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Making Sense of Pandemics in a Global Health Crisis

Lesley Doyal, 30 March 2021

Introduction

Since its arrival in the early 1970s, the HIV/AIDS pandemic has killed about 33 million people, while some 37 million are now living with the virus. Most are in the global south and thus far away from Europe. There is neither a vaccine nor a cure. Therapeutic drugs that can facilitate survival have now been developed, but without their continuous use, death usually ensues after a relatively short period. The African continent remains most severely affected, with nearly 1 in every 25 adults living with HIV, making up more than two-thirds of HIV positive people worldwide.

At the end of 2019 the world was faced with a second pandemic – COVID-19 – which has had dramatic implications for broader aspects of global health. No other infectious disease has engendered such rapid changes in human lifestyles over such a brief period of time, with more than 2 million known deaths occurring by February 2021 (Ritchie et al. 2021). Various vaccines have now been developed with vast resources being poured into distributing them, but the technical as well as the ethical and political challenges involved are vast (Nhamo et al. 2021).

Daily new confirmed COVID-19 deaths per million people for United Kingdom, United States, Germany, France, Canada, and India from 1 March 2020 to 22 February 2021, linear scale, Hannah Ritchie et al. (2021).

For the first time in the history of epidemics, there is a reversal of the countries that are most heavily affected. By November 2020, around 1.5 million people were known to have died from COVID-19 but, unlike with HIV, more than 90% of deaths have been in the world's richest countries. The poorer parts of the world have traditionally been the reservoirs of infectious diseases. In this case, however, they have so far fared better than their richer neighbours, although many are now facing a second wave of COVID-19 while continuing to carry a heavy burden of HIV as well as a wide range of other threats to health (Cash/ Patel 2020).

This paper offers an introductory exploration of the relationship between these two pandemics that are harming the bodies and minds of millions of people as well as causing massive damage to the global economy. This is a challenging task as information is sparse especially in the middle- and low-income regions. It is also significant that this essay reflects the work being undertaken at a single moment during a period of rapid and complex biological, economic and social change, the future of which is very difficult to predict.

The pandemics converge

The HIV pandemic first became visible in the US in the late 1970’s, creating a major new focus for medical research. In the early stages, much attention was focused on HIV/AIDS and white gay men among whom this new disease appeared to be concentrated. However, efforts to tackle what was eventually identified as a retrovirus were seriously inhibited by the stigma addressed towards those groups who were affected (Doyal 1995).

As a result, the early years of the pandemic were characterized by the politicization of HIV/AIDS with gay communities and their allies campaigning for further research and more access to services (Altman/Buse 2012). Indeed, many were fighting for their right to access drugs that were still experimental. At the same time, there were extensive demands for the recognition of the human rights of those affected. As it spread around the world, HIV rapidly became the major concern of international health organizations, leading to the creation of UNAIDS as the first agency dedicated to a single disease. In 2001 the UN declared HIV/AIDS a global emergency that demanded “utmost priority”.

By 1987 the first anti-retroviral drugs (ARV’s) had been developed, enabling infected individuals to limit the damaging effects of HIV on their quality of life and to reduce their capacity to infect others. But these therapies were not curative, with AIDS killing those without regular access to the appropriate drugs. The virus continued to spread rapidly around the world, but the distribution of preventive services and therapeutic drugs was extremely unequal, with those in richer countries faring much better than those in the poorest (Doyal 1995). As a result, political struggles continued, with a focus on meeting the needs of all those diagnosed as HIV positive.

ARV’s did make significant progress possible in the fight against HIV. Infections fell by nearly 40% between 2000 and 2019, and HIV-related deaths were cut in half (UN Strategy for Achieving the Sustainable Development Goals by 2030). However, because the drugs did not offer an ultimate cure, 38 million people were still living with HIV at the end of 2019 and around 1.5 million were being newly infected each year. The cost of treatment remained very high and many of those infected still had no access to drugs or were not aware they were positive.

Prevalence, new cases and deaths from HIV/AIDS in the world from 1990 to 2017. For note: The total number of people living with HIV is ten times more than indicated on the Y-axis, Hannah Ritchie et al. (2018).

Donor funding was declining as adequate coverage was achieved for those in the richest countries. The urgency originally attached to HIV began to fade as many in the global north assumed that the problem had been solved. Donor governments, including the United Kingdom, France, Germany and the U.S. in particular, began to reduce their spending in the follow-up to the global financial crisis of 2008 and the rise of right-wing and inward-looking national populism in many parts of the world. A 2019 UN report calculated that by 2030 there would be a shortage of at least 20% in the basic funding needed for HIV services. Hence, any potential for ending the global HIV pandemic had already been compromised when it was put at even greater risk by the emergence of the COVID-19 pandemic.

