The injustice of COVID-19: we need a moral constitution for our planet's health
Authors: Jennifer Prah Ruger
Journal: The Lancet Planetary Health (2020)

COVID-19 and other diseases strike with inequality both within and between nations. Geographic, racial, social, and economic status affect COVID-19 risk.1Szabo L Recht H The other COVID-19 risk factors: how race, income, ZIP code can influence life and death.https://www.usatoday.com/story/news/health/2020/04/22/how-coronavirus-impacts-certain-races-income-brackets-neighborhoods/3004136001/Date: 2020Date accessed: May 23, 2020Google Scholar These factors dictate whether one receives quality care, substandard care, or no care at all—often the difference between full recovery and death. Did we have a moral obligation to prevent coronavirus? To contain it? To protect all or those within national boundaries? Whose responsibility was it? Who, if anyone, is to be held accountable for the worst human tragedy since World War 2? Despite urgent warnings, the world was unprepared for coronavirus because our global health system is grounded in what John Rawls called a modus vivendi, a consensus based on self-interests and national-interests rather than on principles of justice.2Rawls J The idea of an overlapping consensus.Oxf J Leg Stud. 1987; 7: 1-25Crossref Scopus (619) Google Scholar This modus vivendi fails to focus our reasoning and institutional development on common interests like shared health threats and vulnerabilities. We all have an interest in health protection and promotion—a common interest. Serving common interests requires global health governance rooted in principles of justice and governed by the common good. We need an institution to represent and serve these common interests. We need a moral constitution for our planet's health. Rawls warned of political agreements lacking a principled basis because parties involved can abandon such agreements if they believe they can achieve their own interests at others' expense.2Rawls J The idea of an overlapping consensus.Oxf J Leg Stud. 1987; 7: 1-25Crossref Scopus (619) Google Scholar This scenario is precisely our predicament today. Our global health system was created to control contagions—yellow fever, cholera, plague—to protect trade, travel, and security of wealthy and powerful nations. Now nations are blaming each other for the coronavirus while WHO is threatened with financial ruin.3Reddy SK Mazhar S Lencucha R The financial sustainability of the World Health Organization and the political economy of global health governance: a review of funding proposals.Global Health. 2018; 14: 119Crossref PubMed Scopus (46) Google Scholar 80% of WHO funding is voluntary, member nations' dues are 20%.4Kaiser Family FoundationThe U.S. Government and the World Health Organization.https://www.kff.org/global-health-policy/fact-sheet/the-u-s-government-and-the-world-health-organization/Date: 2020Date accessed: May 23, 2020Google Scholar The USA is the largest WHO donor at $893 million, 15% of WHO's budget. A modus vivendi agreement is less stable than a consensus on principles of justice because it rests on "happenstance and a balance of relative forces," Rawls said.2Rawls J The idea of an overlapping consensus.Oxf J Leg Stud. 1987; 7: 1-25Crossref Scopus (619) Google Scholar An international consensus on pandemic preparedness did not signify a true consensus and guarantee goal achievement. Major reports following H1N1, influenza, SARS, Zika, MERS, yellow fever, and Ebola raised alarms and offered proposals to prepare for global health emergencies. More warnings and recommendations appeared in a 2019 report by the Global Preparedness Monitoring Board (GPMB), "[a]n independent monitoring and accountability body to ensure preparedness for global health crises," created by the UN Secretary General's Global Health Crises Task Force.5Global Preparedness Monitoring BoardAbout us.https://apps.who.int/gpmb/about.htmlDate: 2020Date accessed: May 23, 2020Google Scholar "Preparedness and response systems and capabilities for disease outbreaks are not sufficient," GPMB concluded, "to deal with the enormous impact, rapid spread and shock to health, social and economic systems of a highly lethal pandemic…"6Global Preparedness Monitoring BoardA world at risk: annual report on global preparedness for health emergencies.https://apps.who.int/gpmb/assets/annual_report/GPMB_annualreport_2019.pdfDate: 2019Date accessed: May 23, 2020Google Scholar Still, GPMB resolved, the global community has "the tools to save ourselves and our economies."6Global Preparedness Monitoring BoardA world at risk: annual report on global preparedness for health emergencies.https://apps.who.int/gpmb/assets/annual_report/GPMB_annualreport_2019.pdfDate: 2019Date accessed: May 23, 2020Google Scholar We needed moral leadership and action to enact global recommendations. We got complacency and indifference instead. The world ignored both portents and recommendations. Successful pandemic preparedness requires every nation to prepare its public health, health care, and animal systems, even if it does not think it is at risk. Collaboration of all nations is essential. Our global pandemic preparedness system is only as strong as the weakest