Millions of people were unable to follow basic COVID-19 protections because they lacked adequate housing, social protection or access to public services, according to a new international study published by The Lancet. Researchers warn that these inequalities could again shape the death toll of a future pandemic, even if vaccines and other medical tools are developed rapidly.
The NUS–Lancet PRIME Commission reached its conclusions after conducting 819 interviews across 20 countries in Africa, Asia, Europe and the Americas. The three-year initiative, involving more than 100 researchers, examined the experiences of communities that were left outside formal systems of protection during the COVID-19 emergency, including migrants, homeless people and people with disabilities.
For many, staying at home was not a realistic option. One displaced person in Ethiopia told researchers: “If we do not work, we cannot buy bread.” A street vendor in Indonesia similarly explained: “We need to eat and survive, so we kept going out to look for food.” In India, another participant described living with 10 people crowded into a single room.
Helena Legido-Quigley, a co-chair of the commission, said the barriers extended beyond income. “A person who lives in a crowded flat cannot socially isolate, a person without identity documents cannot access government assistance and a person who does not speak the majority language cannot understand health advice,” she said.
The study found comparable obstacles across different countries. In the United States, migrant workers described collective accommodation in which recommendations to isolate after developing symptoms were “impossible”. In Thailand, a visually impaired participant said people who were not registered in state systems received “hardly any help”. In Mexico, researchers found that official health messages were largely delivered in Spanish and online, without sufficiently accounting for the linguistic and cultural diversity of indigenous communities.
Spain also featured in the research. One case study examined migrant agricultural workers in Lleida, where housing conditions and a lack of documentation prevented some people from following health recommendations or accessing healthcare and government assistance. Montserrat Gea, a researcher with the commission, said pandemic control could not focus only on hospitals, laboratories and vaccines. “You have to have access to all groups so as not to leave anyone behind,” she said.
The researchers also documented instances where communities compensated for weaknesses in formal systems. In Mozambique, community members helped persuade people to accept vaccines after doses arrived. In Thailand, an association organised transport and appointments for people with hearing disabilities, with one participant saying they would not have been vaccinated without that support.
The commission then modelled possible outcomes for a hypothetical influenza A pandemic in 2035 under different levels of international cooperation. Its projections found that rapid vaccine development could reduce global deaths by about 59%, from 58.5 million to 23.9 million. But distribution would remain critical: allocating vaccines according to population rather than countries’ purchasing power could save an additional 2.7 million lives, particularly in middle-income countries. Increased confidence in vaccines could reduce deaths by almost another two million.
Rachel Cohen, a senior advocacy adviser at the Drugs for Neglected Diseases initiative, said developing vaccines quickly would have limited benefit without equitable access. She also warned that treatments remain a major gap in pandemic preparedness. Of the 14 viral families prioritised by the World Health Organisation, six currently have no treatments in clinical development and three have no candidate even at the preclinical stage.
For Legido-Quigley, the commission’s findings point to the importance of public trust as well as medical preparedness. “We have to work now so that people trust the system, trust the response and trust the institutions and the information,” she said.