The first case of what was initially referred to as “pneumonia of unknown origin” was identified in Wuhan, China in November 2019. It spread rapidly, with the first European cases being identified in France in February 2020. By this time the Chinese had passed on the genetic sequencing of this novel virus (SARS-COV-2) which came to be referred to as COVID-19. A massive international research endeavor was initiated with WHO formally designating the spread of Coronavirus a global pandemic in March 2020.

As of January 2021, Johns Hopkins University reported a global total of 2 million deaths, of which approximately 60% had taken place in six countries with the United States continuing to maintain the lead in both case numbers and deaths (Ritchie et al. 2021). Despite having only 4% of the global population and a large proportion of the world’s wealth, the U.S. accounted for 21% of all COVID-19 deaths worldwide and COVID-19 is now the third leading cause of death in the U.S. after heart disease and cancer.1

By contrast, the African region, with a population of 1.2 billion, had recorded about 1.4 million cases and fewer than 35 thousand deaths from the virus. This represents a reversal of the traditional pattern of infectious diseases according to which it is usually the populations of poor countries who are most affected. This lower rate has been attributed to a number of factors including limited reporting, the preponderance of young people in the African region and other low-income countries and the likelihood that life in crowded slums may result in exposure of individuals to a wide range of pathogens making them more resistant to COVID-19 (Cash/ Patel 2020).

Thus, the COVID-19 pandemic presents a threat to the populations of most countries in the world, and its rapid spread means that it is now being declared as an acute health emergency. Not surprisingly, it gained the status of “exceptionality”, previously accorded to HIV, and intense efforts are being made to control it. However, most of these efforts are inward looking domestic initiatives with each country concerned mostly with its own citizens.

How is COVID-19 affecting HIV/AIDS?

A growing volume of evidence demonstrates the degree to which COVID-19 is already affecting the resources available for the prevention of HIV and the treatment of those infected (Chenneville et al. 2020). A recent survey showed that up to 75% of Global Fund-supported programs had already experienced widespread disruptions to HIV, TB and malaria service delivery in particular. The report indicated new challenges to testing and case finding, cancelled prevention activities, and medical and laboratory staff being reassigned to the fight against COVID-19. The Pan American Health Organization (PAHO) recently calculated that around 30% of people tested positive in their region were missing care and that 70% were lacking enough ARV’s for the next two months.2

Turning to sub-Saharan Africa, here too the COVID-19 pandemic is already affecting the HIV response. Local and regional partners that provide vital HIV and sexual and reproductive health services are reporting increased difficulties in reaching people in need. People are not showing up for their substitution therapy and antiretroviral medication, while flights are cancelled, thus blocking the import of ARV’s.

Unfortunately, this is just the tip of the iceberg which is likely to worsen as the pandemics spread. Without regular drugs, those who are already positive will face a reduced quality of life ending in early death. It has been estimated that a 50% disruption in HIV treatment over six months could lead to 300 thousand extra AIDS-related deaths in sub-Saharan Africa bringing the region back to 2011 AIDS-related mortality levels (Jewell et al. 2020). Those who get drugs will be faced with a multiple burden of HIV/AIDS, and possibly TB and/or malaria, which are syndemically associated with HIV infection in many deprived settings. This long-term pharmacotherapy will add considerably to the cost of HIV.

Even in the rich countries there is growing evidence of deteriorating HIV services. In the UK a recent calculation indicated that during the first six months of the pandemic, £210 billion of health expenditure was transferred to COVID-19. Many scientists searching for an HIV vaccine or cure have been moved to work on pharmaceuticals for COVID-19. Less is being spent on community and behavioral preventive strategies. Early in the pandemic, clinics and other medical facilities transitioned to telemedicine, and many health workers were redeployed. A recent Macmillan report estimated that across the UK there are currently around 50 thousand “missing diagnoses” – meaning that compared to a similar timeframe last year, 50 thousand fewer people have been diagnosed with cancer. In 2020, thousands fewer people than in 2019 have started treatment after a cancer diagnosis. In England alone, between March and August 2020, around 30 thousand fewer people had started their first cancer treatment compared to the year before (Macmillan Cancer Support 2020).

Where next?

