13 March 2023, 1.00-2.00 PM (London time)
Epidemics and pandemics represent collective threats to humanity's health and well-being. Effective and equitable responses to epidemics and pandemics arguably require collective action. Collective action is also arguably needed to address some of the causes of epidemics and pandemics, such as climate change. In practice, responding to collective threats can be challenging due to conflicts that can arise between individual interests and collective interests. Even when collective action at a local, national or international level may make individuals, organisations or governments better off, they may fail to cooperate because their individual interests discourage cooperative action. This seminar, was the first in a series focused on epidemics and collective action, and examined the nature and role of individual and collective responsibility in relation to epidemics and begin to consider how ethics can help provide a framework for promoting collective action.
AM Viens, Associate Professor, Director, School of Public Health, York University, Toronto, Ontario, Canada
Dr. Caesar Atuire, Senior Lecturer, Department of Philosophy and Classics, University of Ghana, Accra, Ghana
Professor Daniel S. Goldberg, Director of Education; Director of Public Health Ethics & Law Program, Center for Bioethics and Humanities, Associate Professor, Dept. of Family Medicine, Dept. of Epidemiology, University of Colorado Anschutz Medical Campus
Professor Sir Nicholas J. White, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Thailand
Professor Vijay Kumar Yadavendu, Patliputra University, Patna, India.
Caesar Atuire began the webinar by arguing that most ethical frameworks stem from historical resistance to totalitarianism. As a result, they tend to be based on individual entitlement, as opposed to community obligation. However, ethics is a discipline which exists only in the context of our relationships with others and we ignore this aspect at our peril, because threats we face are universal and reflect shared vulnerability. For this reason, a normative approach to ‘collective action’ is needed. He outlined an approach to challenging the status quo, arguing radical change doesn’t work if there’s no capacity for it, but incremental change is something we can pursue more easily. Two principles should underline the drive toward incremental change. Firstly, solidarity should be a normative concept and something we should to live in accordance with. Secondly, subsidiarity should be focused on agency and justice. Coloniality subtracts agency from decision-making, but subsidiarity means returning decision-making to where it belongs. In terms of epidemics and pandemics, it means enabling those closest to the problem the capacity to address it.
Daniel Goldberg spoke about methodological individualism in public health. He argued within this specific ideology, the individual is seen and positioned as the unit of change. Consequently, any public health intervention tends to be targeted at individuals. However, we can’t understand groups or communities simply by aggregating them into the behaviours of the individuals who make them up. For example, during the COVID-19 pandemic, US citizens were asked to avoid high-risk scenarios such as going to densely populated areas such as bars and pubs. In this case, the public health policy put the onus on the individual to change their own behaviour, but another approach may have been to limit gatherings. In any case, methodological individualism has several deficiencies: Firstly it creates public health policies which expend scarce resources on low-yield interventions. Secondly, these interventions tend to be agentic, meaning their success or failure is mediated by the agent and their individual resources. Finally, any positive effects are usually felt only by affluent communities. As a result, as an ideology methodological individualism exacerbates health inequities and intensifies stigma. All of this can be seen locally, nationally, and internationally; it was evident in the COVID-19 pandemic but is present in the global political order as well.
Nicholas White presented a clinical perspective on collective action. Citing some of the key attributes of epidemics and pandemics, he said that they will continue to occur and as a rule, create a more disruptive environment than other medical threats. Typically, however, they don’t gain attention or money if they don’t pose a threat to wealthy countries. Unsurprisingly, during the COVID-19 pandemic, political and national considerations dominated, and science wasn’t protected. For example, COVID-19 research, with the exception of vaccine development, was distorted by national interests. In consequence, it was poorly coordinated, insufficiently funded, and in many cases not effective. Researchers also tended to act in their own best interests, and so some of the information that was produced was of low quality and published simply because of the topic. It was then taken up and amplified by journalists which caused further confusion and distrust. Industries also acted in their own interests. While many pharmaceutical companies profited from their interventions, very few were willing to provide any intellectual property for objective evaluation. Consequently, countries spent enormous amounts of money on pharmaceuticals, without having the tools to effectively evaluate what they were purchasing. Finally, because there was public concern around research, objective assessment was compromised. During COVID-19 a lot of research was stopped due to public pressure, and this was mediated by regulatory agencies who also surrendered to that pressure. In conclusion, during the pandemic national interests overtook collective interests in almost all regards.
