Health inequalities, social justice and international ethics in the time of coronavirus by Ryoa Chung
This longer blog post is an English translation based on two previous publications in French: Chung, R., “Plus que jamais, les inégalités sont nocives pour la santé », Université de Montréal Nouvelles, April 7th, 2020; Chung, R., « Une pandémie qui met en lumière les injustices sociales », La Conversation, May 1st 2020. Many thanks to Fabio Robibaro for his precious assistance for the English version.
The study of health inequalities reveals the complex nature of intertwined social and ethical issues. This observation rings ever more true as a global health emergency is unfolding before our eyes that will deeply mark the 21st century as we know it. Be it on a global level, or within a country’s borders, the impact of these inequalities will be felt for years to come. Less seemingly acute inequalities that are tolerated within Western liberal democracies under “normal” circumstances, give rise to blatant discriminations between social classes, gender, and race in the context of health crisis. Pandemics exacerbate the stratification of social hierarchies, which is why it is important to denaturalize what appears, at first, to be caused by natural disasters. While COVID-19 is caused by SARS-CoV-2, the consequences and health outcomes are, to an important extent, socially determined. This is why it is crucial to interrogate the health outcomes of the pandemic from the point of view of justice.
This is not to say that all questions of justice should be reduced to their impact on health alone. For instance, we would not want to live in an authoritarian regime, where we would have access to comprehensive and universal healthcare but at the price of sacrificing our fundamental freedoms. Rather, we should be questioning how certain health inequities are related to social disparities, and how this structural interaction deprives some social groups of the exercise of their fundamental rights. It is in this sense that some philosophers discuss access to healthcare and the capability to be healthy as a basic human right.
What is the link between social disparities, health inequities, and the coronavirus pandemic?
In the domain of public health, the “social determinants of health” model is a well-established research framework. It is primarily used to understand the causal relationships between the socio-economic factors that determine the living conditions of an individual, a social group, or population and respective health outcomes. Hence, the study of the degrees of morbidity and mortality affecting a given population is extended beyond the mere physiological or biomedical analysis. The pioneering work by French physician Louis René Villermé focussed on the health of textile workers in the 19th century. Michael Marmot’s conducted ground-breaking research in epidemiology and public health, which initiated in 1967 the longitudinal Whitehall Studies on the “social gradient of health” in British civil servants. Marmot was also commissioned by the WHO in 2008 to examine international health inequalities in light of the social determinants of health model.
Several political philosophers have taken an interest in distributive justice issues arising from this conceptual framework focused on the social gradients of health. N. Daniels, B. Kennedy, and I. Kawachi aptly titled their book Is Inequality Bad for Our Health,which calls attention to the intersection of health and social justice. According to N. Daniels, a just society must create and uphold institutions that will reduce unnecessary health inequalities stemming from damaging social circumstances that could be better neutralized by a fair distribution of basic resources. This defence of a public health system is therefore based on a principle of distributive justice and the principle of equal opportunity at the heart of democratic values.
The social determinants of health model attempt to better identify preventive public health measures and should not be considered as a blueprint for emergency management or a full-blown theory of justice. However, when faced with epidemics or large-scale humanitarian catastrophes, the extent of social inequalities that are often tolerated in non-crisis times, have serious outcomes on the health of a population that is already affected by structural injustice. If political measures are not taken to compensate various forms of socio-economic inequalities, there will be massive health impacts on individuals and large social groups who are already struggling with systemic disadvantage. In the time of coronavirus, we realize that these structural health vulnerabilities were not only morally questionable from a justice perspective long before the disaster, but they are also very costly from a purely pragmatic point of view. Indeed, when these social inequalities left unchecked are exacerbated in times of crisis, the collapse of a dysfunctional society will cost more to reboot and will continue to represent a health menace for all, even to the most advantaged that rely on the stability of the social hierarchy.
It is undeniable that the national management of public health measures represents an enormous challenge for all countries in times of crisis. Several different issues have arisen worldwide that highlight just how much politics determines the health of a population. For example, the COVID-19 pandemic reveals that in countries that lack a robust public healthcare system, deep problems of governance and blatant structural inequalities put millions of citizens and undocumented migrants without private insurance in life-threatening danger. In other countries stained by the historical oppression of colonialism, the health outcome of the pandemic will be disastrous for indigenous groups confined in conditions of poverty resulting from systematic injustice. The devastating impact of this crisis will force all countries to engage in a thorough examination of social disparities to better prepare for future global health, political, and environmental challenges ahead. We can only hope that the COVID-19 pandemic will force our generation to develop alternative models of international economic and social organization to prevent the catastrophic failures we are experiencing at the moment.
