Isabella Martínez, PhD¹*, Kenji Tanaka, MD, MPH², Amara Ndlovu, MSc³
- Department of Global Health Policy, Instituto Superior de Salud Pública, Madrid, Spain
- Division of Public Health and Epidemiology, Kyoto University School of Medicine, Kyoto, Japan
- Centre for Climate and Health Equity, University of Cape Town, Cape Town, South Africa
Centre for Climate and Health Equity, University of Cape Town, Cape Town, South Africa
*Corresponding Author:
Dr. Isabella Martínez
Department of Global Health Policy
Instituto Superior de Salud Pública
Calle Serrano 120, 28006 Madrid, Spain
Email: [email protected]
Abstract
The global health community is confronted with a threefold challenge: preparing for future pandemics, responding effectively to ongoing epidemics, and mitigating the profound health effects of climate change. This commentary examines the intensified emphasis on pandemic preparedness in the aftermath of COVID-19 and the potential risks such prioritization may pose to existing commitments, particularly the Sustainable Development Goal 3.3, which aims to eliminate AIDS, tuberculosis, hepatitis, and malaria. By situating these epidemics within the broader climate crisis and emphasizing the imperative of health equity, we identify critical tensions that arise when competing priorities intersect. We propose four strategic domains that can advance both pandemic preparedness and epidemic control while addressing climate-related health consequences: strengthening and integrating health systems, ensuring equitable global access to essential medicines, reducing health inequities, and fostering collaborative movements for climate and health justice. We argue that progress on these fronts not only protects the health rights of populations most vulnerable to ongoing epidemics but also enhances resilience against future pandemics. Importantly, we highlight that sustainable solutions must extend beyond technocratic approaches to confront the entrenched social and structural inequalities that perpetuate both health and climate crises. Ultimately, advancing global health justice must remain central to navigating this complex triad of global health challenges.
Keywords: Health system resilience; AIDS; Tuberculosis; Climate change crisis; Equity and justice in health
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Introduction
This article examines the growing prominence of pandemic preparedness within the global health landscape following the COVID-19 pandemic, and the potential risks this heightened focus may pose to another critical global priority in infectious disease control: the eradication of AIDS, tuberculosis, hepatitis, and malaria. These goals are embedded in the Sustainable Development Goals (SDGs), specifically Target 3.3, which commits to “ending the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases, and combating hepatitis, water-borne diseases and other communicable diseases by 2030” (UN, 2015). Considering the interlinkages with the climate crisis and the continuing struggle for health equity, this commentary highlights some of the challenges that arise from competing priorities in the global health agenda. It further outlines four areas of action that may advance efforts to address both established and emerging communicable diseases while reinforcing broader goals of global health justice.
For centuries, communicable disease epidemics and pandemics have severely impacted human populations. Prior to the advancement of microbiology—when the role of hygiene practices and proper water and waste management remained unrecognized—water-borne diseases such as cholera and typhoid fever, as well as waste-related vector-borne illnesses like bubonic plague and typhus, were predominant (Bencard, 2021; Sánchez-Vallejo, 2021). With the industrial revolution, epidemics became increasingly common, accelerated by greater human mobility, transportation advances, and international trade. Since then, the majority of major epidemics have been transmitted through respiratory, sexual, or vector pathways, most notably by mosquitoes. The twentieth century illustrates this pattern: the 1918 influenza pandemic was respiratory in nature, whereas AIDS, which emerged later in the century, is caused by the HIV virus and primarily transmitted sexually. In the early decades of the twenty-first century, humanity once again confronted a respiratory pandemic—COVID-19—which, since being declared a pandemic in 2020, has resulted in more than seven million deaths globally (World Health Organization, 2024). Beyond direct morbidity and mortality, COVID-19 has severely undermined progress in controlling other communicable diseases, including those targeted by SDG 3.3, such as tuberculosis and AIDS (The Global Fund, 2021).
