A healthy constitution

In the time it takes to read this article, Covid-19 will have infected a further 2,000 individuals globally.

At the time of writing, Covid-19 cases exceed 16 million in over 210 UN countries and territories. Roughly half of the global workforce could have their livelihoods demolished as a result of the pandemic, according to the International Labour Organization.

The pandemic is an unprecedented global scourge, with unquantifiable health, social and economic consequences. It has proven that we are inextricably interdependent and share vulnerabilities. A risk anywhere is a risk everywhere; globalisation has eliminated the barriers that might have impeded the coronavirus from spreading across the Earth with such speed, sickening and killing chaotically. However, the burden of Covid-19 is unequally distributed both within and between nations. Where a person contracts Covid-19 and falls ill determines if they will receive quality care, substandard care, or no care at all, and whether they will fully recover, experience permanent ill effects or die. Healthcare and public health system access and affordability vary significantly across the world, both between countries and within them, with the lack of universal healthcare in some countries creating barriers to access.

This unevenness of access constitutes health inequities – unnecessary and avoidable differences in health – that are unfair and unjust. While the coronavirus itself is a natural hazard, the way the Covid-19 pandemic has ravaged communities worldwide is a man-made disaster.

Warning signs

The world knew a pandemic of this nature was coming, but in spite of this we were not ready. Our lack of preparedness was not inevitable, and it was not due to an inadequate supply of high-level panels, commissions or institutions. Nor was there a dearth of analyses, recommendations or reports. Dozens of reports, published over many years, offered lessons to be learned. These include major reports following the 2009 H1N1 influenza pandemic, the 2014 Ebola outbreak, Middle East Respiratory Syndrome (MERS; the first outbreak of which was in 2012), Severe Acute Respiratory Syndrome (SARS; a major outbreak of which occurred in 2002), Yellow Fever and Zika, as well as reports on influenza and plague preparedness. The reports provided forewarnings on many topics, such as the risks to global human health caused by the intersection of animal and human populations (including issues around the poor conditions in which animals are kept, as well as the unceasing human encroachment on animals’ natural habitats), systemic vulnerabilities in global supply chains and connectedness, and the importance of developing strong, flexible risk assessments and response plansable to adapt to and contain outbreaks of disease.

There were plenty of harbingers of what was to come. Over the period 2011–18, the World Health Organization (WHO) traced 1,483 epidemic events in 172 countries. Most recently, in its 2019 report, A World at Risk, the Global Preparedness Monitoring Board (GPMB) warned that the world was at grave risk of a global pandemic like Covid-19. The GPMB was conceived as a result of recommendations by the UN Secretary-General’s Global Health Crises Task Force in 2017. It was set up as an independent monitoring and accountability body whose mission is to ensure preparedness for global health crises. It is co-convened by the World Bank and the WHO.

In its 2019 report, the GPMB concluded that global preparedness and response systems were not sufficient to deal with a highly lethal pandemic. It warned that there was insufficient R&D investment and planning for vaccine development and manufacture, antivirals and non-pharmaceutical interventions. Yet, it offered a note of hope, saying that the world had the tools it needed to react to a pandemic and that “what we need is leadership and the willingness to act forcefully and effectively”.

The world did not take heed. Our international health governance system was inadequate to the charge. But it did not have to be this way.

Crumbling systems

Our global health system is deficient because it is grounded in conventional international-relations theories of realism, neo-realism and liberalism. These paradigms privilege nations as actors seeking to independently maximise national interest by managing distrust, conflict and disorder in international relations.

Our international health system was created for nations to control the spread of infectious disease in order to protect travel, trade, national and global security, and national interest. International agreements constitute bargains that are the result of convergences of independent national interests. If power relations change, or if powerful nations shift positions and lack the ability to strike a deal and hold their nations to it, international agreements will not be implemented. These agreements are unstable, as they are contingent on precarious relationships grounded in power asymmetries and balances rather than on the principles of justice. Nations can abandon an international agreement to pursue their own national interests as soon as any one of them deems that they can position themselves better at others’ expense. This is what is happening with the friction between the US and China, as well as in the latest controversy around vaccine allocation and distribution.

The dispersal of vaccines is likely to be determined by national interest, resulting in competition between nations and steep price fluctuations based on ability and willingness to pay for and secure vaccines. This will favour the rich and powerful, exacerbating existing inequities, and delay getting the pandemic under control. This competitive national-interest- driven approach could even create setbacks in the manufacture of vaccines, as supply chains for drug development and distribution will be overwhelmed by demand, and redirected to the benefit of richer nations. Hoarding could also be a problem, as seen earlier in the pandemic with respirators and masks, and the purchase by the US of huge supplies of remdesivir (an antiviral medication that has shown promise in combating Covid-19).

