Preparing for future pandemics while responding to the current ones in the midst of a planetary climate crisis: Can we face this triple global health challenge?

ABSTRACT

Global health faces the triple challenge of preparing for future pandemics while responding to current ones in the midst of a climate crisis. In this commentary, we discuss the heightened focus on pandemic preparedness after the COVID-19 pandemic and the risks that this may pose to addressing the elimination of AIDS, tuberculosis, hepatitis and malaria, established in the Sustainable Development Goals as target 3.3. Considering their interconnections with the climate crisis and advocating for global health justice, we identify impasses that such a dispute over priorities can imply, and comment on four fronts of actions that could contribute convergently to both agendas as well as to facing the consequences of climate change to health: strengthening health systems, global commitment to equitable access to strategic medicines, addressing social inequalities and joining efforts for health and climate justice We conclude that addressing these fronts safeguards the health rights of the most vulnerable to existing epidemics while enhancing readiness for future pandemics. Moreover, solutions must transcend technocratic approaches, necessitating the confrontation of inequalities perpetuated by systems of power and privilege fueling both health and climate crises. Ultimately, health justice should guide responses to this intricate triple global health challenge.

KEYWORDS:

• Pandemic preparedness
• AIDS
• tuberculosis
• climate crisis
• health justice

Introduction

This commentary discusses the emphasis that pandemic preparedness has gained in the field of global health in the wake of the COVID-19 pandemic and the risks that this may pose to addressing another global priority in the realm of communicable diseases: the elimination of AIDS, tuberculosis, hepatitis and malaria, established in the Sustainable Development Goals as target 3.3 (Sustainable Development Goal, Target 3.3: by 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases) (UN, 2015). Taking into account their interconnections with the climate crisis and the need to strengthen the struggles for global health justice, we identify some of the impasses that such a dispute over priorities in the global health field can imply, and comment on four fronts of actions that could contribute convergently to tackling both current and emerging communicable diseases global health justice more broadly.

For centuries, epidemics and pandemics of communicable diseases have afflicted humanity. Before the development of microbiology, when the importance of hygiene measures and treatment of water and waste was still ignored, water-borne diseases (such as cholera and typhoid fever) or those transmitted by vectors present in waste (such as bubonic plague and typhus) prevailed (Bencard, 2021; Sánchez-Vallejo, 2021). Over time, particularly since the industrial revolution, epidemics and pandemics became more frequent, facilitated by advancements in transportation and global trade. Most of the diseases observed since then are transmitted through respiratory, sexual, or vector-borne routes, predominantly mosquitoes. The twentieth century is exemplary in this sense: the first pandemic of that century, the 1918 influenza pandemic, was respiratory transmitted, while AIDS, from its emergence on up to the present, is caused by a virus that is primarily transmitted sexually, HIV. At the end of the second decade of the twenty-first century, humanity was, once again, confronted with a respiratory-transmitted disease that reached pandemic level. Affecting nearly all countries, COVID-19 has caused over 7 million deaths since its classification as a pandemic, in 2020 (World Health Organization, 2024). Besides its direct impact, COVID-19 has had devastating effects on the control of other communicable diseases, including some of the listed under SDG 3.3, such as tuberculosis and AIDS (The Global Fund, 2021).

The health, humanitarian and socioeconomic catastrophe left by COVID-19 is widely acknowledged (Sirleaf & Clark, 2021). Beyond the effects of the disease itself, such catastrophe was also a result of a global response marked by a blatant lack of global solidarity, where wealthy nations rushed to purchase all stocks of protective equipment and vaccines, leaving entire populations unprotected, precisely in regions where health systems were more fragile (Parker, 2023). In the aftermath of COVID-19, there is a strong consensus among global health actors around the need to prepare for future pandemics, aligning the United Nations (UN), multilateral agencies, donors, stakeholders, governments and academia. Setting their priorities, funders have established mechanisms to concentrate on this agenda, as evident in initiatives such as the Pandemic Fund, created by the G20 and managed by the World Bank (2022; Gold, 2022), the Coalition for Epidemic Preparedness Innovations (CEPI) and the Strategic Investment Fund from the Gates Foundation (n.d.) for pandemic preparedness in low- and middle-income countries (LMICs). In its turn, the World Health Organization (WHO) established an intergovernmental negotiating body (INB) that, since 2021, is working to develop an international instrument under the Constitution of the World Health Organization to strengthen pandemic preparedness (World Health Organization, n.d.).

