Interview: Global Health Emergencies and the Capabilities Approach

In this interview, [1] we sat with Dr. Sridhar Venkatapuram to revisit Global Health Emergencies by resituating them in the broader context of global health justice, and various ethical responses to global health inequalities, and in particular, the capabilities approach and freedoms. This conversation resonated deeply with the issues were are trying to address from the perspectives of structural injustice and epistemic injustice.

Rebecca Richards [RR]: What is your background, your main area of work and what got you interested in Global Health Justice matters?

Sridhar Venkatapuram [SV]:  The problems that motivated me are really two-fold. The first is a real-world issue about governments—and  more broadly societies—neglecting  the health of certain people, but also making it harder for people who are vulnerable to various kinds of diseases, making their life even worse as a result of various policies. The neglect or worsening the health of people by governments and societies is a real-world problem that continues to motivate me today.

The second, a philosophical and intellectual problem that I was interested in was this: imagine if someone said to you that there’s no such thing as a human right to health. And they say, “well it says so in this or that covenant, but we don’t think that it is a meaningful or legitimate human right. We believe and can show powerful arguments that human rights are only  civil and political rights.” In that context, how do you make an intellectual or rigorous philosophical argument for a human right to health?

RR: You’re a proponent of the capabilities approach in relation to global health. What is particularly interesting and important about this approach to global health issues?

SV: The story really begins with thinking about development economics over the last 30-40 years. When we look at Low and Middle income countries (LMICs) and are planning how we think these countries should develop, there is a lot of debate around what these countries should aim for and how they should do it–whether it should just be industrialisation policy; whether we are just talking about wealth in terms of growing Gross Domestic Product (GDP), or whether we should be focusing on something else.

The Capabilities Approach (CA) starts from the point of criticising the dominant thinking about development as being only or largely economic growth. We still tend to  think that a society is doing better if the GDP is growing. We think GDP represents wealth, and more wealth is good for personal welfare, and, therefore, everyone is going to do better under a system where there’s more money and wealth. Just within the past few years, most news aware people know that more money in a country does not necessarily mean everyone has been doing better. The people who originally developed the capabilities approach – Amartya Sen, later Martha Nussbaum and many others since – wanted to criticise the singular focus on GDP by showing all the various weaknesses and harms it produces.  Instead of GDP or national opulence, then wanted to shift the focus onto the quality of people’s everyday lives.

A second aspect of the capabilities approach arose in the late 1970s, in Anglo-American political philosophy, where there were renewed debates around what we mean by social justice and, in particular, what we mean by a ‘good society’. Various theories were being proposed. So what Sen and later Nussbaum did is bring two conversations together by linking the question ‘what’s the point of development?’ with the philosophical question ‘what’s a good society?’

What they argued was that a good society is not reflected in the size or growth of  GDP or wealth. It is reflected in the quality of people’s lives; what kind of lives they’re living in their daily existence. GDP or even individual wealth isn’t a good indicator of what people’s lives are like. While there are many ways to illustrate this point, the simplest case is to recognise that the same amount of money in the hands of a disabled individual versus non-disabled individual will not produce the same improvement in both people’s quality of life.  The illustration shows that quality of life is what we really care about, and money is the means.

The term ‘capability’ was used in order to reflect the ability of people to be and do things they value on a daily basis. A capability reflects the ability of people to be and do something. Importantly, they didn’t want to use the term ‘ability’ because ability is often understand as being about the individual’s internal physical and mental aspects. Capability is an awkward term, but the point of it is really to highlight that a person’s capability is their internal and external conditions combining, in order to make it practically possible for them to be or do something valuable. It can also be understood as another word for freedom. We might alternatively ask: how free are people to be and do things that they value with their lives?

In a nutshell, think of the capabilities approach as a theory of freedom or a theory about good quality of life.

The other important thing is that the capability approach is not just an analytical approach that helps us better evaluate a person’s quality of life.  It is also an ethical approach that asserts that “any human being anywhere in the world, by virtue of their ‘humanness’ has a moral claim to be free, to have certain basic capabilities.” That to me is also appealing. From a health advocate perspective, not only can it explain what people need in order to be healthy and help conceptualise what is healthy. It also grounds it in an ethical theory about moral claims and universal rights.  People have a moral right to health capability.

RR: You said in your TED talk that “We are implicated in the un-freedom of people. That is a question of justice.” How does this relate to who has the responsibility to address global health issues, especially in our interconnected world with histories between countries?

SV: I remember, in the late 1990s when I was a graduate student, that most graduate students felt as though they were not implicated in the poor health of other people anywhere else. They just thought that health was a national, domestic matter. I think that a lot of philosophers thought that as well. For example, if you read The Laws of Peoples (1999) by Rawls, he has this great sense that somehow economic development and health is a domestic issue, the state of the economy or development reflected national culture–essentially ignoring history and the way our world is shaped by the last two centuries of nations and states acting on each other. In the early 1990s people were also unaware of the deep military relationships and the implications of trade and arms. So, without being aware of these relationships, people just assumed that they were acting to improve global health out of beneficence rather than justice. The question asked by philosophers was: so what can we do for them? I have no relationship with them, so what do I owe them over there? Whereas, for people who were from “there”, or people who had been the recipients of this relationship and long-standing history which was being ignored, the question more appropriately should have been and still is  “what have we done already and what is it that we’re doing that is unjust?”

From a theoretical point of view, we now recognise – and if we don’t, we should recognise – that wherever we stand in the world, it’s likely that we stand in some relationship, or some part in a chain reaction of harm. If you think about any society, and its social gradient of health and where you stand on that social gradient of health, it isn’t random that you ended up on this part of the gradient. Some people are not choosing to hangout at the bottom of the gradient, nor is their position a natural event; they’re actually stuck there due to various reasons.  This is true about the global social gradient in health and human wellbeing.  The hierarchy is there because we made it like that.

