'Inequality-pandemic cycle' must be broken to achieve health security
JOHANNESBURG, SOUTH AFRICA, 3 November 2025 - A report by world-leading economists, public health experts, and political leaders released today ahead of G20 meetings, Breaking the inequality-pandemic cycle: building true health security in a global age , shows that inequality is making the world more vulnerable to pandemics.
In landmark findings based on two years of research and convenings around the world, the new report shows that high levels of inequality are linked to outbreaks becoming pandemics and that inequality is undermining national and global responses, making pandemics more disruptive, deadly, and longer in duration. The report also shows that pandemics increase inequality, fuelling a cycle that research shows is visible not just for COVID-19, but also for AIDS, Ebola, Influenza, Mpox and beyond.
Evidence gathered by the experts also shows that "inequality-informed" pandemic responses, alongside actions on inequality taken before pandemics hit, can protect the world from the next global disease crisis more effectively than current preparedness efforts. The report lays out the social determinants of pandemics and actions that can be taken to address them, linked also to communities and multi-sectoral governance. It provides recommendations for global economic policy, and access to affordable medicines. As well as strengthening preparedness for future pandemics, the proposals in the report can also help decisively end existing health crises, such as HIV, tuberculosis and Mpox.
Co-chaired by Nobel laureate Joseph E. Stiglitz, former First Lady of Namibia Monica Geingos and renowned epidemiologist Professor Sir Michael Marmot, and convened by UNAIDS, the Global Council on Inequality, AIDS and Pandemics report distils practical steps toward that governments can take, redefining "health security."
The new findings arrive as G20 Health Ministers prepare to meet amidst reports of new and growing outbreaks internationally of Avian Flu and Mpox, and as breakthrough HIV prevention drugs are being approved by drug regulators.
Monica Geingos, Former First Lady of Namibia said: "Inequality is not inevitable. It is a political choice, and a dangerous one that threatens everyone's health. Anyone concerned with pandemics and their impact must be concerned with inequality. Leaders can break the inequality-pandemic cycle, by applying the proven policy solutions in the Council's recommendations."
Professor Sir Michael Marmot, Director, UCL Institute of Health Equity said: "The evidence is unequivocal. If we reduce inequalities-including through decent housing, fair work, quality education and social protection-we reduce pandemic risk at its roots. Actions to tackle inequality are not 'nice to have'; they are essential to pandemic preparedness and response."
Joseph E. Stiglitz, Nobel Laureate in Economics said: "Pandemics are not only health crises; they are economic crises that can deepen inequality if leaders make the wrong policy choices. When efforts to stabilize pandemic-hit economies are paid for through high-interest on debts and through austerity measures, they starve health, education and social protection systems. Societies then become less resilient and more vulnerable to disease outbreaks. Breaking this cycle requires enabling all countries to have the fiscal space to invest in health security."
Winnie Byanyima, UNAIDS Executive Director and United Nations Under-Secretary-General said: "This report shows why leaders urgently need to tackle the inequalities that drive pandemics, and it shows them how they can do this. Reducing inequalities within and between countries will enable a better, fairer and safer life for everyone."
The report arrives as South Africa's G20 presidency reaches its climax. In a challenging period for multilateralism, rising insecurity and faltering progress on socio-economic development, the Council's recommendations align with South Africa's efforts to centre this year's G20 discussions around the theme "Solidarity, Equality, Sustainability".
The inequality-pandemic cycle
Over the last two years, research conducted and reviewed by the Global Council has revealed an inequality-pandemic cycle: inequality drives pandemics, and pandemics deepen inequality, making future crises more likely, more deadly and more economically damaging.
The research found:
High levels of inequality, within and between countries, are making the world more vulnerable to pandemics, making pandemics more economically disruptive and deadly, and making them last longer; pandemics in turn increase inequality, driving the cyclical, self-reinforcing relationship.
Within countries, intersectional inequality is clearly linked to pandemics. Research by the Global Council shows that more unequal countries have seen significantly higher COVID-19 mortality, higher rates of HIV infection, and higher AIDS mortality as they struggled to mount effective pandemic responses. Another study co-authored by Council members shows that people living in informal settlements (urban "slums") in most African cities studied had a higher HIV prevalence than non-slum dwellers, reflecting multidimensional inequalities including wealth, education, employment and housing. By contrast, more equal contexts are more resilient to pandemics. Meanwhile, IMF data following H1N1 influenza, SARS, MERS, Ebola, and Zika show that pandemics led to a persistent increase in inequality, with a peak of about five years after.
Social determinants of pandemics create underlying vulnerability, enabling viruses and bacteria to thrive. In Brazil, for example, people without basic education were several times more likely to die from COVID-19 than those completing elementary school. In England, living in overcrowded housing was linked to higher mortality rates from COVID-19.
International inequalities between countries globalize pandemic vulnerability. When some countries can respond effectively to an outbreak, but others lack the means to do so, the world is more vulnerable. Insufficient fiscal space in some countries during Ebola and AIDS limited roll out of effective public health interventions and let the viruses spread. During COVID-19, high-income countries spent 4 times more than low-income countries to address the pandemic's effects. Unequal access to medicines and vaccines allowed preventable infections in HIV, COVID-19, and Mpox, which has been linked to the rise of variants and resistant strains.
