Positive Public Health Ethics: Toward Flourishing and Resilient Communities and Individuals

Abstract

The COVID-19 pandemic is a global contagion of unprecedented proportions and health, economic, and social consequences. As with many health problems, its impact is uneven. This article argues the COVID-19 pandemic is a global health injustice due to moral failures of national governments and international organizations to prepare for, prevent and control it. Global and national health communities had a moral obligation to act in accordance with the current state of knowledge of pandemic preparedness. This obligation—a positive duty to develop and implement systems to reduce threats to and safeguard individuals’ and, communities’ abilities to flourish—stems from theories of global health justice and governance. The COVID-19 pandemic revealed and amplified the fragility and deficiencies in our global and domestic health institutions and systems. Moving forward, positive public health ethics is needed to set ethical standards for building and operating robust public health systems for resilient individuals and communities.

Keywords:

• Health economics
• health policy
• international/global health
• public health
• risk/benefit analysis

This article is referred to by:

The Shield and Sword of Biosecurity: Balancing the Ethics of Public Safety and Global Preparedness

Are Immunity Licenses Just?

Maryland’s Experience With the COVID-19 Surge: What Worked, What Didn’t, What Next?

Guiding Principles of Global Health Governance in Times of Pandemics: Solidarity, Subsidiarity, and Stewardship in COVID-19

COVID-19, Pandemic Triage, and the Polymorphism of Justice

COVID-19 PANDEMIC CONSEQUENCES: CONTRACTING CAPABILITIES, EXPANDING INSECURITIES

The COVID-19 pandemic has caused far-reaching morbidity and mortality, social chaos, and economic disturbances. The International Labor Organization (ILO) estimates that the COVID-19 crisis will eliminate 6.7% of global working hours from April through June 2020, the equivalent of 195 million full-time workers (ILO 2020b). ILO Director-General states, “[w]orkers and businesses are facing catastrophe, in both developed and developing economies,” (ILO 2020b) and the ILO Monitor states that COVID-19 is “the worst global crisis since the Second World War” (ILO 2020a).

In the United States, the unemployment rate rose 0.9% point in March alone, the largest monthly increase in 45 years, and the number of unemployed persons increased by 1.4 million to reach 7.7 million (U.S. Bureau of Labor Statistics 2020). During this time, although all major worker groups experienced increased unemployment rates, they were higher for Blacks and Hispanics, at 6.7% and 6.0% respectively, as compared to Whites, at 4.0% (U.S. Bureau of Labor Statistics 2020). The labor statistics for permanent job losses, temporary layoffs, joblessness less than 5 weeks, and overall labor force participation all worsened (U.S. Bureau of Labor Statistics 2020). Employment in establishments such as manufacturing, mining, construction, retail trade, professional and business services, health care and social assistance, leisure and hospitality, and other services all declined in this same time period.

These individuals’ ability to work—a critical capability and dimension of human flourishing—both contracted considerably for and fell disproportionately on persons of color. A joint increase in economic and financial insecurity—peoples’ inability to have a stable income and resources to support a current and future standard of living—has ensued. The insecurity in individuals’ and households’ income (Western et al. 2012) triggered by this crisis is massive. The impacts are on our local, state, national, and global economies. While the U.S. $2 trillion coronavirus stimulus package offers relief in terms of unemployment benefits, aid to industries and hospitals, loans and loan payment suspension, protections against foreclosures and evictions, one-time checks to Americans as well as food stamps (CNN 2020), it is too little, too late. This package, as well as additional stimulus that might be coming down the pike, is an important and necessary gesture toward relief for Americans during this crisis, but it constitutes deficient and inadequate conditions for individuals’ and communities’ abilities to work and be self-sufficient. It is an ineffective and inefficient approach to risk management.