The health, humanitarian, and socioeconomic devastation caused by COVID-19 is widely recognized (Sirleaf & Clark, 2021). However, these outcomes were not solely the result of the virus itself. They were compounded by a global response characterized by limited solidarity, with high-income nations stockpiling vaccines and protective equipment, leaving vulnerable populations unprotected in regions where health systems were already fragile (Parker, 2023). In the post-COVID landscape, consensus has emerged among global health stakeholders that strengthening pandemic preparedness is imperative. This alignment includes the United Nations (UN), multilateral agencies, donors, governments, civil society, and academic institutions. To operationalize this, funders and organizations have introduced dedicated mechanisms such as the Pandemic Fund, initiated by the G20 and administered by the World Bank (2022; Gold, 2022), the Coalition for Epidemic Preparedness Innovations (CEPI), and the Gates Foundation’s Strategic Investment Fund (Citationn.d.), particularly supporting preparedness in low- and middle-income countries (LMICs). Meanwhile, the World Health Organization (WHO) established an Intergovernmental Negotiating Body (INB) in 2021 to draft an international agreement under its Constitution, intended to strengthen global pandemic preparedness (World Health Organization, Citationn.d.).
At face value, prioritizing pandemic preparedness in the global health agenda is a welcome development, as structured emergency planning facilitates more efficient and equitable allocation of resources compared to fragmented responses (Kapiriri et al., 2022). Moreover, the likelihood of new health crises emerging is heightened by the climate emergency, which increases the risk of novel pathogens or the resurgence of existing ones (Tong et al., 2021). Yet, the concern addressed here is that this focus may unintentionally detract from other pressing health goals, particularly the communicable diseases that SDG 3.3 seeks to eliminate. This tension is concerning for at least four critical reasons, which will be elaborated in the sections that follow.
The first concern relates to the substantial health burden caused by the diseases targeted in SDG 3.3. Collectively, the four most prominent—AIDS, tuberculosis, hepatitis, and malaria—account for nearly 4 million deaths worldwide each year. Among them, tuberculosis represents the largest contributor, remaining the principal cause of mortality among individuals living with HIV. Approximately 1.5 million people die annually from tuberculosis (World Health Organization, 2023), a figure comparable to the combined toll of AIDS (UNAIDS, 2023) and hepatitis. Malaria, in turn, is responsible for over 600,000 deaths annually on a global scale (World Health Organization, 2021). Taken together, this constitutes a public health catastrophe on par with COVID-19, which, as previously noted, has resulted in an estimated seven million deaths to date.
The second point of concern is the persistent financial shortfall that hinders disease elimination strategies. For decades, there has been a consistent gap between the resources available and those required to combat these illnesses effectively. Although this issue predates the COVID-19 crisis, the pandemic further intensified the diversion of funds away from elimination agendas (Tacheva et al., 2022; WHO, 2020). Our argument here is that this funding gap could widen even more if financial and institutional priorities continue shifting toward pandemic preparedness. To illustrate, let us consider two examples—AIDS and tuberculosis.
In the case of AIDS, after decades of sustained investments, recent years have witnessed a retreat of donors, redirecting their attention to other health challenges (Coester et al., 2023). As a result, global funding for AIDS has dropped below historic levels (Wexler et al., 2023), and the disparity between available and required resources continues to grow (UNAIDS, 2023). UNAIDS reported that in 2022, funding available for HIV programmes in LMICs stood at US$ 20.8 billion—2.6% less than in 2021, and far short of the US$ 29.3 billion deemed necessary by 2025 to achieve global objectives (UNAIDS, 2021). According to UNAIDS, this financial shortfall is a major obstacle to the AIDS elimination agenda (UNAIDS, 2023), defined as reaching the 95-95-95 targets: 95% of people living with HIV tested, 95% of those diagnosed receiving treatment, and 95% of those treated achieving viral suppression. Regardless of differing views on how AIDS elimination should be measured (Assefa & Gilks, 2020), even if a feasible path exists—as demonstrated by some successful countries—the lack of clarity remains on how to mobilise sufficient funding to bridge both historic and current deficits.
For tuberculosis, the most recent figures, released in late 2023 (World Health Organization, 2023), show that LMICs face financing needs of US$ 15–32 billion annually (Stop TB Partnership, 2023). This includes resources required to support the development and distribution of a novel TB vaccine anticipated after 2027. Commitments made in the political declaration at the second UN High-Level Meeting on TB in September 2023 set ambitious targets: US$ 22 billion annually by 2027 for diagnosis, treatment, and prevention, and US$ 35 billion per year by 2030 (UN, 2023). Yet, funding available for TB in LMICs remains well below both estimated requirements and UN-set goals, and has declined since 2019. In 2022, only US$ 5.8 billion was available, less than half the funding projected as necessary under the Global Plan (2018–2022) and far short of the commitments made at the 2018 UN High-Level Meeting on TB (World Health Organization, 2023).