link. Rawls adds that a modus vivendi is a consensus on "accepting certain authorities, or on complying with certain institutional arrangements, founded on a convergence of self- or group interests" and thus "contingent on circumstances remaining such as not to upset the fortunate convergence of interests."2Rawls J The idea of an overlapping consensus.Oxf J Leg Stud. 1987; 7: 1-25Crossref Scopus (619) Google Scholar If power relations shift or if powerful nations can no longer hold others to the bargain, the international agreement disintegrates. This situation is what we are seeing today with tension between China and the USA. WHO's international legitimacy, its right to exercise authority, is vulnerable to power relations underlying it. The current approach has left our world fragile and vulnerable. But if not a modus vivendi, then what? Fundamentally, justice lies at the root of global health issues. On an alternative view, provincial globalism,7Ruger JP Global health justice.Public Health Ethics. 2009; 2: 261-275Crossref Scopus (62) Google Scholar justice in global health requires equal respect for all humans' flourishing and capabilities for all. Capabilities, what people and societies are able to do and be, enable flourishing. We have a moral duty to safeguard individuals' and communities' health capabilities, particularly their core health capabilities –to be free from premature death and avoidable morbidity. Justice requires creating the conditions for all to be healthy. We have a moral obligation to care for others' health and to fulfil our own roles and responsibilities in doing so. This is authentic cooperation in global health. The tragedies of COVID-19 have demonstrated that health capabilities are indispensable to our flourishing, a shared moral aim, particularly as other functionings and agency are premised on being alive and being protected from severe illness and death. Still COVID-19 is only the latest evidence against the current rational actor approach to global health, based on a modus vivendi rather than on principles of justice. Accumulating evidence proves that creating an effective global architecture oriented toward human flourishing and health capabilities in the common interests of all requires collaboration. The global health community must strive to meet health needs and enhance justice. Responsibility is global and national. Threats to persons' health capabilities measure the effectiveness of global and domestic institutions and actors. These are claims of justice, not charity. Humanitarianism and charity are insufficient bases for achieving health justice. The world knew a pandemic was coming. COVID-19 has revealed the injustices and amplified the deficiencies in our global health institutions. The pandemic proves the failures of the current global health approach. Our indifference toward our fellow humans has constrained our capabilities to implement the policies and programmes necessary to prevent such global pandemics. A lethal respiratory infectious agent poses a shared threat that requires a shared response to achieve health security through shared resources, shared sovereignty, and shared responsibility. This shared response requires shared health governance8Ruger JP Global health governance as shared health governance.J Epidemiol Community Health. 2012; 66: 653-661Crossref PubMed Scopus (30) Google Scholar with specific roles and responsibilities for individuals, communities, national and sub-national governments, and global institutions. Public institutions and private actors engage to coproduce conditions for health and flourishing of all. Instead of relying on individualistic rationality, shared health governance employs social rationality to effect global health justice. Rather than pitting self-interest and other-regarding behaviour against each other, social rationality recognises that health is good for both self and other. Shared health governance aims to achieve global health justice through actors' genuine efforts in collective action. Without a world health government with global authority and enforcement powers, a global health system requires multiple actors performing disparate functions to solve global health problems. This enterprise can be fostered with a global health constitution—a moral constitution—that provides an overarching structure to coordinate interdependent, yet independent actors. A global health constitution holds global and domestic actors accountable to duties of cooperation arising from duties of developing and protecting health capabilities. Actors' conduct aligns with principles of justice. A global health constitution offers common principles and common ground. It offers a basis for coordinating actors and actions; brings coherence, clarity, and legitimacy to formerly chaotic conditions; and generates and limits authority. Solving the world's health problems and shaping effective health policy will require new approaches to coordinate interdependent yet independent actors. Quite literally, our lives and livelihoods depend upon it. I declare no competing interests. I acknowledge funding, in part, from the Vice Provost for Research University Research Foundation at the University of Pennsylvania.