At the same time as so many people are losing their jobs and their homes, whether owned or rented, many schools in the United States are closing and students’ education is being disrupted and compromised. The US Department of Education’s mission is “to promote student achievement and preparation for global competitiveness by fostering educational excellence and ensuring equal access” (U.S. Department of Education 2020). Yet, elementary and secondary school children and teachers are unable to engage with each other in learning environments that support the social, emotional, and cognitive development of children. Higher education institutions are closing, and college students are being evacuated from campuses across the country. Housing-insecure and lower-income students face disproportionate environmental challenges to meeting expectations for home schooling and virtual learning (Van Lancker and Parolin 2020).

Educational excellence is a distant fantasy under current and potentially ensuing conditions. These students’ ability to be educated, to learn, and to develop—a critical set of capabilities and dimensions of human flourishing—also contracted considerably for and fell disproportionately on those with lower socio-economic backgrounds during the COVID-19 crisis.

COVID-19 is affecting practically every area of life, including individuals’ and communities’ abilities to exercise their faith, practice their religion, vote, and exercise their civil and political rights. These cascading effects provide evidence that our ability to be healthy is essential for and central to our ability to flourish (Prah Ruger 2004a, 2004b).

Indeed, the COVID-19 pandemic is having immense morbidity and mortality impacts. At the time of writing, there are over 5.13 million COVID-19 cases confirmed worldwide, with 1.58 million in the U.S., as well as over 330,000 confirmed deaths from COVID-19 worldwide, including over 95,000 Americans (Johns Hopkins University and Medicine Coronàvirus Resource Center 2020c). Initial data also suggests that COVID-19 is disproportionately impacting racial minorities in the U.S., especially low-income groups (Barrett et al. 2020).

The cumulative number of cases and deaths reported by country at each date in time and since the 50^th confirmed case is particularly illuminating for understanding the fact that the COVID-19 pandemic is characterized by explosive growth and early exponential growth in cases, statistics that are related to the ability to prevent, contain and control the virus. Cumulative case statistics are available for the total number of COVID-19 cases, cases per 100k population, total deaths, and deaths per 100k population.

The data on early exponential growth and the data on “either a time of explosive growth of coronavirus cases in a given country or a change in how cases are defined or counted” (Johns Hopkins University and Medicine Coronavirus Resource Center 2020b) tell a clear story of the increasing health insecurity and decreasing ability to be healthy, even to be alive. The individuals’ and communities’ ability to be healthy, to avoid premature mortality and preventable morbidity, and to even just survive—a critical set of capabilities for human flourishing—contracted considerably during the COVID-19 crisis.

PUBLIC HEALTH ETHICS: AN EXPANDING FIELD OF INQUIRY AND POLICY

Public health ethics as an academic field of inquiry and applied policy has been growing extensively over the past several decades. From 2006 to 2012, the United States Centers for Disease Control and Prevention (CDC) convened an Ethics Subcommittee as part of the Advisory Committee to the Director (Table 1). The American Public Health Association’s Ethics Section, formerly the Ethics Special Primary Interest Group (SPIG), started in the 1980s as the Bioethics Forum (Table 2). The American Public Health Association continues to publish practical ethical guidance, such as the Principles of the Ethical Practice of Public Health (Public Health Leadership Society 2002, 4) and the Public Health Code of Ethics (American Public Health Association 2019, 5–6).

Table 1. Membership of the Ethics Subcommittee of the Advisory Committee to the Director, US CDC (2006–2012).

