By Mike Frick and Mark Harrington
The articles in this 30th anniversary issue of TAGline grapple with “pandemic equity,” an increasingly common catchphrase in global health. COVID-19 has shown that “equity,” like its cousins “justice,” “fairness,” and “equality,” is one of those words whose use rises in proportion to its absence in practice. If it feels easier to define its opposite, inequity, that is because inequities have more often been the lasting outcome of pandemic responses — whether to HIV in 1981 or to COVID-19 in 2020.
TAG’s home of New York City has afforded many opportunities to consider pandemic equity, both historically and within our lifetimes. NYC has frequently found itself at the epicenter of pandemic outbreaks, including multiple bouts of cholera in the nineteenth century, smallpox in 1947 (to which the city responded by immunizing 6 million people in five weeks — a striking example of having the right tools in the right quantities at the right time), HIV in the 1980s, multidrug-resistant TB in the early 1990s, COVID-19 in March 2020, and now monkeypox in 2022.
As the articles that follow show, understanding pandemic equity requires looking backward as well as forward to consider both inequities within pandemics and inequities among pandemics and over time. Take, as a starting point, differences between the exceptional response to COVID-19 and the three diseases at the heart of TAG’s work: HIV, tuberculosis (TB), and hepatitis C virus (HCV). As of August 8, 2022, the World Health Organization (WHO) had recorded 6,410,961 deaths from COVID-19 and estimated the full death toll of the pandemic — considering both direct and indirect mortality — at 15 million. Over the nineteenth and twentieth centuries, TB claimed one billion lives — more than smallpox, malaria, cholera, and the relative newcomer: HIV, which has killed 40 million people since the first cases of AIDS-defining illness were reported in 1981. Untold millions have died from HCV before and since its discovery in 1989. That some diseases spark tremendous resolve to bring about their end (COVID-19) while others last for millennia (TB) signifies the greater inequalities plaguing global health.
After three decades of activism at the intersection of HIV, TB, and HCV, we know that pandemic equity cannot be limited to ending COVID-19 or anticipating Pathogen X. Pandemic equity requires addressing pandemics that predated COVID-19 and applying lessons from these ongoing struggles to achieve health for all. The inequities that have defined COVID-19 were predictable to communities of people who have weathered the harshest effects of HIV, TB, and HCV.
- The global vaccine apartheid seen in COVID-19 came as no surprise to HIV activists, who early on recognized vaccine hoarding by wealthy nations in the Global North as a recurrence of the treatment access disparities that marked the years following the advent of antiretroviral therapy in 1996 and have led to millions of preventable deaths from AIDS. Even today, ten million of the world’s 5 million people living with HIV are not receiving life-saving combination antiretroviral therapy.
- TB activists could have told us that early scientific triumphs against COVID-19, most notably the development of mRNA vaccines and oral antiviral therapy with nirmatrelvir/ritonavir (Paxlovid), would not be enough to end the pandemic for everyone. After all, TB research drove some of the biggest advances in twentieth century medical science — the use of serial in vitro passaging to create the BCG vaccine, the invention of randomized controlled trials to study TB treatment, and the antibiotic revolution that followed — yet TB continues to kill more people each year than any other infectious disease, second only to COVID-19.
- And hepatitis C activists, for their part, could have foretold that offering expensive treatment without providing access to diagnosis would leave many vulnerable people without care, as is the case today where millions with HCV lack access to an easy-to- take, two-month, all-oral cure.
In short, activists who have fought for equity in earlier (still present) pandemics have a lot to teach us about current ones.
The articles that follow coincide with the 30th anniversary of TAG’s founding and draw on the past as they look to the future. Dorrit Walsh and Mark Harrington’s closing retrospective (p. 12) covers major TAG milestones over its history.
Cheriko Boone, Abraham Johnson, and Richard Jefferys reflect on the past 40 years of advocacy to make HIV research inclusive and representative of the people living with and affected by HIV in all of their diversity (p. 7). They tally what’s been achieved, how efforts have fallen short, and what’s still needed to ensure that the communities most affected by the HIV epidemic can participate in and benefit from scientific progress — as both study participants and investigators.
Lindsay McKenna’s contribution (p. 4) introduces the 1/4/6×24 campaign, aimed at building the political will to implement one-month or once-a-week TB preventive treatment, four-month drug-sensitive TB treatment, and six- month treatment for drug-resistant TB worldwide. While these shorter treatment regimens have been scientifically validated and recommended by WHO, it’s up to advocates to demand the “staff, stuff, space, systems and support” required to make them available to people with TB by 2024. The 1/4/6×24 campaign, devised by TAG, Partners in Health, and other close allies in honor of the late physician-anthropologist Paul Farmer, harkens back to the earlier 3×5 initiative, which jumpstarted the global scale-up of antiretroviral treatment for HIV.
The “staff, stuff, space, systems, and support” at the heart of 1/4/6×24 add up to what Farmer called “a prescription for global health equity.” Among the “stuff” needed to secure global health are diagnostic tools and essential medicines, discussed in an interview with David Branigan and Joelle Dountio Ofimboudem (p. 10). They analyze the barriers preventing scientific breakthroughs from being used to improve lives and consider future strategies to combat the corporate power and government reluctance that bars access to these technologies. They imagine a world in which rapid, accurate diagnosis is available, affordable, and convenient for all people.
“If everyone has a right ‘to share in scientific advancement and its benefits,’ where are our programmatic efforts to improve the spread of these advances?”
– Paul Farmer, Pathologies of Power: RethinkingHealth and Human Rights, AJPH 1999
Writing in 1999, Farmer laid out a dilemma we’re still contending with as we seek to envision and enact equitable responses to pandemics. He observed that “even as our biomedical interventions become more effective, our capacity to distribute them equitably is further eroded.”
“If everyone has a right ‘to share in scientific advancement and its benefits,’” Farmer asked, “where are our pragmatic efforts to improve the spread of these advances?”
We hope this issue of TAGline provides modest yet powerful examples of such pragmatic efforts, gleaned from our 30 years fighting HIV, TB, and HCV.