find the money for essential services, we will all pay a much higher price.

End stigma and discrimination

Punitive laws are hurting countries’ ability to end AIDS

 Human rights are central to effective pandemic preparedness and response. When people fear the state, many will hide from it. When they fear public shaming, many will seek to prevent themselves from being seen, and will be marginalised. Gay men, men who have sex with men, transgender women, sex workers, and people who use drugs face a risk up to 35 times greater of acquiring HIV.

Punitive laws are hurting countries’ ability to end AIDS. In countries whose laws criminalise them, men who have sex with men are put at twice the risk of acquiring HIV compared to countries which do not. This applies even when such laws are not operationalised into arrests.

The ability of communities to protect themselves depends on their ability to exercise their human rights. Progress has been fastest when countries have not only repealed stigmatising laws but enacted human rights protections. In times of crisis, some in power have shown a tendency to treat human rights as “in the way” of the response. But the evidence is clear: human rights are not only intrinsic, but they are also the very means by which governments can successfully beat a pandemic. We will beat COVID, beat AIDS, and be safely prepared for the pandemics to come while – and indeed by – valuing the rights and dignity of every person.

Support community-led, people-centred infrastructure

 HIV treatment coverage has grown much faster where governments have allowed community-led organisations to deliver it. It has also been more resilient to disruption. During the pandemic, teams successfully delivered anti-retrovirals and TB medicines to people’s homes or drop-in centres in Eswatini in Kenya. Civil society groups have delivered condoms, lubricants, and HIV testing kits.

But such networks, critical for effective pandemic response, and too often overlooked, neglected or pushed aside.

Communities, who know the situation on the ground and have the essential relationships of trust, need be given the resources and the space to lead. Countries need to ensure an enabling environment for communities to be involved in providing services as an integral part of the public health response, be involved as co-planners, be able to highlight experiences and concerns and be able to play their essential role ensuring accountability. Countries need to lift those legal, policy and programmatic barriers that hold this back, and to scale up financial support to unleash the incomparable contribution of communities.

So too, while the international community often responds to crisis by establishing new mechanisms, it is imperative to leverage existing experience, networks, and capabilities, including especially those of communities. The evidence is clear that the systems built to fight the AIDS pandemic and other disease outbreaks have been among the most effectively-mobilised response mechanisms to fight COVID.  And yet some voices in Northern governments are floating new parallel systems. A more effective approach will be to build for the pandemics of today and tomorrow together.

History provides hope, but our future depends on courage

We know, from the evidence, what will work in beating pandemics: shared science, strong services, and social solidarity; plus supporting community leadership to enable all these. We know too that we can only succeed in these together, worldwide.

It has often been in times of crisis that leaders have found the opportunity to make long-overdue transformative change

Indeed, world leaders have even promised such an approach. At the United Nations General Assembly High-Level Meeting on HIV/AIDS in June last year, member states adopted a bold new plan that affirmed that they would end the AIDS epidemic by ending the inequalities which drive it.

And in some places we are seeing the bold action needed and the transformative progress against AIDS that many had believed impossible. These prove that it can be done, and guide us in what we need to take to scale worldwide.

One hopeful lesson from history is that it has often been in times of crisis that leaders have found the opportunity to make long-overdue transformative change. With growing attention to the ways inequalities drive pandemics, we have a window of opportunity in which to build rights-based, human-focused responses to save millions of lives, beating the pandemics raging today and building a pandemic-resilient for the future. But this is possible only if leaders seize that opportunity, by working courageously and together to tackle the inequalities endangering us all.

This post represents the views of the author and not those of the COVID-19 blog, nor LSE. It is based on Winnie Byanyima’s address at the LSE event How to Beat Pandemics: a route map to ending COVID-19, ending AIDS, and keeping safe from the threats of the future.