COVID-19 and the moral imagination
Authors: Mahomed Said Patel, Christine Beatrice Phillips
Journal: The Lancet (2021)

As Arundhati Roy has highlighted, "Historically, pandemics have forced humans to break with the past and imagine their world anew. This one [COVID-19] is no different. It is a portal, a gateway between one world and the next. We can choose to walk through it, dragging the carcasses of our prejudice...and dead ideas…Or we can walk through lightly, with little luggage, ready to imagine another world. And ready to fight for it."1Roy A The pandemic is a portal.The Financial Times. April 4, 2020; https://www.ft.com/content/10d8f5e8-74eb-11ea-95fe-fcd274e920ca/Date accessed: January 19, 2021Google Scholar Pandemics spread along fault lines created by the way we live—inequities in wealth, health, social protection, and access to basic services.2Sachs JD Karim SA Aknin L et al.Lancet COVID-19 Commission statement on the occasion of the 75th session of the UN General Assembly.Lancet. 2020; 396: 1102-1124Summary Full Text Full Text PDF PubMed Scopus (98) Google Scholar, 3Horton R The COVID-19 catastrophe: what's gone wrong and how to stop it happening again. John Wiley & Sons, London2020Google Scholar Through concerted efforts the knowledge and technologies to respond to COVID-19 are being amassed. Whether we are up to the challenge of avoiding the next global crisis is another question. The COVID-19 pandemic has been described by Reinhard Mechler and colleagues4Mechler R Stevance AS Deubelli T et al.Bouncing forward sustainably: pathways to a post-COVID world. Governance for Sustainability. International Institute for Applied Systems Analysis and International Science Council, 2020http://pure.iiasa.ac.at/id/eprint/16550/1/Background%20Paper%20%20-%20Governance%20for%20Sustainability.pdfDate accessed: January 15, 2021Google Scholar as a manifestation of "compound, systemic and existential" risks, resulting from multiple inter-related determinants, threatening coping capacities and jeopardising livelihoods for whole societies. Epidemics, along with other interconnected systemic risks, such as hunger, food insecurity, economic meltdowns, climate-related disasters, and large-scale involuntary migration, are likely to increase in frequency and severity in the future.4Mechler R Stevance AS Deubelli T et al.Bouncing forward sustainably: pathways to a post-COVID world. Governance for Sustainability. International Institute for Applied Systems Analysis and International Science Council, 2020http://pure.iiasa.ac.at/id/eprint/16550/1/Background%20Paper%20%20-%20Governance%20for%20Sustainability.pdfDate accessed: January 15, 2021Google Scholar, 5World Economic ForumThe global risks report 2020.https://www.weforum.org/reports/the-global-risks-report-2020Date: 2020Date accessed: January 15, 2021Google Scholar, 6Ottersen OP Dasgupta J Blouin et al.The political origins of health inequity: prospects for change.Lancet. 2014; 383: 630-667Summary Full Text Full Text PDF PubMed Scopus (392) Google Scholar In July, 2020, the Lancet COVID-19 Commission issued a statement to assist governments, civil society, and UN institutions in framing their response to the COVID-19 pandemic,2Sachs JD Karim SA Aknin L et al.Lancet COVID-19 Commission statement on the occasion of the 75th session of the UN General Assembly.Lancet. 2020; 396: 1102-1124Summary Full Text Full Text PDF PubMed Scopus (98) Google Scholar setting out "practical solutions" and some radical ideas on deep restructuring of global finances, strengthening international collaborations, driving a green recovery, and accelerating the adoption of the Sustainable Development Goals (SDGs) and the Paris Agreement. As we deliberate on how such ideas can inform policies in the current global context, it is instructive to consider the past. Previous pandemics led to revolutionary reforms: improved living and working conditions for labourers in Europe after the 14th-century epidemics of plague,7DeWitte SN Kurth MH Allen CR et al.Disease epidemics: lessons for resilience in an increasingly connected world.J Public Health. 