Many commentators have suggested that this is an important moment in the history of global health on the grounds that we can look forward to a new future constructed on the basis of more progressive and humanitarian values. COVID-19 is assumed to have highlighted the relationship between inequalities in human health and other dimensions of social and economic life that have too frequently been accepted as “normal”. However, any such achievement of a progressive “new normality” will face major challenges (Zakaria 2020).

Before the arrival of COVID19, the global economy was struggling to recover from the major recession of 2007–2008. But economic growth was dramatically curtailed by the impact of COVID-19 itself, which led the global economy to shrink by 4.3% in 2020 – the sharpest contraction since the Great Depression. Virtually every country in the world now has a financial deficit and most health care systems cannot meet the needs of their populations which are already expanding via the increase in non-communicable diseases (NCD’s) as well as the pandemics.

Central to this global health crisis are huge inequalities both between and within countries and these run along the fault lines of existing divisions. That is to say, the socio-economic and geopolitical context has as much to do with the pandemics as the original viruses. Thus, these inequalities will need to be tackled in a context that reflects not just the biological characteristics of the diseases themselves but also the social and economic settings in which they are rooted (The World Bank 2020).

This will be very difficult to achieve at a time when the world is characterized not only by declining financial resources, political rivalries, obstacles to international cooperation, and a relatively powerless WHO but also a lack of overall global governance. Several new vaccines appear to be successful in preventing COVID-19 but their distribution demonstrates the challenges posed in any attempt to achieve equity and equality in this fragmented world. Hence, it is clear that we are not “all in this together”, as is often suggested, and radical social and economic change will be required alongside nuanced and appropriate medicine if a “new and improved normal” is to be achieved for all. In short, we have no idea at present how the competing demands of HIV/AIDS and COVID-19 can be met in either the long or the short term, especially when they are viewed against the increasing crisis of climate change.

Dennis Altman/Kent Buse: ‘Thinking Politically about HIV: Political Analysis and Action in Response to AIDs’, Contemporary Politics, June 2012, 18 (2), 127–140.

Richard Cash/Vikram Patel: ‘Has Covid-19 Subverted Global Health?’, The Lancet, May 2020, 395 (10238), 1687–1688.

Tiffany Chenneville et al.: ‘The Impact of COVID 19 on HIV Treatment and Research: A Call to Action’, International Journal of Environmental Research and Public Health, June 2020, 17 (12), 4548.

Lesley Doyal: ‘What Makes Women Sick – Gender and the Political Economy of Health‘, New Brunswick, 1995.

Britta Jewell et al.: ‘Potential Effects of Distribution to HIV Programmes in Sub-Saharan Africa Caused by Covid-19: Results from Multiple Mathematical Models’, The Lancet HIV, Sep. 2020, 7 (9), 629–640.

Macmillan Cancer Support: ‘The Forgotten ‘C’? – The Impact of Covid-19 on Cancer Care’, Oct. 2020.

Godwell Nhamo et al.: ‘Covid-19 Caccines and Treatments Nationalism: Challenges for Low-Income Countries and the Attainment of the SDGs’, Global Public Health, March 2021, 16 (3), 319–339.

Hannah Ritchie et al.: ‘HIV / AIDS‘, OurWorldInData.org, Nov. 2019.

Hannah Ritchie et al.: ‘Coronavirus (COVID-19) Deaths’, OurWorldInData.org, Feb. 2021.

The World Bank: ‘Social Protection and Covid-19 (Coronavirus)’, 21 April 2020.

Fareed Zakaria: ‘A Pandemic Should be the Great Equalizer. This One had the Opposite Effect’, Washington Post, 16 Oct. 2020.

Lesley Doyal, Making Sense of Pandemics in a Global Health Crisis, CAS LMU Blog, https://doi.org/10.5282/cas-blog/20

Lesley Doyal

University of Bristol

Lesley Doyal is Emeritus Professor of Health and Social Care at the School for Policy Studies at the University of Bristol. She has published widely in the field of international health and health care, with a particular focus on political economy and gender. Her books The Political Economy of Health (1979) and What Makes Women Sick (1995) were both highly influential and received international recognition. Most recently, her research has focused on HIV and AIDS, looking at these issues from political economy, ethnographic, and intersectional perspectives.

Her book Living with HIV and Dying with AIDS: Inequality, Diversity and Human Rights in the Global Pandemic (2013) was acclaimed as the first attempt to offer a global and interdisciplinary approach to life with HIV. She has been a consultant for many organizations, including the World Health Organization, the United Nations Department for the Advancement of Women, the Global Forum for Health Research and the British Council.

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