Africa: Why Inequality, Not The Next Virus, Could Be the World's Greatest Pandemic Threat
IAS - International AIDS Society
Council member and human rights activist Richard Lusimbo.
5 August 2026
allAfrica.com
By Melody Chironda
Inequality doesn't just make pandemics worse; it helps create the conditions for them to spread, persist and return
For decades, the world has poured billions into laboratories, surveillance systems, vaccines and emergency preparedness in the hope of stopping the next pandemic. But new research presented at the AIDS2026 conference argues that the single biggest factor determining whether countries survive pandemics is not the strength of their health systems - it's the gap between rich and poor. The findings suggest that unless governments confront deep-rooted inequality, the world will remain vulnerable not only to HIV and COVID-19, but also to Ebola and whatever pandemic comes next.
"Inequality shapes who is exposed to disease, who can protect themselves, who can access medicines and whose lives are treated as urgent."
"Inequality shapes who is exposed to disease, who can protect themselves, who can access medicines and whose lives are treated as urgent," said Muleya Mwananyanda, UNAIDS Director of Communications and Influencing. "It also weakens trust, limits countries' ability to respond and determines whether scientific breakthroughs reach everyone or only those who can afford them."
"The missing piece is inequality... Inequality doesn't simply make pandemics worse; it creates a cycle. Inequality allows outbreaks to spread and become more deadly, and pandemics then deepen inequality, making the next outbreak even harder to control," he said.
The findings build on new research by the Global Council on Inequality, AIDS and Pandemics, which concludes that disparities within countries are a stronger predictor of pandemic outcomes than traditional measures of preparedness. The Council argues that reducing inequality is essential not only for improving responses to HIV, COVID-19 and Ebola, but also for strengthening resilience against future disease outbreaks.
The research, presented at the 26th International AIDS Conference (AIDS2026) in Rio de Janeiro, found that countries with higher levels of economic inequality consistently performed worse during pandemics, regardless of how well they ranked on conventional health security measures. The findings challenge the long-held belief that investments in laboratories, surveillance systems and emergency preparedness alone are enough to protect populations during health emergencies.
The Council's analysis has been published in the New England Journal of Medicine, with the full supporting data and background analysis available on the Council's website.
A widening gap
Joseph E. Stiglitz, Nobel Prize-winning economist and co-chair of the Global Council on Inequality, AIDS and Pandemics, said the Council's research shows that inequality within countries has become one of the strongest determinants of how nations respond to pandemics. He said that concentrated wealth weakens public investment, erodes trust in institutions and leaves countries less able to tackle health emergencies.
In his presentation at AIDS2026, Stiglitz said that wealth and income have become increasingly concentrated among a small elite since HIV/AIDS emerged in 1981.
He cited a report he helped prepare for the G20; he said the large majority of countries - home to roughly 90% of the world's population - have now crossed the World Bank's threshold for high inequality. He also cited figures showing the richest one percent captured the overwhelming share of new global wealth in recent years, while the poorest half of the world's population saw almost none of the gains.
"When a pandemic hits, inequality undermines trust and social cohesion... and where inequality drives underinvestment in public goods, it weakens our ability to respond."
He argued that when wealth and influence are concentrated among a small elite, policies that could protect public health are often resisted if they threaten economic interests.
That underinvestment, he said, leaves ordinary people more vulnerable to outbreaks, pointing to poor nutrition, inadequate health services, and crowded housing as conditions that inequality worsens and that, in turn, accelerate the spread of disease.
"Inequality is not a fact of nature. It is, in that sense, a policy choice."
He said the Council's research found that countries considered highly prepared under conventional health security measures did not necessarily perform better during the AIDS and COVID-19 pandemics. Instead, he said, more economically equal countries proved more resilient in practice, even when their formal preparedness scores or GDP were lower.
"That should force us to rethink health security," Stiglitz said. "It is not only about hospital beds, laboratories, surveillance systems and emergency stockpiles."
He called for what the Council describes as "inequality-informed pandemic preparedness," arguing that tackling the underlying social and economic conditions that leave populations vulnerable should become a central pillar of global health security.
Stiglitz criticized what he described as a shortfall in public funding for health systems in lower-income countries, arguing that international aid cuts and heavy sovereign debt burdens have left many nations unable to keep pace even as they increase their own health spending. He said the problem is not a lack of global capital - trillions of dollars circulate worldwide in search of returns - but a lack of what he called public fiscal space.
Stiglitz also warned that widening financing gaps are undermining the global response to HIV and future pandemics. He said many low- and middle-income countries remain constrained by mounting debt and shrinking international aid, leaving them unable to invest adequately in health systems and preparedness.