2017; 39: 254-257Google Scholar transformations in sanitation systems in the UK after the 1832–66 cholera epidemics,8Hardy A Water and the search for public health in London in the eighteenth and nineteenth centuries.Med Hist. 1984; 28: 250-282Crossref PubMed Scopus (34) Google Scholar and the introduction of affordable public housing in New York after the 1918–19 influenza epidemic.9Richmond M New York rent strikes during the "Spanish" influenza. Open Democracy.https://www.opendemocracy.net/en/oureconomy/new-york-rent-strikes-during-the-1918-spanish-influenza/Date: May 22, 2020Date accessed: January 19, 2021Google Scholar But such transformations are not inevitable. Cholera epidemics since the late 20th century have not secured safe water and sanitation consistently across global risk zones, but resulted in effective biomedical interventions such as oral rehydration solutions, antibiotics, and vaccines.10Hamlin C "Cholera forcing". The myth of the good epidemic and the coming of good water.Am J Public Health. 2009; 99: 1946-1954Crossref PubMed Scopus (23) Google Scholar A decade ago, it was suggested that the HIV/AIDS pandemic in Africa might drive radical social change processes to mitigate individual and population vulnerability; instead, technical innovations such as drug therapies and diagnostics have largely dominated the intervention repertoire.11Leclerc-Madlala SM Relating social change to HIV epidemiology.Future Virol. 2011; 6: 785-787Crossref Scopus (3) Google Scholar The COVID-19 pandemic offers what Ulrich Beck termed a "cosmopolitan moment", when the existing order is destabilised to open up a new arena of moral and political responsibility.12Beck U Critical theory of world risk society: a cosmopolitan vision.Constellations. 2009; 16: 3-22Crossref Google Scholar In this cosmopolitan moment, the global community could come together to create new institutions or mechanisms to address the structural causes of global inequity and promote the wellbeing of people and the planet. Multilateral organisations historically have faced instability during global wars and economic strife, particularly when organisations focus on issues like security or trade.13Eilstrup-Sangiovanni M What kills international organisations? When and why international organisations terminate.Eur J Int Relat. 2020; (published online July 22.)https://doi.org/10.1177/1354066120932976Crossref Scopus (35) Google Scholar A recovery pathway that focuses on reanimating the SDGs and the Paris Agreement, each reliant on international cooperation, is necessary but not sufficient for the social transformations needed to prevent the next global crisis. The COVID-19 pandemic has revealed the dysfunctional system of global governance and exacerbated other barriers and bottlenecks to achieving the SDGs and the Paris Agreement, because the economic reforms to enable them come into conflict with powerful global actors pursuing their own economic goals, national security, and sovereignty.6Ottersen OP Dasgupta J Blouin et al.The political origins of health inequity: prospects for change.Lancet. 2014; 383: 630-667Summary Full Text Full Text PDF PubMed Scopus (392) Google Scholar, 14Gill S Benatar S Global health governance and global power: a critical commentary on the Lancet–University of Oslo Commission Report.Int J Health Serv. 2016; 46: 346-365Crossref PubMed Scopus (39) Google Scholar, 15NatureTime to revise the sustainable development goals.Nature. 2020; 583: 331-332Crossref PubMed Scopus (74) Google Scholar Even before COVID-19, international support for the SDGs was tenuous, premised as it was on assumptions of rising economic growth and positive international cooperation, including wealthy countries contributing 0·7% of the gross domestic product for official development assistance.15NatureTime to revise the sustainable development goals.Nature. 