None of us are prepared unless all of us are prepared: research for the next health shock must be inclusive and equitable

Abstract

Rich countries like the UK will need to match rhetoric with investment and action at home and internationally to ensure global health security and resilience to health shocks, write Ebere Okereke and colleagues

The covid-19 pandemic revealed serious gaps in health systems readiness for health shocks and underscored the urgent need for inclusive and equitable preparedness strategies.¹ As the world reflects on the challenges and shortcomings exposed, high income countries have a pivotal role in shaping research and investment priorities for global benefit, ensuring resilience for all. The current mpox outbreak shows again how absence of engagement and leadership results in health crises spreading worldwide, affecting populations far beyond their origin.²

The power to determine global health priorities remains concentrated in high income countries. Lack of meaningful representation of low and middle income countries (LMICs) in key institutions skews policy decisions and access to resources. This is evidenced most recently by the early ending of the 2022 international public health emergency declared for mpox despite ongoing outbreaks, rising cases, and limited access to vaccines in Africa.³

Health research priorities are still defined mostly by white men from high income countries.⁴ Women, disproportionately affected by health shocks,⁵ are barely considered. Improving the representation of LMICs, minority groups, and women in preparedness design is crucial, as are strengthening regional research and development capabilities and including regional public health bodies (such as Africa Centres for Disease Control and Prevention) in decision making.

Exclusion has far reaching, detrimental consequences. Under-representation of ethnic minority populations in clinical trials during the covid-19 pandemic, in the UK and globally, resulted in a lack of data on vaccine efficacy and side effects in these groups, raising concerns about the fairness and universality of healthcare interventions.⁶ This policy decision also contributed to suspicion and hesitancy among these communities.⁷ Our global response to health shocks is only as strong as its weakest link. Mistrust wastes research and development resources and is an inevitability of failing to make preparedness design a truly inclusive process.

Actions for UK

The UK has a leading role in advancing understanding of infectious diseases, with commitments to increase annual investment in research and development to £20bn by 2025.⁸ UK gross expenditure on research was £38.5bn in 2019—1.74% of gross domestic product (GDP).⁹ The government has invested over £554m in covid-19 research,¹⁰ redirecting many ongoing projects to address lessons emerging from the pandemic.

This is welcome but insufficient to prepare for the next health shock. Even with advanced science and technology, policies and implementation strategies must be rooted in resilient health systems and equitable access to resources.¹ The UK must embed equity in its investment frameworks, promoting representation and inclusion in decision making bodies and ensuring that marginalised communities and voices are heard when setting research agendas.

UK health leaders must ask: have we done enough to be confident that a “patient zero” from a marginalised group would engage early with the health system? The global mpox experience underscores persistent failure to learn from discriminatory, stigmatising, and dismissive approaches to disease based on the affected population.¹¹

Quality science and best practices in pandemic management have emerged from regions with experience managing such crises. For example, countries like Vietnam and Thailand implemented successful containment strategies in the early stages of the covid-19 pandemic, showing the importance of incorporating diverse experts and approaches into global preparedness strategies.¹²

The UK, along with other high income countries that are global health leaders, must strengthen global health equity and resilience, first by increasing financial and collaborative commitments, boosting contributions to initiatives that build LMIC health system capacity, and prioritising research partnerships with LMIC institutions. It should fund accessible early warning systems and support local manufacturing capacity in LMICs.

Equally crucial is reforming research and decision making processes to address biases, by diversifying advisory boards, implementing equity audits, creating funding streams for under-represented populations, and mandating community engagement in research design and implementation. The UK should also advocate for greater LMIC representation in global health institutions—for example, the global partnership the Coalition for Epidemic Preparedness Innovations.

The UK should prioritise need based global health responses, guiding its approach to health threats by need rather than geopolitical interests. This means giving equal attention to health crises regardless of where they occur, recognising that in our interconnected world any outbreak has the potential to become a global threat.

The UK should also align domestic policies with global health goals. This requires examination and reform of trade and immigration policies that undermine global health equity and NHS resilience. Populist posturing that scapegoats immigrants and refugees is fundamentally incompatible with an equitable health system that can respond robustly to shocks. The Windrush scandal shows deep rooted problems in the UK’s approach to immigration and healthcare access.¹³ Addressing structural inequalities in the healthcare system and providing genuine career development pathways for staff from marginalised groups are essential.

While the UK has made some progress in its approach to global health security, much work remains to prepare for future shocks. The disparity in responses to mpox outbreaks in different parts of the world serves as a stark reminder of the persistent inequities in global health and our collective vulnerability to emerging threats. The UK must now translate its rhetoric of solidarity into concrete actions that prioritise the health needs of the most vulnerable populations worldwide. None of us are truly prepared unless all of us are prepared in our pursuit of global health security and resilience against future shocks.