Persistent health inequalities around the world mean that people in poverty are consistently the hardest hit by disease outbreaks such as the COVID-19 crisis.
The unequal impact of COVID-19 is being felt the world over: it’s seen in the differences between richer and poorer countries, and in the differences between richer and poorer communities within countries too.
But we knew this prior to the pandemic: when the world’s health is in danger, the poorest and most vulnerable suffer most, but get treated last.
Take the HIV/AIDs epidemic in the 1980s, for example. The development of treatment options — such as a combination of three different antiretroviral drugs taken together that was approved and advanced in 1996 — did not immediately signal a global, equitable improvement for everyone suffering with the disease.
Mortality and hospitalisation rates fell dramatically in countries and communities where those treatments became available: in 1997 the death rate for HIV/AIDs dropped by 50% in the US, for example; and, for the 23 years since then, HIV/AIDS has completely dropped off the list of the 15 leading causes of US deaths.
But it remained the leading cause of death in Africa until 2017 and it remains a major public health issue. By 2018, it was estimated that 68% of all people living with HIV reside in sub-Saharan Africa.
It’s a lesson in extreme health inequality that the world can’t afford to repeat as scientists race to develop COVID-19 testing, treatments, and vaccines.
We spoke to some health experts to learn more about health inequalities globally, how they come about and impact people’s lives, and how we can take steps now to help solve the problem.
“Put simply, health inequality means different health outcomes for different people, and some sections of society suffering poorer outcomes — normally as a result of them not having the same access to health services, or health services not being adapted to their needs,” Louise McGrath, the director of programmes at a leading UK health NGO, the Tropical Health and Education Trust (THET), told Global Citizen.
“It can also be a result of underlying social circumstances, such as being prone to ill-health due to not having adequate nutrition, not being able to afford to travel to a health facility, or not being able to afford the cost of receiving health care,” she added.
McGrath’s work at THET involves setting up partnerships between hospitals, and other institutions in the UK, and health organisations in low- and middle-income countries. The aims of the collaborations include identifying aspects of the world’s health systems that need improving and empowering countries to learn together from each other’s health systems.
In low- and middle-income countries people often pay out of pocket for health care, even at public hospitals, McGrath explained. Provision can also be patchy within countries — it might be easier to access a high quality hospital in a city, for example, than it would be in a rural area. Meanwhile, information about what health care is available is sometimes lacking, meaning people often don’t seek treatment even when they could, she said.
Even when public health messaging does break through, poorer communities still face additional challenges when it comes to following health advice.
During the COVID-19 crisis, for example, people living in poverty have found it harder to take preventative measures to avoid contracting the disease. Staying home to minimise contact with others is impossible if going out to work every day is essential for survival, while frequent hand washing isn’t an option if there is no access to clean water.
COVID-19 also poses a severe threat to people living in conflict zones or in crowded refugee camps — people who are among the world’s most marginalised — according to the UN Refugee Agency (UNHCR).
Over 80% of the world’s refugees and nearly all the world’s internally-displaced people are hosted in low- and middle-income countries, the agency reported, and limited access to water, sanitation systems, and health services increases their vulnerability to the virus.
Kathryn Bolles, associate director for health and nutrition at Save the Children, told Global Citizen that children growing up in extreme poverty are faced with huge obstacles for survival when it comes to avoidable health problems and preventable disease.
“We know that the most marginalised children — often in areas of conflict, deprivation, and those in the poorest areas of a community or country — are the ones disproportionately dying of illnesses that are entirely preventable,” she said.
Save the Children works on providing health care and immunisation programmes that protect children from these preventable diseases.
Bolles points to the huge progress made on reducing deaths from malaria, diarrhoea, and newborn illnesses in the past 20 years — diarrhoea, for example, is the second-highest cause of death for children under five in the world, but the total annual number of deaths decreased by 60% between 2000 and 2017.
“We focus on those children because they don’t yet have the foundations they need to survive and thrive,” Bolles says. “We also know that it’s often girls that are more marginalised than boys… if a girl has inadequate access to health care, nutrition, and education, she is more likely to grow up to have a child who suffers from poor health too."
While the work being done has led to giant leaps forward on the child mortality rate for 5-year-olds and younger — it fell by nearly 50% between 1990 and 2013 — there is so much more to do, and Bolles believes COVID-19 threatens the progress made.
“What is the impact of COVID-19 going to be like on an already struggling health care system?” Bolles said. “Italy has 40 doctors for every 10,000 people while Senegal has just one doctor for 10,000 people... Bangladesh has a population of 160 million, but only 2,000 ventilators.”
But living in a wealthy country doesn’t necessarily mean being protected from the pandemic, either.
Low-income workers are more likely than their high-income counterparts to be affected by coronavirus because, among other health and lifestyle factors, they are more likely to be in public-facing roles such as transport, social care, and retail — and therefore more at risk.
In the US and the UK, for example, studies have shown that people in Black, Asian, and minority ethnic (BAME) communities have been disproportionately impacted by, and are more likely to lose their lives to, coronavirus.
Even before this pandemic, men from the poorest neighbourhoods in the US could expect to die 15 years younger on average than men from the richest areas due to health inequality. For women the respective gap is 10 years in the US.
Bolles said that the work that’s already been done in strengthening global health systems — from the health facilities available, to community engagement to help get accurate health information circulating — has been shown to have a positive impact and must continue.
But time is of the essence: country projections for both direct and indirect COVID-19 deaths must be looked at, she said, and funding must be invested immediately in strengthening the systems that will struggle to cope with the pressure.
“We can protect the systems now as much as we can by investing in them and advocating within our professional communities and to our governments to do so right now — before things hit, as in, before peak transmissions occur in other parts of the world,” Bolles said.
“We also can’t see routine health care provision stop during this crisis. Even as we face COVID-19, we must continue routine immunisations, because we can’t have an outbreak of measles come at the same time,” she continued. “We must continue to deliver mosquito bed nets [to reduce the risk of malaria] too."
As well as dealing with the pressing issue of COVID-19, Bolles says that every level of care in a wide health system has points that can be strengthened to help deal with future outbreaks “from community engagement to the health facilities.”
McGrath, meanwhile, highlighted the issues of supply and demand for the tools needed to fight COVID-19 — such as the lack of personal protective equipment (PPE) for health and frontline workers that’s been seen around the world throughout the COVID-19 pandemic.
As we saw in the efforts to tackle the global HIV/AIDS epidemic, there is a real and present danger that the tools needed to combat COVID-19, as they become available, won’t reach the world’s marginalised people. Again, we risk seeing a health crisis solved for the wealthy, while those in poverty and in marginalised communities are left behind.
McGrath also mentioned the importance of trusted relationships and partnerships between countries to strengthen health systems globally.
She cited an example at the beginning of the COVID-19 outbreak, where the university King’s College London in the UK, in partnership with health agencies in Somaliland, was able to quickly offer advice to health managers about how to manage the situation — because of a pre-existing working relationship.
“The challenges of reaching everyone with the right health care is to make sure that the health system as a whole functions,” McGrath said. “If there’s a health workforce but there isn’t the equipment to deliver services, or those services aren’t well managed, then it’s going to falter.”
The important thing to do now and in the future, McGrath said, is to ensure all the building blocks fit together.
You can join the movement to help ensure that everyone, everywhere, has access to the tools needed to end the COVID-19 pandemic by taking action to support our Global Goal: Unite for Our Future campaign. Through the campaign, you can urge world leaders to step up funding to ensure the development of tests, treatments, and vaccines against COVID-19; and ensure that these tools reach everyone in the world equally.