At a first glance, the prioritisation of pandemic preparedness on the global health agenda is welcome because planned responses to health emergencies can enable optimal and more equitable use of resources than uncoordinated efforts (Kapiriri et al., 2022). Moreover, the probability of a new health crisis emerging soon is considered particularly high due to the climate crisis, which, in various ways, increases the risks of the emergence of new pathogens or the re-emergence of existing ones (Tong et al., 2021). However, the risk that we want to discuss here is that this agenda may divert attention from other global health priorities, particularly from the communicable diseases that SDG 3.3 aims to eliminate. In our view, this should be a cause of concern for at least four main reasons, discussed below.

The first is the health burden represented by the diseases listed under the SDG 3.3. Combined, the four most prevalent ones – AIDS, tuberculosis, hepatitis and malaria – are responsible for around 4 million deaths every year globally. Tuberculosis is the one responding for the highest number of deaths, and the leading cause of deaths among people living with HIV. Around 1.5 million people die of tuberculosis per year (World Health Organization, 2023), which is similar to the number of deaths caused by AIDS (UNAIDS, 2023) and hepatitis combined, while malaria responds for more than 600 thousand deaths worldwide annually (World Health Organization, 2021). This could be considered a catastrophe comparable to COVID-19, which, as previously mentioned, was responsible for an estimated seven million deaths to date.

The second reason is that the underfunding of the disease elimination agenda is already happening. Over the years, a permanent gap persists between the available and the necessary global budget to fight these diseases, and, although this problem predates COVID-19, it was worsened by the diversion of financial resources from these diseases to combat the pandemic (Tacheva et al., 2022; WHO, 2020). Thus, our warning here is that this gap could increase even more if resources and efforts migrated to the pandemic preparedness agenda. Let's take two examples, starting with AIDS. After decades of increasing investment, in recent years there has been an exodus of funders, who have turned away from the AIDS agenda to focus on other health problems (Coester et al., 2023). The long-term trend shows that AIDS funding is currently below historical levels (Wexler et al., 2023) and the gap between the available and the necessary resources is widening (UNAIDS, 2023). According to UNAIDS, in 2022 the total available funding for HIV programmes in LMICs was US$ 20.8 billion – 2.6% less than in 2021 and way below the US$ 29.3 billion that the agency estimates to be needed by 2025 to reach the global goals (UNAIDS, 2021). The agency highlights that this gap is holding back the AIDS elimination agenda (UNAIDS, 2023), which, according to its definition, would be reached when 95% of the estimated population living with HIV are tested, 95% of those diagnosed are treated and 95% of those have suppressed viral load. Leaving aside possible disagreements about what should be considered as indicators of AIDS elimination (Assefa & Gilks, 2020), if there is, as UNAIDS affirms, a clear path to end AIDS that some countries are following with success, there is not a clear path to how the necessary funding will be mobilised to overcome the historical and current budget gap.

The second example is tuberculosis, for which the most recent data was released at the end of 2023 (World Health Organization, 2023). Estimated financing needs are between US$ 15–32 billion per year in LMIC (Stop TB Partnership, 2023), including funding for the development and implementation of a new TB vaccine after 2027. The political declaration adopted at the second UN High-Level Meeting on TB, held in September 2023, included funding targets to mobilise US$ 22 billion per year by 2027 for TB diagnosis, treatment and prevention services and US$ 35 billion per year by 2030 (UN, 2023). Funding currently available for TB in LMICs falls far short of globally estimated needs and UN global targets, and it has been declining since 2019. In 2022, the total was just US$ 5.8 billion. This represents less than half of the budget estimated to be necessary in 2022 according to the Global Plan (2018–2022) as well as the global target established at the UN High-Level meeting on TB in 2018 (World Health Organization, 2023).