What are the main pitfalls and challenges to be addressed from the perspective of international ethics?
The crisis we are facing as a result of this pandemic exposes fundamental flaws of our international order that allows for global inequalities at such a massive scale. Recent developments in theories of global justice argue for moral obligations and international institutions upholding duties of mutual humanitarian assistance, not based on charity, but in the name of universal human rights. One might challenge this perspective by objecting to cosmopolitan ideals because nation-states might be incentivized to close borders in circumstances of need to preserve their national interest. However, history shows that the contemporary evolution of the configuration of political entities requires a multi-national approach to address the challenges of our time. From the nation-states to federal regimes, to regionalisms, there is a crucial emphasis on multilateralism that is necessary to manage collective issues most optimally. Yet, the case of Brexit highlights a tension between opposite positions and illustrates a new kind of skepticism towards multilateralism. But in the era of the COVID-19 pandemic, it is clear that only transnational coordination, information, and resource sharing can orchestrate the efforts of individual states by coherent and efficient ways.
The world order defined by the pandemic has introduced a complex paradox. Containment measures, although deemed necessary, reflect an “everyone for themselves” mentality in hopes of containing the virus within borders. However, these lockdown orders capture an individualized solution to a multi-national problem that gives way to pernicious discourses and actions of moral egoism, social Darwinism, racist rhetoric, and forms of xenophobia targeting already suffering groups like undocumented migrants who are subjected to circumstances of extreme poverty in abandoned refugee camps. But in the long run, coronavirus does not require a passport to thrive in contexts of poverty, across national borders, and threaten once again the health of the most opulent peoples. Indeed, this crisis of our generation is a worrying indication of the structural interdependence that binds us together. Although very unequal, we are in this together, and no country will be able to sustain the closure of its borders forever. Deconfinement thus implies multilateralism if we are ever to defeat the COVID-19 pandemic. To be sure, the moral argument presented here emphasizes the ethical principles of solidarity, regardless of self-interest motivation and gain. However, to convince the moral skeptics, we must also stress the pragmatic argument according to which the national interest of each truly depends on the cooperation of all.
A major challenge awaiting our generation will be to overcome the dilemma between the securitization of health in the name of national interest and the pursuit of the ideal of global health for all. There is no doubt that our interdisciplinary research efforts need to focus on the development of feasible models of global governance of public health compelling all countries towards greater international transparency, accountability, information sharing, and distribution of resources to develop means of prevention, adaptation, and mitigation for future crises to come. In closing, the best way to prepare future generations is to learn the lessons of the current crisis and to think about health justice today. While much emphasis has been placed on the prudential, pragmatic benefits of reducing social inequalities and health disparities, at the domestic and global scale, it is important to stress that solidarity for all in the context of this current pandemic rests first and foremost, from a philosophical point of view, on ethical principles of social, international and intergenerational justice.
 N. Bhala and others, ‘Sharpening the global focus on ethnicity and race in the time of COVID-19‘, (2020)The Lancet, S0140-6736(20) 31102-8.
R. Chung R. and M. R. Hunt, ‘Justice and Health Inequalities in Humanitarian Crises. Structured Health Vulnerabilities and Natural Disasters’ in P. Lenard and C. Straehle (eds.), Health Inequalities and Global Justice (Edinburgh University Press, 2012), pp. 197-212;
See also: E. Enarson, Women Confronting Natural Disaster. From Vulnerability to Resilience (Boulder:Lynne Rienner Publishers, 2012).
 S. Venkatapuram, Health Justice (Cambridge: Polity Press, 2011).
 Commission on Social Determinants of Health, ‘Closing the gap in a generation: health equity through action on the social determinants of health‘, (World Health Organization, 2008).
 N. Daniels and others, Is Inequality Bad for Our Health? (Boston: Beacon Press, 2000).
On the notion of “structural injustice”, see I. M. Young, Responsibility for Justice (Oxford: Oxford University Press, 2011);
More recently, M. Powers and R. Faden, Structural Injustice. Power, Advantage, and Human Rights (Oxford: Oxford University Press, 2019).
 S. E. Davies, Global Politics of Health (Cambridge: Polity Press, 2009).
Ryoa Chung is Professor in the Department of Philosophy at the Universitéde Montréal.
Her research interests include ethics in international relations, feminist philosophy and applied political philosophy, especially in the field of global health.