2006	John Arras, Georges Benjamin, Vanessa Northington Gamble, Thomas Hooyman, Bruce Jennings, Mary desVignes-Kendrick, Barbara Koenig, Kathy Kinlaw, Robert Levine, Ruth Macklin, James Thomas (Kinlaw and Levine 2007, 1)
2007	John Arras, Georges Benjamin, Vanessa Northington Gamble, Thomas Hooyman, Bruce Jennings, Mary desVignes-Kendrick, Barbara Koenig, Kathy Kinlaw, Robert Levine, Ruth Macklin, James Thomas (Ethics Subcommittee of the Advisory Committee to the Director 2007, 1)
2008	John Arras, Ronald Bayer, Vivian Berryhill, Vanessa Northington Gamble, Robert Hood, Thomas Hooyman, Bruce Jennings, Nancy Kass, Kathy Kinlaw, Bernard Lo, Leslie Wolf (Jennings and Arras 2008, 1)
2009	Ruth Gaare Bernheim, Ronald Bayer, Vivian Berryhill, Robert Hood, Pamela Sankar, Leslie Wolf (Department of Health and Human Services 2009, 3)
2010	Ronald Bayer, Ruth Gaare Bernheim, Vivian Berryhill, LaVera Marguerite Crawley, Norman Daniels, Robert Hood, Bernard Lo, Jennifer Prah Ruger, Pamela Sankar, Leslie E. Wolf (Department of Health and Human Services 2010, 18)
2011	Ronald Bayer, Ruth Gaare Bernheim, Norman Daniels, Nancy Kass, Sara Rosenbaum, Jennifer Prah Ruger, Pamela Sankar, Marion C. Wheeler, Leslie E. Wolf (Department of Health and Human Services 2011, 14)
2012	Ruth Gaare Bernheim, Janice Chilton, LaVera Marguerite Crawley, Kenneth Goodman, George Isham, Jeff Kahn, Alan Melnick, Sara Rosenbaum, Jennifer Prah Ruger, Ani Satz, Matthew Stefanak (Department of Health and Human Services 2012, 19)

Table 2. American Public Health Association (APHA) Ethics Section, formerly Special Interest Group (SPIG) (American Public Health Association 2020).

Policy Committee

Chair: Ann Mongoven

The policy committee works to develop Ethics Section APHA policy proposals. We also collaborate with other APHA components to comment on and support their policy work.

Public Health Code of Ethics Task Force

The public health Code of Ethics was first developed in 2002. After working with the original authors and APHA leadership, a new Public Health Code of Ethics was written and approved by APHA in 2020.

Membership Committee

Chair: Patrick Masseo

The membership committee works to sustain current membership and welcome new members.

An Oxford Handbook of Public Health Ethics (2019) edited by Mastroianni et al., included a list of leading contributors in this importantly expanding field of ethics. Seventy-three chapters and two major parts, foundations and public health topics, covered a comprehensive array of topics including four chapters on topics in emergency preparedness and response such as biosecurity, natural and industrial disaster events, pandemic disease, public health and ethics (Mastroianni et al. 2019).

The field of bioethics continues to evolve and expand from early work to develop systematic, practical, and interdisciplinary principles of biomedical ethics (Beauchamp and Childress 1979), to explore professional medical ethics (Kleinman 1988), apply bioethics to specific diseases (Grady 1995), integrate feminist perspectives (Wolf 1996), and discuss justice in research across society (Kahn et al. 1998) and internationally (Macklin 1998). Contemporary bioethics includes movements that focus on progressivism, pragmatism, and liberalism (Berger and Moreno 2010; Charo 2010), as well as measurement and methodology in population-level bioethics (Emanuel 2002; Wilker and Brock 2009).

There is increasing recognition of the need for broader ethical theories in public health and health policy health to address social determinants of health (Daniels et al. 2002; Prah Ruger 2004a; Bayer and Galea 2015), social justice (Powers and Faden 2006, Prah Ruger 2004b), and collective concerns (Churchill 2002). Debates about the role of the market (Havignhurst 1995), function of the law (Gostin et al. 2007, 2017), and rationing (Capron 2017), as well as scenario analysis (Annas 2011), responses to innovative technologies (Clayton and Rothstein 2007), and systems of healthcare coverage (Hall 2017; Jost 2017) continue to advance.