The third source of concern lies in the scope and definition of pandemic preparedness itself, which has proven difficult to delineate (Belfroid et al., 2020). While adaptability is crucial in planning for unpredictable future threats, the absence of consensus on core priorities risks producing fragmented and poorly coordinated responses across national and regional systems. For instance, a comparative study of influenza preparedness strategies across European nations highlighted such inconsistencies, concluding that divergences could impede cross-border cooperation (Holmberg & Lundgren, 2016). Following the crisis triggered by COVID-19, the WHO launched the Preparedness and Resilience for Emerging Threats (PRET) initiative (World Health Organization, 2022a, 2022b), shifting the emphasis from pathogen-specific to transmission-focused strategies. Yet, drawing from prior and ongoing pandemic experience, we anticipate a central risk: global health industry–driven initiatives (Parker, 2023) may privilege biomedical and epidemiological aspects of preparedness, while neglecting the equally vital social and political determinants of communicable disease control.
Finally, the fourth consideration is that the accelerating climate crisis poses compounding risks for both pandemic preparedness and communicable disease elimination. Climate disruptions influence disease dynamics through multiple pathways. Rising temperatures and altered rainfall patterns reshape ecosystems, fostering conditions conducive to the appearance of new pathogens (El-Sayed & Kamel, 2020). Environmental disasters intensify food insecurity and forced displacement, heightening the vulnerability of populations to both novel communicable diseases and those already targeted by SDG 3.3—AIDS, TB, malaria, and hepatitis (Kharwadkar et al., 2022; Kulkarni et al., 2022; Li & Managi, 2022; Lieber et al., 2021; Maharjan et al., 2021). These disruptions also limit access to treatment, whether due to migration or damaged infrastructure restricting travel to health facilities (Chrispin, 2023). Simultaneously, the twin pressures of new outbreaks and resurgent existing diseases threaten to overwhelm already strained health systems, risking collapse in the absence of adequate resources (Chrispin, 2023).
Within this complex landscape, two demanding but essential undertakings emerge. First, there must be alignment between global commitments to eliminate TB, AIDS, malaria, and hepatitis, and the mobilization of sufficient financial resources to realize those commitments. Second, and equally important, is the integration of pandemic preparedness with SDG 3.3, grounded in the principles of health equity. This requires moving beyond disease-specific approaches to embrace structural strategies that strengthen collective responses across multiple health threats. Without presuming to offer conclusive solutions to this immense challenge, the following section highlights four strategic areas of action that could advance progress in both arenas.
Reinforcing Health Systems
The COVID-19 pandemic has highlighted the critical importance of resilient and inclusive health systems in confronting public health emergencies. Likewise, there is broad recognition that the most effective strategy for tackling HIV, hepatitis, and tuberculosis lies in integrated and coordinated responses (World Health Organization, 2021), rather than disease-specific, vertical programmes (Assefa & Gilks, 2020).
Prioritising investments in strengthening health systems helps avoid competition between diseases for attention and resources. Ensuring that systems are adequately equipped to prevent and treat HIV, tuberculosis, malaria, and hepatitis not only upholds the right to health for those affected but also enhances system capacity to address communicable diseases overall. Such reinforcement prevents health structures from collapsing under crisis pressure, while simultaneously building adaptability to emerging health demands and sustaining essential services and core functions (Fridell et al., 2020; Haldane et al., 2021).
Although defining the precise actions required to establish and maintain strong, universal systems is complex, several critical components consistently emerge in the literature (Fridell et al., 2020; Thomas et al., 2020):
- Leadership and governance for implementing robust health plans and evidence-based policies. Governance structures should operate at multiple, decentralised levels with strong community involvement. Upholding accountability, transparency, and equity must remain priorities, even in times of crisis.
- Sustainable financing, ensuring adequate and diversified resources, efficient allocation, and reduced reliance on out-of-pocket payments.
- Infrastructure and supply chains that are well-maintained, with reliable access to medicines, vaccines, and health technologies.
- Workforce capacity, including sufficient numbers of well-trained staff, prepared for both routine and emergency demands, with fair remuneration and safe working conditions.
- Health information systems, enabling continuous data collection, analysis, and dissemination to guide ongoing disease responses and prepare for emerging threats, with rapid deployment in emergencies.
- For nations with sufficient resources and scientific capacity, investment in research and development (R&D) to reduce reliance on imported medical goods.