The third reason for concern is around what will be funded under the umbrella of pandemic preparedness, since defining what pandemic preparedness entails has proven to be challenging (Belfroid et al, 2020). Although flexibility is important when preparing for unknown diseases, the lack of consensus around the core elements of this agenda may lead to uncoordinated efforts within and between countries. In that sense, a study of pandemic preparedness plans from European countries regarding influenza found that the divergences among them could impede their interoperability (Holmberg & Lundgren, 2016). After the global sanitary crisis caused by COVID-19, the World Health Organization (WHO) launched the ‘Preparedness and Resilience for Emerging Threats Initiative’ (PRET) (World Health Organization, 2022a, 2022b), and proposed focusing preparedness on modes of transmission rather than specific diseases. Based on the experience of previous and current pandemics, the main risk we anticipate from such fluid definitions is that actions taken under the umbrella of pandemic preparedness led by the global health industry (Parker, 2023) will prioritise biomedical and epidemiological components and overlook the political and social dimensions of addressing communicable diseases.

Finally, the fourth reason we should pay attention to these two agendas is because the climate crisis threatens to worsen the situation for both. The intersections between climate crises and communicable diseases manifest across multiple dimensions. For example, increasing temperatures and rainfall alter ecosystems and can facilitate the emergence of new pathogens (El-Sayed & Kamel, 2020). Socio-environmental disasters contribute to food insecurity and forced migratory flows, which can increase the vulnerability of large populations both to emerging communicable diseases as well as to TB, AIDS, hepatitis and malaria (Kharwadkar et al., 2022; Kulkarni et al., 2022; Li & Managi, 2022; Lieber et al., 2021; Maharjan et al., 2021). Such disasters can also make it difficult for people to access necessary treatments, either because of migration or due to changes in the landscape and transportation needed to access health facilities (Chrispin, 2023). Moreover, the emergence of new communicable diseases along with the increase of existing ones can add an unsustainable burden to health systems, which could be at risk of collapsing without the necessary resources (Chrispin, 2023).

In this intricate scenario, we identify two challenging yet crucial endeavours. The first is quite obvious and is at the core of the struggles of those committed to eliminating TB, AIDS, malaria and hepatitis: the global agreement around this priority needs to be followed by the necessary funds to implement it. The second endeavour, which we will discuss more thoroughly, is to find ways to align pandemic preparedness with SDG 3.3 with a focus on global health justice. For this, we should not focus on the particularities of each disease, but rather on structural actions that strengthen responses to all of them. Without the ambition to provide definitive answers to such a major challenge, in the next section we will comment on four fronts that we consider strategic in order to advance in this direction.

Strengthening health systems

The COVID-19 pandemic has evidenced the importance of robust, universal health systems to face sanitary crises. Similarly, there is widespread acknowledgment that the most effective approach to addressing HIV, hepatitis and TB involves coordinated, joint responses (World Health Organization, 2021), steering clear of vertical programmes (Assefa & Gilks, 2020).

Focusing investments and efforts on strengthening health systems is important precisely because it avoids the struggle to prioritise certain diseases over the other. Moreover, ensuring that health systems have adequate conditions to prevent and treat HIV, tuberculosis, malaria and hepatitis not only respects the right to health of those already affected by these diseases but also builds capacity within health systems to deal with communicable diseases more broadly. This contributes to preventing systems from being overwhelmed when a sanitary crisis arrives, and strengthens their ability to absorb the impact of crises, adapting to the emerging health needs while maintaining their essential functions and characteristics (Fridell et al., 2020; Haldane et al., 2021).

Although it is complex to determine the actions needed for building and maintaining strong, universal health systems, some of the key elements that require investments can be identified in the literature (Fridell et al., 2020; Thomas et al., 2020):

• Leadership and governance to implement strong health plans and evidence-based policies. Governance should be planned at various, decentralised levels and with community participation. Accountability, transparency and equity are key principles and efforts should be made to ensure that they continue to be respected during crises;

• Adequate funding, with effective financial resource allocation, using diverse and stable financial resources and minimising out-of-pocket expenditures;

• A well-maintained infrastructure, and a reliable supply of medical products, vaccines and technologies;

• Properly supported and trained workforce, which means having an adequate capacity to respond to both routine and exceptional demands during crises, with fair salaries and suitable working conditions;

• Organised information systems, ensuring the continuous collection of data, their use to guide the responses to the current diseases and to prepare for the risk of emerging ones, and their rapid dissemination and use during emergencies;

• For those countries with available funding and scientific and technological capacity, investment in R&D to reduce dependence on health goods produced by other countries.