The first key thing is that I think philosophers have it right in that you have a moral obligation first and foremost to assist those people you’ve harmed in the past. I think we all know and agree with that. The idea is that if you run over somebody with your car, you have to stop and help them because you ran them over. Philosophers are increasingly arguing that this obligation is not just relevant on a local scale, but also applies globally.  Whether you harmed someone while you were holidaying in a distant country or by clicking your computer mouse it home, you have a duty to correct the harm you caused. This then becomes, partially, an empirical claim and must be shown. How can we show the link between my action, and the harm elsewhere? Some people of course do not want to recognize this, and want to shut down that conversation. But acknowledging and rectifying that harm you/we caused is the first important step.

The second thing is to think about future harms: if you continue acting the way you do, who are you going to be harming?  Then you might also want to start thinking about how you are harming other people. And  of your hands are all clean after step 1 and 2, you can start thinking about what you can do to help someone who you have no harm-related connection with.  There are a variety of arguments being made about what kind of obligations could work here.  The one that I am considering at the moment is related to capacity or capability, that is also found in various religions and traditions.  The idea is that if you have the capacity to help someone who is suffering, then you should consider doing so. It is similar to the Christian principle which I think goes like, to whom much is given, much is expected.

The first two steps will take a significant effort, and required action not only on the individual level. But I think once we start recognising as a collective – as social groups or national entity – that our health, wealth and wellbeing are dependent on the domination and inequalities of other people, we will  see that we have an obligation to correct it and do something about it.

RR: Putting on your global health hat, what do you think the biggest challenges will be going forward in the next 20 to 30 years for global health and global health researchers and governments trying to tackle global health issues?

SV:  It’s a question that’s been at the forefront of my thinking for the last few years. It really is a very self-centred concern in that I was meant to write a book called “Global Health Justice”. I had it all laid out and ready to be written in 2015. For me, the world really changed in 2015 and 2016. So you had a profoundly different government come into power in India–one of the largest countries in the world in terms of demographics and a country I’m connected to. You had Brexit in the UK, the country where I live and work. And then you had the United States and the election of Trump and their profound rejection of everything that had come before Trump.

So a lot of people and academics continued as if nothing had changed. They just kept going. It was very clear to me that something had significantly changed and was significantly changing. So I had to throw away that book outline and begin thinking about ‘what does the world look like now’ and ‘what does the world need now?’

So the three things that I would think about is:

1. What happens after the current multilateralism no longer works? We’re not talking about one or two years, but about 5, 10, 15, 20 years, about  profound changes in the hierarchy of global actors and new alliances.
2. The second is about the different kinds of global actors, who are not states (and not regulated in the same way) who are quite powerful in the global scene(think for example of international NGOs and foundations, and their status and power the in world).
3. The third one is thinking about how health is not just about healthcare but all these other kinds of conditions that determine health. Who is going to be responsible for moving the conversation about health beyond healthcare to the people and places that can have significant impact?

RR: In the next global health emergency epidemic – which we know is going to come along at some point – what do you think the biggest ethical challenges are that NGOs and governments need to watch out for when going into these contexts to try and help on the ground?

SV:  I have been profoundly troubled by how quiet many people who were big HIV activists and women’s health activists have been watching what’s been happening with Ebola in West Africa. Just watching how inhumanely people are being treated. Not only people who are alive, but also people who are dead or vulnerable. I don’t understand how it’s possible that just ten years ago, people were marching in the streets for privacy and anonymity and dignity. And now, we watch quietly as people are being abused and disrespected.

It was because of the horrors of how governments and societies were treating people vulnerable to or living with HIV/AIDS that Jonathan Mann, a medical doctor, become such a passionate advocate for human rights.  For well over two decades he motivated an entire generation of people to recognise the treating people with dignity, respecting their human rights results in better epidemic control, and better sustainable individual and population health. But here we are again, where the ‘contain and control’ mentality has come back in full force. And, such as in Democratic Republic of the Congo (DRC), the more people resist what they believe to be draconian measures, the more force is being increased.  It is a downward spiral, and I am very afraid for how the Ebola epidemic will evolve in the DRC and beyond.

Aside from this, what I am troubled by is that a large number of people who are currently identifying ethical issues around emergencies tend not to be ethicists. They tend to be researchers, who are observing these epidemics, and they seem to be identifying ethical problems that are, in a way, recognisable to people who are from Western countries. I’ve been watching a lot of different kinds of reporting, and it tends to be about research ethics and how patients are treated. But the people  living in the affected communities are actually talking about a lot of others kinds of ethics, questions of fairness and justice, as I mentioned earlier. Many issues don’t get recognised as being ‘ethical’ because they’re seen to be about poverty or ignorance or powerlessness.

What I would like to see more of is these researchers being asked, ‘if this was happening in your own country, how would you be treating the people affected? How would you actually engage in this kind of conversation about ethics?’ Is it that your view of what is right and wrong in that particular environment is actually hugely coloured by your power in that environment? Do think that because you’re a benevolent actor you somehow have a wiser view of the situation, as opposed to if you were in your own home town and were just another academic?

Different epidemics have different facets. But we know from all these other epidemics that they trace inequalities within populations. So if they’re affecting people, it’s not just random people. The infections are following certain kinds of inequalities. What is it about those inequalities that we can identify and how can we mitigate them and treat them? Why have we given up on that dream that a society that treats its people well is more resilient to health rather than identifying the disease and controlling it?

 

[1] Answers were transcribed from an oral interview and have been edited slightly for the sake of clarity. The interview in its current form was published with the approval of Dr. Venkatapuram.

 

Original image by Patrick Fore on Unsplash. Image edited on Canva.