Our international institutions and policies reflect the shifting values and priorities of the most powerful nations around the world and are therefore vulnerable to the power relations that underlie them. Powerful national actors determine the legitimacy of the global health system. Politics, rather than science and justice, prevails.

The Covid-19 pandemic has conclusively demonstrated that our international health structures are inadequate for the globalised world. Individuals, societies and economies are increasingly interdependent; people and products move more rapidly worldwide than ever before. Conventional paradigms of international relations, embedded in international institutions and law, have left us fragile and vulnerable. The coronavirus pandemic, like other global health externalities, inequalities and cross- border issues, is a moral and governance failing.

An international consensus on pandemic preparedness, for instance, does not denote a veritable accord and guarantee implementation. Successful pandemic preparedness necessitates that each nation continues to equip and develop its animal, public health and healthcare systems, even if that nation believes it is invulnerable to infectious disease. All nations must collaborate in this project, and the international community must provide the financial support so that less-resourced nations are able to do so. Borders are porous and the weakest link determines the strength of the whole system.

The pandemic has also shown our mutual interdependence and shared vulnerabilities at the local level. For example, by following lockdowns and stay- at-home orders, and adhering to social distancing and mask-wearing rules, we protect ourselves and one another from becoming ill. By contrast, going out in public without wearing a mask, attending large gatherings and continuing to socialise when feeling unwell may cause you to sicken yourself and others. Mutual consideration and cooperation are key.

A moral system of care

Global health problems defy conventional assumptions about international relations. They require a different type of cooperation, one that is global rather than international (meaning its focus is on all people worldwide, not just nations), and one that involves all actors, not just national actors. By its nature, considering the health of all individuals worldwide is a question of justice. The current state of global health involves an unfair distribution of costs and benefits among morally equal individuals.

Health inequities are rooted in injustices that make some populations more vulnerable to poor health outcomes than others. To eradicate these injustices, we must ask: what do we owe each other when it comes to health?

On the one hand, individuals are sacrificing their own lives for the lives of others, as when frontline health workers treat Covid-19 patients without sufficient personal protective equipment. These sacrifices are injustices in themselves, falling disproportionately on racial and ethnic minorities and individuals in lower income and educational groups. On the other hand, communities are being left to their own devices, such as when nations and sub-national entities compete for necessary counter-measures such as ventilators, masks and test kits, or individuals receive treatment only if they can afford to pay for it.

Global health needs a moral conception, one that is affirmed on moral grounds rather than on the basis of self-interest or national interest. We have a moral obligation to genuinely care for our own health and the health of others and to behave responsibly. We need institutions that represent and serve these common interests. Our established theoretical frameworks – the aforementioned realism, neo-realism and liberalism, but also neoliberalism and utilitarianism – have fallen short in providing a theoretical grounding for the injustices of global health.

Provincial globalism

An alternative approach, provincial globalism, grounds global health justice in the idea of human flourishing. It builds on the health capability paradigm, which argues that the ability to be healthy – health capabilities – should be the central focus for evaluating justice in health policy, both at the global and national level. This view centres the special moral importance of health capabilities, arguing that humans’ ability to flourish is the proper end of social and political activity. This obligation to human flourishing is universal. In provincial globalism, charity and humanitarianism are a deficient basis for achieving health justice because they depend on hand-outs from others rather than empowering collective action to solve societal problems.

Components of health capability are essential to human flourishing. Deprivations in health capability are unjust; they reduce the ability for health functioning, diminish agency and undermine flourishing. Policies that fail to provide for the prevention of and high- quality treatment for Covid-19 are morally troubling because they undercut survival for certain groups. Avoiding premature death and preventable morbidity should claim priority in evaluating global health institutions and policies. This applies to many threats; for example, prenatal and obstetric care for women of colour, malaria prevention in rural settings and tuberculosis treatment in prisons. All human lives deserve respect, and it is incumbent upon us to break down structural barriers to health equity.

Provincial globalism signifies a global view of health capabilities under which the global health community does all it can to achieve a comprehensible set of goals to enhance justice. The importance of health is self- evident and has been a priority of societies for at least the past 3,000 years. In ancient Egypt, healthcare and a form of sick leave were available to workers during the building of the pyramids. As societies and nations grow economically and develop, they tend to pass legislation and establish health systems to guarantee all citizens access to healthcare and financial protection from its costs. Societies eventually come to acknowledge common health needs and seek to meet them, suggesting a transpositional view.