Global commitment to equitable access to strategic medicines and other health products

This topic could be a part of the previous one, since access to medicines and other health products is a critical part of well-functioning health systems (Fridell et al., 2020). However, we choose to address it separately to shed light on one of the important lessons that COVID-19 has taught us: the need to improve global health governance mechanisms that are capable of ensuring justice and equity (Parker, 2023).

Globally, nearly 2 billion people have no access to essential medicines (Ozawa et al., 2019), a major global health issue that was exacerbated during the COVID-19 pandemic. While it is evident that the unequal distribution of protective equipment and vaccines (Garber et al., 2020; Tatar et al., 2021, 2022) was a result of power inequalities that allowed rich countries to stockpile supplies while LMICs were faced with extreme shortages (Parker, 2023), the solutions that are currently being recommended to avoid such shortages are mainly technological ones: investment in local production, forming regional cooperation mechanisms, reducing intellectual property barriers (Seventy-fourth World Health Assembly, 2021) and promoting technological transfer of particular technologies (Gostin, 2023).

These are certainly important initiatives and have been proven critical in the fight of other communicable diseases. The AIDS response in Brazil, for instance, exemplifies how combining them can ensure access to treatments that were deemed impossible for LMICs (Parker, 2023). Nevertheless, they will be insufficient if they are not combined with initiatives aiming to address the power imbalances between countries that led to the injustices observed during COVID-19 pandemic and that continue to allow individuals in impoverished nations to die from diseases long conquered in affluent countries, Such imbalances can only be rectified through the establishment of a robust global governance structure committed to promoting health justice and equipped with mechanisms explicitly designed to redress them (Parker, 2023).

Addressing social inequalities

The relationships between epidemics and social inequalities are widely documented and globally recognised as one of the main limitations to achieving SDG 3.3 (World Health Organization, 2021). Social inequalities not only affect the distribution of infectious diseases but also the course of the disease in those affected (Benita et al., 2022). The most marginalised, vulnerable and underserved populations, who face the highest rates of infection, often have the poorest access to services. This was observed in the case of past pandemics, such as influenza in 1918, and is widely demonstrated in the case of AIDS, TB, malaria and hepatitis, and was also documented in the case of COVID-19 (Benita et al., 2022; Mishra et al., 2021), indicating that future pandemics will also follow the path of social fissures.

All diseases included in SDG 3.3 – AIDS, tuberculosis, hepatitis and malaria – have well-known modes of transmission, as well as effective prevention and treatment methods. However, they persist at epidemic or endemic levels largely due to social inequalities that prevent everyone from having access to such methods, according to their needs and in a timely manner (Fauci & Lane, 2020). This proves that only technological and biomedical solutions will not be enough to eliminate them or prepare us for the next pandemics. It also highlights that investing in tackling the inequalities that determine the diseases prioritised in SDG 3.3 is fundamental both to immediately guarantee the right to health for those most vulnerable, respecting the principle of equity, and to prevent new pandemics from spreading disproportionately between segments of the most marginalised members of the population and further deepen inequalities, as occurred during the COVID-19 pandemic (Apolonio et al., 2022).

This implies implementing an extensive and intersectoral agenda, ranging from policies to reduce poverty and violence, access to decent housing, protection of displaced people and migrants and rural populations and confronting stigma and discrimination based on gender, race, sexuality, age and ableism, to name a few essential fronts. An example of action in this direction is the creation in Brazil of the Programa Brasil Saudável (Healthy Brazil Programme), which integrates 14 ministries for the multisectoral confrontation of the social determinants of 11 communicable diseases, including those from SDG 3.3 (Brasil, 2024). The guiding principles of the Programme encompass: addressing hunger and poverty to alleviate vulnerabilities stemming from socially determined diseases; promoting human rights and social protection with a focus on vulnerable groups and priority territories; training health workers and civil society to identify and respond to vulnerabilities that condition or result from diseases; and the expansion of infrastructure and initiatives for basic and environmental sanitation. As the Programme was launched on February 2024, it is not possible to evaluate its results yet, but monitoring its progress in the coming years appears warranted. Joining efforts for health justice and climate justice.

Joining efforts for health justice and climate justice The climate crisis is one of the greatest challenges of our time. The intense human activity on the planet based on the capitalist mode of exploration of natural resources has led to changes in the environment that may be irreversible if in the coming years the global temperature increases more than 1.5°C above preindustrial levels, threatening the very conditions that make life on Earth possible (David et al., 2021; Ripple et al., 2020; Robinson & Shine, 2018).