"We can do better," he said. "Together with comprehensive debt restructuring, changes in the global financial architecture could help address the AIDS funding crisis and let countries invest against future pandemics."
"What we need is a new inequality-informed vision of pandemic preparedness."
Rethinking pandemic preparedness
Matthew Kavanagh, Director of the Georgetown University UNAIDS Collaborating Center on HIV and Inequality, said the findings challenge long-standing assumptions about pandemic preparedness.
Despite major scientific advances in effective vaccines and long-acting antiretroviral drugs, pandemics continue to cause devastating health and economic consequences. This, he argued, suggests that the current model of preparedness is missing a critical factor.
The Council analysed global data to examine which factors best predicted countries' responses to both HIV and COVID-19. Researchers compared pandemic outcomes with traditional preparedness measures, including the Global Health Security Index, as well as poverty and inequality. According to Kavanagh, countries that ranked highest on conventional preparedness measures, including the United States, the United Kingdom, Brazil and South Africa, did not consistently achieve better pandemic outcomes.
The United States, he said, ranked as the world's best-prepared country on multiple major indices in 2019 and 2021. It was rated the least vulnerable nation on one global infectious disease index, yet suffered a COVID-19 death rate more than double the worldwide average, along with persistently high HIV rates. He said Britain, ranked second in global preparedness, saw comparable shortfalls, and that Brazil and South Africa, each rated the most pandemic-ready country in their respective regions, likewise underperformed during COVID-19. By contrast, he pointed to Mauritius, Ethiopia, Ireland, and Uruguay, countries ranked far lower on preparedness indices, as having mounted notably stronger pandemic responses.
To test what actually explains these gaps, Kavanagh said the council built a global dataset spanning four outcome measures: COVID-19 excess mortality, cumulative COVID-19 infection rates, UNAIDS-tracked AIDS death rates, and HIV incidence, controlling statistically for standard cross-national differences between countries. The results, he said, showed that neither a country's overall preparedness score nor its narrower emergency-response capacity predicted better outcomes on either COVID-19 or HIV/AIDS. Poverty levels also failed to predict how countries performed. Instead, income inequality emerged as the strongest and most consistent predictor of pandemic outcomes.
Each one-point increase in a country's Gini coefficient, a widely used measure of income inequality, was associated with approximately 5.7 additional excess COVID-19 deaths per 100,000 people and a 5% increase in HIV incidence, even after accounting for differences in countries' preparedness.
"Countries with better global health security did not have better COVID mortality rates, had worse COVID infection rates, and did not have better HIV responses," he said.
Kavanagh said the finding reinforces the council's central claim: that inequality within a country creates conditions that make outbreaks spread faster, persist longer, and exact a steeper human and economic toll - and that pandemic-readiness frameworks need to be rethought accordingly.
Lessons from HIV for future pandemics
Speaking on behalf of UNAIDS Executive Director Winnie Byanyima, Kavanagh said HIV must remain central to discussions on global health security, arguing that AIDS is still a pandemic and that many of the interventions needed to end it are the same ones required to prepare for future outbreaks. He said governments should broaden pandemic preparedness beyond health infrastructure by addressing inequality and embedding social protection measures into emergency plans.
He said the Global Council's research demonstrates that many of the actions needed to end AIDS are the same ones required to strengthen preparedness for future outbreaks. Kavanagh said governments have invested in pandemic treaties, surveillance systems, and emergency response capacity, but they are failing if they do not address inequalities.
"AIDS remains a pandemic," Kavanagh said. "What we need to fight AIDS, to end AIDS, is also what we need to be pandemic prepared for the next outbreak."
He said overlapping disease outbreaks further illustrate why pandemic responses cannot be developed in isolation. Pointing to the Democratic Republic of the Congo, where Ebola outbreaks have occurred in areas with high HIV prevalence. Kavanagh said health emergencies often intersect, placing even greater pressure on already vulnerable communities. According to Kavanagh, governments should strengthen social protection programs, expand access to healthcare, and ensure people are not forced to choose between their health and earning a living during outbreaks in order to reduce inequality.
"No one is arguing that laboratories are not essential. No one is arguing that health workers are not fundamental to the response. They are necessary, but clearly they're not sufficient," he said. "Countries have to be able to assess the inequalities they have, how they are likely to inform what happens when a pandemic hits. They need to work to reduce those inequalities as part of pandemic preparedness."
Kavanagh said practical measures such as paid sick leave, unemployment support and direct cash transfers should be built into pandemic preparedness plans so that people living in poverty are not forced to choose between protecting public health and putting food on the table.