Vijay Yadavendu remarked that COVID-19 was a catastrophic public health crisis, but it was also the result of a complex ecosystem involving natural, social and environmental factors which were then exacerbated by market failures and populism. Infectious diseases, in general, kill millions of people worldwide and exacerbate existing health inequalities, including access to healthcare. It is estimated, that healthcare inaccessibility contributes to the death of 5.6 million people each year, which can be attributed to the privatisation of the healthcare industry - where citizens have become customers. However, during the COVID-19 pandemic, problems also arose because of the way in which national governments introduced biosecurity public health strategies which were overly reliant on surveillance, subjugation, and segregation. Behavioural modification, along with clinical medicine, and the genetic decoding of disease became the guiding principles of public health, meaning the social and economic determinants of health were overlooked. In this environment, the idea of the individual exercising agency in order to work toward a collective intervention became almost impossible. He concluded by arguing that the current global disorder is the result of the hegemonic neoliberal capitalism, and there is now an urgent need for the reconstruction and reconstitution of public health, where individuals are not seen as discreet entities, but as part of the collective, with shared problems and shared solutions.
Questions and answers
1. What is the role of the United Nations in ensuring collaboration between rich and poor countries?
The structure of the United Nations is both historically and constitutionally problematic. As a union of sovereign states, the principle of sovereignty remains very strong; often tipping over into nationalism. However, it is also the only institution which brings countries together, so it is perhaps better to work within existing structures to affect change. This could include developing mechanisms to hold countries to account. During COVID-19 the behaviour of some high-income countries, such as when pre-purchasing vaccines, was harmful. Therefore, when low-income countries ask high-income countries for ‘help’, they are also asking them to stop harming them.
The idea of ‘helping’ also needs clarification. High-income countries should ensure that help doesn’t constitute another form of colonialism - robbing countries of agency and allowing leaders to abdicate from the responsibility of providing for their citizens. One way to counter dysfunctional patterns of help and harm would be to adopt the principle of solidarity. However, as we know, the COVID-19 pandemic induced panic among nations and so collective action, as a principle and practice, was compromised. It’s possible that if the threat was less urgent, states would have cooperated better, but this was unlikely in the so-called ‘heat of battle.’
Arguably if we are going to find an ethical framework to deal with the next epidemic or pandemic, we should do so now when there is less pressure. One such framework could be the ‘pandemic treaty’ which is seeking to establish mechanisms which can address future pandemics. However, this is not without problems. Once this document has passed through the WHO general assembly, what’s to stop countries from simply bowing out when convenient? Sanctions, while warranted, complicate matters further, because when you are asking the same people who may renege on their commitments, to sign a document under the threat of sanction, they may abstain from signing it altogether.
As a general point, the panel considered to what extent public health needs to return to its historical mission, and core tenants in order to actually fulfil its purpose of working for the population, and how high-income countries and institutions should cultivate trustworthiness to promote collective action.
What role might ethics play in establishing trust and trustworthiness (including across international and national domains)?
Strikingly, whilst various committees were set up to advise national governments during the COVID-19 pandemic, hardly any contained any ethicists. This begs the question, how can ethical considerations be bought to the table from the beginning if experts are not at the table? One way is by ethicists and scientists talking more to one another. One example of this is COVID-19 Research Coalition, which has both ethics working groups and scientific working groups working alongside each other. Another way is embedding ethics into educational curriculums. Educators should be teaching ethics across all disciplines. Notwithstanding this, during the pandemic, science wasn’t protected either. The research was distorted, held up and received inadequate funding. You might excuse it and say the political pressures were too great, but that’s why ethical science should be cultivated, and once established, protected even in times of duress.