2020; 583: 331-332Crossref PubMed Scopus (74) Google Scholar COVID-19 and the priorities of some politicians have led to a further contraction in funding for development assistance, partly due to investment diversion to technological solutions (eg, vaccines, drugs, and therapeutics) and emergency preparedness and response. Systemic risks require systemic responses. We need a major shift in global governance to address global inequities and the political determinants of health. This shift should facilitate an inclusive and democratic global economy to counter the disproportionate political and economic power exerted by state and non-state actors in framing policies that perpetuate inequities in global health.3Horton R The COVID-19 catastrophe: what's gone wrong and how to stop it happening again. John Wiley & Sons, London2020Google Scholar, 4Mechler R Stevance AS Deubelli T et al.Bouncing forward sustainably: pathways to a post-COVID world. Governance for Sustainability. International Institute for Applied Systems Analysis and International Science Council, 2020http://pure.iiasa.ac.at/id/eprint/16550/1/Background%20Paper%20%20-%20Governance%20for%20Sustainability.pdfDate accessed: January 15, 2021Google Scholar, 6Ottersen OP Dasgupta J Blouin et al.The political origins of health inequity: prospects for change.Lancet. 2014; 383: 630-667Summary Full Text Full Text PDF PubMed Scopus (392) Google Scholar, 14Gill S Benatar S Global health governance and global power: a critical commentary on the Lancet–University of Oslo Commission Report.Int J Health Serv. 2016; 46: 346-365Crossref PubMed Scopus (39) Google Scholar, 15NatureTime to revise the sustainable development goals.Nature. 2020; 583: 331-332Crossref PubMed Scopus (74) Google Scholar, 16Reyes E Body politics in the COVID-19 era from a feminist lens.Development. 2020; 13: 1-8Google Scholar, 17Feminist COVID Response CollectiveFeminist response to COVID-19.https://www.feministcovidresponse.com/principles/Date accessed: January 19, 2021Google Scholar The moral imagination—seeing the world from different stances to envision a wider spectrum of possibilities for a post-COVID-19 world—requires us to examine how problems and their solutions are framed. A gender or human rights lens, for example, enables us to focus on the multiple ways in which COVID-19 has particularly impacted on women and marginalised communities, and how they are elided in many national responses.16Reyes E Body politics in the COVID-19 era from a feminist lens.Development. 2020; 13: 1-8Google Scholar, 17Feminist COVID Response CollectiveFeminist response to COVID-19.https://www.feministcovidresponse.com/principles/Date accessed: January 19, 2021Google Scholar A lens on race may highlight the undue discourse of blame often applied to racial minorities.18Chowkwanyun M Reed AL Racial health disparities and COVID-19—caution and context.N Engl J Med. 2020; 383: 201-203Crossref PubMed Scopus (502) Google Scholar A political economy lens clarifies that inequalities in the distribution of power and wealth undermine efforts to develop a sustainable future for humans in their environments.6Ottersen OP Dasgupta J Blouin et al.The political origins of health inequity: prospects for change.Lancet. 2014; 383: 630-667Summary Full Text Full Text PDF PubMed Scopus (392) Google Scholar, 14Gill S Benatar S Global health governance and global power: a critical commentary on the Lancet–University of Oslo Commission Report.Int J Health Serv. 2016; 46: 346-365Crossref PubMed Scopus (39) Google Scholar To drive our moral imagination, policy making should articulate diverse perspectives and avoid the too-early consensus or broad-brush solutions that can characterise expert panels. Influential idea-generators, multilateral agencies, advocacy coalitions, and philanthropists should incorporate clear articulation of the values that underpin the framing of problems, solutions, and challenges, and consciously seek out and present dissenting views. Health leaders and policy makers are likely to make better decisions for the aftermath of COVID-19 if they are presented with a range of voices, including those from outside the political and economic centre, that propose contesting, viable pathways to recovery for a healthier and more equal future for people and the planet We declare no competing interests. Women, children, and adolescents in the post-pandemic worldMahomed Patel and Christine Phillips1 offer compelling arguments for a post-COVID-19 world that breaks with business as usual. I wholeheartedly agree. An early study2 of the indirect impact of COVID-19 on maternal and child mortality estimated 2 million additional deaths in 2020–21 compared with pre-pandemic figures because of the disruptions to essential health services. Full-Text PDF