Global Responsibility for Fair Access to Medicines and Health Products
While closely tied to system strengthening, equitable access to essential medicines and health technologies warrants separate consideration. Access to these resources forms a cornerstone of effective health systems (Fridell et al., 2020), and one of the most significant lessons from COVID-19 has been the urgent need to improve global governance mechanisms to safeguard justice and equity (Parker, 2023).
At present, nearly 2 billion individuals lack access to essential medicines (Ozawa et al., 2019), a challenge that worsened during the pandemic. The inequitable distribution of vaccines and protective equipment (Garber et al., 2020; Tatar et al., 2021, 2022) underscored structural power asymmetries, whereby high-income countries stockpiled resources, leaving low- and middle-income countries (LMICs) facing severe shortages (Parker, 2023). To prevent such inequities in the future, many proposed solutions remain technological in nature: fostering local production, promoting regional cooperation, easing intellectual property restrictions (Seventy-fourth World Health Assembly, 2021), and encouraging technology transfer (Gostin, 2023).
These approaches are undoubtedly valuable and have demonstrated effectiveness in addressing other communicable diseases. Brazil’s response to AIDS, for instance, illustrates how a combination of these strategies can secure access to treatments once deemed unattainable for LMICs (Parker, 2023). Nonetheless, such efforts alone are insufficient unless paired with initiatives to confront the systemic global power imbalances that perpetuate health inequities. Without structural reforms, impoverished populations will continue to experience preventable deaths from diseases long controlled in wealthier nations. Rectifying these inequities requires a strengthened global governance framework that is explicitly designed to advance health justice and incorporate mechanisms to address such disparities (Parker, 2023).
Tackling Social Inequities
The interplay between epidemics and social inequalities is well documented and widely acknowledged as one of the greatest barriers to realising SDG 3.3 (World Health Organization, 2021). Inequities influence not only the distribution of infectious diseases but also the trajectory of illness among those affected (Benita et al., 2022). The most marginalised, vulnerable, and underserved populations—those with the highest infection rates—are often the ones least able to access services. This pattern has been observed historically, such as during the 1918 influenza pandemic, is evident in the cases of AIDS, tuberculosis, malaria, and hepatitis, and was again documented during COVID-19 (Benita et al., 2022; Mishra et al., 2021). These examples indicate that future pandemics are also likely to follow and deepen existing social divides.
All of the diseases outlined under SDG 3.3—AIDS, tuberculosis, hepatitis, and malaria—have established transmission pathways alongside proven prevention and treatment strategies. Yet, they continue to persist at epidemic or endemic levels primarily because social inequalities prevent timely and equitable access to these interventions (Fauci & Lane, 2020). This demonstrates that technological and biomedical advances alone will be insufficient to eradicate these diseases or to prepare adequately for future pandemics. It also underscores the importance of targeting the inequalities driving these conditions, both to guarantee immediate health rights for vulnerable groups and to uphold the principle of equity. Moreover, addressing inequities is crucial to preventing new pandemics from disproportionately burdening marginalised populations and amplifying disparities, as observed during COVID-19 (Apolonio et al., 2022).
Achieving this requires the implementation of a broad, cross-sectoral agenda, encompassing poverty reduction, violence prevention, access to adequate housing, protections for migrants, displaced groups, and rural communities, and measures to challenge stigma and discrimination based on gender, race, sexuality, age, and disability. One example is Brazil’s Programa Brasil Saudável (Healthy Brazil Programme), which brings together 14 ministries in a multisectoral response to the social determinants of 11 communicable diseases, including those listed in SDG 3.3 (Brasil, 2024). The programme is guided by principles such as: combating hunger and poverty to mitigate vulnerabilities linked to socially determined illnesses; advancing human rights and social protection with emphasis on vulnerable groups and high-risk territories; training health professionals and civil society to identify and address vulnerabilities associated with diseases; and expanding infrastructure and services related to basic and environmental sanitation. Since the programme was only launched in February 2024, its outcomes cannot yet be evaluated, but monitoring its development in coming years will be essential.
Integrating Health Justice and Climate Justice
The climate emergency is among the most pressing challenges of our era. Human activity—driven by capitalist exploitation of natural resources—has triggered environmental changes that may become irreversible if global temperatures rise more than 1.5°C above pre-industrial levels, thereby threatening the very foundations of life on Earth (David et al., 2021; Ripple et al., 2020; Robinson & Shine, 2018).