Provincial globalism is a global minimalist view, a mean between cosmopolitanism and nationalism, in which a provincial (national-level) consensus accompanies a global accord on health morality. Human health needs and enhancing health capabilities serve as the basis of claims individuals have upon society. Provincial globalism seeks global health citizenship, such that all persons, wherever they live or travel in the world, will have what they need to protect their health and prevent disease and injury. Global health citizenship signifes global standards of right conduct to promote central health capabilities for all.

Shared health governance should aim to prevent and reduce shortfall inequalities in central health capabilities. It should allocate responsibility both nationally and globally, and its framework should set forth distinct but complementary responsibilities for governments, non-governmental organisations, the private sector and individuals. Shortfalls in, or threats to, health capabilities measure the justice of global and national institutions, actors, policies and governance. We need to rework the terms of international cooperation and the structure of international institutions to transform our global health system.

Creating new institutions

Despite the current state of global health, cooperation is not incongruent to human nature. Genuine collaboration for common benefit developed in humans because groups that failed to cooperate did not survive. And authentic cooperation is vital to achieving global health justice.

But cooperation requires fairness, which is lacking in our current global health systems. Trust is inhibited by unchecked power inequalities; greater accountability and legitimacy, as well as constraints on power, such as transparent monitoring, would facilitate trust. A Global Health Constitution (GHC) and Global Institute of Health and Medicine (GIHM) could foster cooperation. These structures would represent the interests of all, not just a privileged few. They would specify rules based on the common good. Good governance necessitates regular evaluation of global and national actors and institutions in terms of the common good; a GHC and GIHM would provide the means to do so.

There is at present no world health government with global authority and enforcement powers. The global health system we need would be able to compel multiple actors, executing distinct functions, to solve global health problems by formulating and implementing effective global health policy. A GHC could coordinate these actors, defining obligations in general terms. Unlike a treaty, a GHC would enable relations among people and institutions and reduce or eliminate the influence of powerful nations and actors. Authoritative principles would inform the framework and procedures of a GHC, obligations would be clearly delineated, and evasive or irresponsible behaviour easy to highlight. A GHC would specify functions and establish checks and balances between global health actors, integrating global health work. It would bring clarity, coherence, legitimacy and accountability to formerly ineffective conditions, and generate and limit authority. Without such a structure, the global health community will continue coasting visionless, and will suffer consequences of pressured consensus and exploitation.

A primary task in global health governance is establishing an independent organisation that consults not only its own scientists, but those from external bodies as well as other experts, to be responsible for the objective, authoritative and substantive scientific basis for global health policy. A GIHM could serve this function. It would establish and sustain a network of technical and scientific experts worldwide.

The use and efficacy of scientists and experts thus far in the prevention and control of the Covid-19 pandemic has been profoundly insufficient globally and uneven nationally. The global community needs independent and unbiased expertise; a GIHM would serve this function through a networked approach of technical and scientific experts across the world. It would provide a set of experiments and perspectives from national- and subnational-level institutions, and through GIHM committees would give scientific advice to inform strategic programmatic choices for global health. It would be proactive and directive, rather than reactive and circuitous.

As an entity independent of politics, a GIHM would provide the impartial, objective advice so critically needed to develop and implement more equitable and cost-effective global health policies. It would also give voice to many key stakeholders, not just scientists, in the decision-making process, in the interests of fostering individual and collective health agency.

A GIHM would be responsible for developing a global health master plan. This would make commitments for health policies (for example, universal health coverage for all nations) that would achieve global health equity. These commitments would be evidence-based, objective and explicit. The plan should clearly identify those responsible for objectives based on functional requirements and capabilities. This shared health governance would insulate health and disease control from the narrow interests of powerful nations and wealthy non- governmental actors.

A healthy world for all

In shared health governance, ensuring that all people have the opportunity to flourish, the common good, is the end goal. A well-organised global society that realises the common good is to everyone’s advantage. The global health system we currently have is tainted by asymmetries in bargaining power, information, expertise and representation, even though these institutions purportedly espouse norms of consensus, fairness and equality. These conditions have not ameliorated persistent deprivation and destitution for people all over the world, in poor and rich countries alike. They did not prepare the world for the coronavirus.

Shared health governance offers an explicit, coherent system for organising health efforts and reducing inefficiency. It calls for minimalist global involvement, with global networks instead drawing on national expertise and scientific prowess, comprehensive national obligations and normative guidance of all actors. Both governance and government must come together in a mutually reinforcing, multi-level system if we are to create a world where all can be healthy. This is the global health system we need.