The negative effects of climate change on global health are already evident and can be expected to become even more severe, given that international agreements established to control the crisis are not being adequately enforced (The Lancet Planetary Health, 2023). If the climate crisis threatens to exacerbate both the situation of existing communicable diseases and the risk of new ones emerging, it must be noted that these risks do not equally threaten everyone. Following the same line of thought as discussed above regarding epidemics and pandemics spreading through social fissures, the negative consequences of climate change disproportionately affect marginalised populations and developing countries(Porter et al., 2020; Rouf & Wainwright, 2020). Therefore, if actions to control these crises are not taken in a coordinated manner with a focus on social justice, a catastrophic synergistic effect is expected to befall the most vulnerable populations on the planet, characterising what some authors have termed as ‘eco-pandemic injustice’ (Powers et al., 2021).

In this scenario, approaches such as One Health (Adisasmito et al., 2022) and Planetary Health (Moysés & Soares, 2019), i.e. those that recognise the interdependence of and aim to optimise the health of people, animals and ecosystems, are important guides for thinking about health in the post-COVID-19 pandemic scenario (Gostin, 2023). However, it is important to note that, if uncritically applied, these methods can result in scientistic and depoliticised approaches that obscure capitalism's responsibility for the climate crisis, ignore the role of social inequalities in the distribution of its negative impacts and even propose solutions that reinforce the instrumental relationship with nature and the living world that is the very cause of the crisis (Biehl & Ong, 2018; David et al., 2021).

It is in this sense that we emphasise the need for actions to prepare for future health emergencies and address the diseases listed in SDG 3.3 to be considered within the framework of health justice aligned with climate justice (Guinto et al., 2022; Robinson & Shine, 2018; Rouf & Wainwright, 2020). This requires addressing issues of power and privilege that disproportionately threaten the lives of marginalised people, as well as envisioning solutions that take into account the need to protect the lives of other animals and ecosystems, in the direction of a biocentric solidarity (Tomasini, 2021). This implies, for instance, integrating into these agendas the claim that affluent nations of the Global North, who have historically contributed the most to carbon emissions, honour the agreements set forth on the international stage and implement robust measures to achieve zero emissions by 2050. Additionally, pressuring for financial assistance from these countries to address the losses and damages experienced by climate-affected developing countries and the most vulnerable communities, including addressing the health repercussions thereof (Guinto et al., 2022). Once again, a robust global governance structure committed to principles of health and climate will be key to address these aspects.

Final remarks

The coming years will be pivotal in tackling AIDS, TB, malaria and hepatitis, as well as in confronting emerging health threats, amidst the backdrop of profound climate changes that are anticipated to trigger severe health crises, particularly in the world's most vulnerable regions. This scenario reinforces the need to coordinate efforts and to ensure adequate resources to respond to current and emerging communicable diseases, bringing in new funds and avoiding the diversion of resources from one agenda to the other. The failure to do so may have devastating consequences to global health, rolling back decades of progress achieved through years of work and investment in the realm of communicable diseases.

Aware that there will be no easy solutions to these crises, in this commentary we aimed to contribute by identifying structural, convergent interventions that can be strategic to strengthen both the disease elimination and the pandemic preparedness agendas. These include investing in health systems, developing global governance mechanisms to ensure equitable access to medicines and health products, addressing social inequalities as part of public health policies and through the implementation of an extensive, intersectoral agenda, and joining efforts for health justice and climate justice.

By doing so, we aim to convey two main messages in this commentary. The first is that the next pandemics will present challenges similar to those posed by the current ones. Therefore, by investing in improving responses to AIDS, hepatitis, malaria and TB, besides caring for the most vulnerable and contributing to the elimination of these diseases, we will be synergistically investing in preparing for potential future pandemics. The ability of global health actors to engage with the SDG 3.3 agenda will serve as a good indicator of their commitment to the world's most vulnerable populations.

The second message is that there will be no purely technocratic solutions to this triple crisis. The challenges of existing or potential communicable diseases require addressing the inequalities produced by systems of power and privilege that contribute to both the health and global climate crises. Thus, the ideal of health justice aligned with climate justice will be fundamental guides in constructing responses that tackle both programmatic and structural determinants of this triple global health challenge.

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