The adverse health consequences of climate change are already visible and are projected to intensify, particularly given the insufficient enforcement of international agreements aimed at addressing the crisis (The Lancet Planetary Health, 2023). If left unchecked, climate change will not only worsen the prevalence of existing communicable diseases but also increase the likelihood of new ones emerging. Importantly, these risks are not equally distributed. As with epidemics and pandemics, the impacts of climate change disproportionately harm marginalised populations and low- and middle-income countries (Porter et al., 2020; Rouf & Wainwright, 2020). Without coordinated responses rooted in social justice, the combined effects of climate change and infectious disease will produce what has been described as “eco-pandemic injustice” (Powers et al., 2021).
Conceptual frameworks such as One Health (Adisasmito et al., 2022) and Planetary Health (Moysés & Soares, 2019), which emphasise the interconnectedness of human, animal, and ecosystem health, provide valuable guidance for rethinking health in the post-COVID-19 context (Gostin, 2023). However, applied uncritically, these approaches risk leading to scientistic and depoliticised perspectives that obscure capitalism’s role in driving the climate crisis, minimise the impact of social inequalities, and sometimes propose solutions that reinforce exploitative relationships with nature—the very dynamic that caused the crisis (Biehl & Ong, 2018; David et al., 2021).
Accordingly, it is essential that strategies for future health emergency preparedness and for addressing SDG 3.3 diseases be situated within a framework that unites health justice with climate justice (Guinto et al., 2022; Robinson & Shine, 2018; Rouf & Wainwright, 2020). This entails confronting issues of privilege and power that disproportionately endanger marginalised communities while envisioning solutions based on a broader ethic of biocentric solidarity that acknowledges the rights of animals and ecosystems (Tomasini, 2021). In practical terms, this requires ensuring that wealthier Global North nations, which have historically contributed most to carbon emissions, fulfil their international commitments by implementing decisive measures to reach net-zero emissions by 2050. It also necessitates pressing for financial compensation to support climate-impacted low- and middle-income countries and vulnerable communities, including mitigating the health-related consequences of climate damage (Guinto et al., 2022). Ultimately, an enhanced global governance architecture firmly anchored in principles of both health and climate justice will be indispensable for addressing these intertwined crises.
Concluding Reflections
The coming years will be decisive in addressing AIDS, tuberculosis, malaria, and hepatitis, while also preparing for emerging health threats against the backdrop of accelerating climate change, which is expected to precipitate severe health crises, particularly in the world’s most vulnerable regions. This context underscores the urgency of coordinating efforts and securing sufficient resources to respond simultaneously to ongoing and novel communicable diseases—by mobilising new funding streams while preventing the redirection of resources away from existing agendas. Failure to achieve this balance risks inflicting profound harm on global health, undoing decades of progress that resulted from sustained investment and commitment to combating communicable diseases.
Recognising that straightforward solutions to these crises are unlikely, this commentary seeks to contribute by identifying structural and convergent interventions that can strategically reinforce both disease elimination and pandemic preparedness agendas. These include prioritising investments in resilient health systems, strengthening global governance to guarantee fair access to medicines and health products, embedding social inequality reduction within public health policies through comprehensive intersectoral action, and aligning responses with the joint pursuit of health justice and climate justice.
In doing so, we advance two key messages. The first is that future pandemics will pose challenges resembling those of current ones. Accordingly, investing in responses to AIDS, hepatitis, malaria, and tuberculosis—while ensuring care for the most vulnerable and supporting the elimination of these conditions—will simultaneously strengthen preparedness for future pandemics. The extent to which global health actors engage with the SDG 3.3 agenda will therefore be an important marker of their genuine commitment to the world’s most at-risk populations.
The second message emphasises that technocratic approaches alone will not suffice in addressing this triple crisis. The persistence of communicable diseases, along with the threats of future pandemics and the climate emergency, are rooted in systemic inequities created by entrenched structures of power and privilege. For this reason, advancing the principle of health justice in alignment with climate justice will be indispensable in shaping responses that address both the programmatic and structural determinants underlying this multidimensional global health challenge.
Acknowledgements
The authors thank colleagues at the Global Health Policy Forum (Madrid) and the Climate and Health Equity Network (Cape Town) for insightful discussions that informed this review.
Funding
This work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of Interest
The authors declare no conflicts of interest.
Author Contributions
I.M. conceptualised the review and drafted the initial manuscript. K.T. contributed sections on pandemic preparedness and epidemiological frameworks. A.N. contributed sections on climate change and health equity. All authors critically revised the manuscript and approved the final version.
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