Kavanagh said governments also need to address the structural policies that fuel inequality, arguing that reducing pandemic risk requires reforms well beyond the health sector.
Echoing Stiglitz, he said inequality is the result of policy choices rather than an unavoidable reality. He called on countries to close tax loopholes, tackle tax havens and support a fairer global tax system to generate the public resources needed to strengthen health systems and prepare for future pandemics. Kavanagh also urged governments to invest in regional manufacturing capacity for new vaccines, medicines and other health technologies, saying local production would improve countries' ability to respond rapidly when the next pandemic emerges.
"All of these are pandemic preparedness, and yet they are largely missing," he said.
He warned that the world risks becoming even less prepared for future outbreaks as HIV programmes and community systems are weakened while broader pandemic preparedness efforts fail to incorporate the lessons learned from the AIDS response.
"We have two problems," Kavanagh said. "One, what's happening in HIV is that we are dismantling these capacities. And two, other pandemic preparedness measures don't include them... So that means we are potentially more vulnerable and less prepared for a pandemic than we were before COVID-19 hit. And that should worry us all."
Innovation without access
The Global Council also identified unequal access to health technologies and weak social protection systems as major factors driving the link between inequality and poor pandemic outcomes.
Council member Nisia Trindade, senior researcher at Fiocruz and Brazil's former Minister of Health, said scientific advances alone are not enough to protect populations if access to new medicines and vaccines remains unequal. She warned that international patent rules continue to limit many low- and middle-income countries' ability to build the research, manufacturing and production capacity needed to respond rapidly during health emergencies.
"If you have scientific and technological development without the process of considering the impact of inequalities, the inequalities increase a lot. This is what happened with HIV/AIDS, COVID-19 and so on," Trindade said. "Science gives us results like vaccines. But if we do not focus on the problem of inequality, we have innovation without access."
Spain's Secretary of State for Health and Council member Javier Padilla Bernáldez said the research also highlights the importance of addressing the social conditions that shape people's vulnerability during health emergencies. He argued that pandemic preparedness must extend beyond healthcare systems to include social protection measures that help people weather economic shocks and guarantee access to essential health services.
"Once pandemics arrive in a society, people need a guarantee that they are going to survive even if they cannot go to work," Padilla said. "We should be taking a look at universal public services, especially universal health coverage. We still have in many countries population groups that are not provided health coverage."
Communities are the missing link in pandemic preparedness
Ugandan human rights activist and Global Council member Richard Lusimbo said community-led organisations must be recognised as a core part of pandemic preparedness rather than treated as an afterthought.
"Laboratories may detect a pathogen, but communities detect fear, misinformation, stigma and resistance."
Lusimbo said inequalities determine who can safely follow public health advice, access healthcare and remain connected to treatment during outbreaks. He argued that while laboratories and surveillance systems are critical, communities play an equally important role by reaching vulnerable populations, combating misinformation and building trust.
"Communities operate precisely in those spaces where formal systems are weakest," he said. "During the AIDS response, we have seen that community-led organizations have built trust, identified missing populations, supported treatment and challenged harmful laws. The same lessons apply to Ebola, Mpox, COVID and future outbreaks."
Lusimbo said the research presented by the Council reflects the realities experienced by communities every day, where poverty, discrimination, insecure housing and criminalisation continue to shape people's ability to protect themselves during health emergencies.
He argued that community organisations should be viewed as part of the health system itself, warning that they continue to be overlooked despite being relied upon during crises.
"Laboratories may detect a pathogen, but communities detect fear, misinformation, stigma and resistance," Lusimbo said. "A government may issue public health guidance, but communities translate that guidance into language and action that people understand."
Lusimbo said the Uganda Key Populations Consortium is an example of community-led emergency response mechanisms that have provided support to victims of violence, eviction, medical emergencies and legal threats, and community information systems that documented service gaps and human rights violations in real time.
However, he warned that cuts to HIV funding are placing many of these organisations at risk at a time when they are needed most.
"Communities must not be treated as an optional addition to the health system. They are part of the health system," he said.
He called for governments to formally recognise community-led organisations as part of national pandemic preparedness, provide them with predictable and direct funding, and include them in decision-making processes.
"The next pandemic will test not only our science, but also our relationships," he said.
"When communities are excluded, outbreaks spread in silence. When community organizations collapse, trust collapses with them. But when communities are funded, protected and empowered, they can interrupt inequalities before an outbreak becomes a catastrophe," said Lusimbo. "Communities are not simply beneficiaries of pandemic preparedness. Communities are how preparedness becomes real."