Failure to tackle key inequalities and social determinants since COVID-19 has left the world extremely vulnerable to, and unprepared for, the next pandemic.
Since the start of the AIDS pandemic, income inequality has grown to high levels in most countries and remained. The COVID-19 pandemic pushed 165 million people into poverty while the world's richest people increased their wealth by more than a quarter. Social inequalities on gender, sexuality, ethnicity, and key population status intersect with the economic. Women, informal workers, and ethnic minority groups for example, experienced the largest employment and income shocks in COVID-19. Choices between feeding one's family and following advice to stay home undermined public health. Yet pandemic preparedness efforts largely do not account for this in future outbreak plans.
Despite lower COVID-19 spending, developing countries find themselves suffocating under $3 trillion in debt, with more than half of low-income countries either in debt distress or at high risk of it. Debt repayments crowd out spending on today's pandemics and preparation for tomorrow's, yet recent efforts to manage debt troubles created by COVID-19 failed to deliver significant results. Meanwhile, the world still lacks clear surge funding structures to support pandemic response and address the economic impact during pandemics.
As new breakthrough pandemic technologies like long-acting HIV prevention shots arrive in high-income countries, there remain major barriers to sharing these technologies for sustainable production and affordable access in much of the world.
Insufficiently rapid action on today's pandemics and outbreaks like AIDS and TB sustains the cycle.
As pandemics increase inequality and undermine global capacity to respond next time, it is deeply worrying that AIDS remains a pandemic; together with TB and malaria it continues to cause millions of deaths, disproportionately in low- and middle-income countries and among marginalised groups in high-income countries. Despite progress-new HIV infections fell to their lowest level since 1980 by end-2024-rapid donor withdrawal in 2025 threatens gains and leaves the most vulnerable behind.
- There is clear evidence the cycle can be interrupted. A new approach to health security is needed that is capable of interrupting this cycle with practical and achievable actions on the social and economic determinants of pandemics at both national and global levels. The Council calls for a new PPR approach:
- Inequality-informed responses during a pandemic, which take account of existing inequalities and respond with evidence-based polices to counter their effects.
- Preparing for future pandemics by reducing inequality in specific, actionable areas shown to be driving vulnerability to disease.
Four recommendations to break the inequality-pandemic cycle
1. Remove the financial barriers in the global architecture to allow all countries sufficient fiscal capacity to address the inequalities driving pandemics.
During a pandemic, including AIDS today: As a first step, call for an urgent debt repayment standstill for distressed countries to 2030. Pair that with new standby pandemic financing facilities that include automatic issuance of IMF Special Drawing Rights.
To make the world safer from future pandemics: Decisively reorient the International Financial Institutions, directing them to end approaches to financial assistance that encourage pro-cyclical austerity policies and to address the underlying structural flaws that lead to insufficient fiscal space to reverse inequalities and to stop pandemics.
2. Invest in the social determinants of pandemics. Use social protection mechanisms to reduce socioeconomic and health inequalities and build societal resilience in order to prepare for, and respond to, pandemics.
During a pandemic, including AIDS today: Surge social protection during health crises through a ready system, with particular attention to the most vulnerable, as part of a broad outbreak response going beyond just the health care sector to include, for instance, housing, nutrition, and other determinants of health.
To make the world safer from future pandemics: Make societies healthier and stronger with strategic action on the social determinants of pandemics, which cause broad health inequalities and increase vulnerability to pandemics when they occur.
3. Build local and regional production alongside a new governance of research & development capable of ensuring the sharing of technology as public goods needed to stop pandemics.
During a pandemic, including AIDS today: Put far more serious global funding behind coordinated regional production for the pandemics of today like HIV and TB to create the pull-mechanism for technology transfer and institute an immediate waiver of intellectual property on pandemic related products.
To make the world safer from future pandemics: Automatically waive global intellectual property rules on pandemic technology when a pandemic is declared. Create a R&D model for the long term that treats pandemic health technology as public goods, using innovative mechanisms like prizes instead of patents, increasing funding and expanding Southern-led efforts.
4. Build greater trust, equality, and efficiency in pandemic response by investing in multi-sectoral response and community-led pandemic infrastructure in partnership with government.
During a pandemic, including AIDS today: Shift funding and measurement of pandemic preparedness and response to include community-based and -led organizations to reach those unreached by public and private health services. This should accompany, not replace, universal public services.
To make the world safer from future pandemics: Establish multi-sectoral governance structures for pandemic response that include multiple ministries as well as community-organizations, rights groups, and scientific leadership.
The Council will use the findings of the report to guide engagement with the G20, with international financial institutions and with health leaders.
The world needs a pandemic prevention, preparedness and response approach capable of interrupting the inequality-pandemic cycle. Failing to do so would lead to devastating consequences. Concrete actions can be taken to tackle inequality that can protect the world from the next global disease crisis and help decisively end existing ones.