The purpose of this article is not to survey or critically engage with this expanding and important body of work; rather, it is to respond to a crisis and put forth a positive public health ethics steeped in human flourishing, the embodiment of mutual interdependence and shared vulnerabilities. Bioethics and public health ethics have been, understandably, centered in the important principle of individual autonomy; positive public health ethics aims to enrich the discussion by presenting a set of ethical standards for building and operating robust public health systems for resilient individuals and communities. Here human capabilities, including agency and functioning, is the foundation. Individual and collective capabilities are central. This article employs the COVID-19 pandemic as a case study lens into the positive moral obligations of national governments and international organizations to develop and implement systems to reduce threats to and safeguard individuals’ and communities’ abilities to flourish.

COVID-19 PANDEMIC: EMBODIMENT OF MUTUAL INTERDEPENDENCE AND SHARED VULNERABILITY

Witnessing the global animations of the spread of COVID-19 across the world, an illustration of the total number of cases in each country at each point in time evidences humans’ mutual interdependence and shared vulnerabilities.

From China, confirmed cases of COVID-19 spread within days to the United States, Canada, Australia, Japan, South Korea, and Europe, specifically France, Italy, Spain, and Germany (Johns Hopkins University and Medicine Coronavirus Resource Center 2020a). Within another few days, COVID-19 continued to spread within countries and across geographic boundaries to bordering countries. By early April 2020, COVID-19 had spread to most countries throughout the world, except for several African countries that were still reporting few to no cases (Johns Hopkins University and Medicine Coronavirus Resource Center 2020a).

The COVID-19 pandemic has proven that our global society and economy and our domestic societies and economies are mutually interdependent and share vulnerabilities through, for example, population movement and travel, supply and demand chains of goods and services, revenues and expenses, and trading in financial markets. COVID-19 has caused extensive cancelations and reductions in commercial and cargo flights and voyages. Financial markets have fluctuated, worrying investors who are in turn reluctant to invest. People all over the world have become sick and, in many cases, died. Our fatalities are especially linked at the local level. For example, while a public transport bus driver may get sick when a rider sneezes on him, those who practice social distancing and follow shelter-in-place orders can protect their neighbors and coworkers from illness.

The COVID-19 pandemic has highlighted growing global and domestic interdependencies and shared vulnerabilities. For example, since China’s economy is closely linked with domestic economies across the globe, the initial disinvestment from companies that operated in China spread throughout the global economy. When factories in China reduced production significantly, 50% by some estimates, goods to fill ships and airplanes importing products into the U.S. and Europe reduced significantly or disappeared altogether. An estimated 80% reduction in flights in China had rippling effects throughout the global economy. For example, China-based airlines initially experienced reductions in air traffic to East Asia, followed by other airlines who reduced traffic to East Asia and subsequently, around the globe. China’s increased economic power has had increased negative impact on the interconnected global economy.

Governments and central banks can provide economic stimulus to offset slowdowns, through cutting interest rates, reducing taxes, and providing aid, but these tools do not bring back lost jobs and lost lives. Moreover, increases in mitigated spending reduce tax revenues and available revenues for investments in forward-looking infrastructure, such as the systems needed to prevent future epidemics and educate future generations. Supply depends on demand and vice versa; our market and government institutions also provide education, public health, and health care for our populations.

In sum, the social scientific evidence from COVID-19 demonstrates that our mutual interdependencies are our shared strengths but also our shared vulnerabilities. COVID-19 has shown us how our future is shared and is forcing us to come to terms with what we value and prioritize.

COVID-19 AND PROVINCIAL GLOBALISM: WHAT DOES JUSTICE ENTAIL?

From a moral perspective, COVID-19 clearly establishes that the current approach of repeated emergency responses to and neglect of sufficient investments in global and domestic public health is inadequate; moreover, it exacerbates the chances of another pandemic of historic proportions. The current view cannot accommodate the pervasive interdependence and interaction involved in global and domestic public health, such as the constant individual, community, and population interactions that, in a cascade of iterative and cumulative processes, lead to mutual interdependencies and shared vulnerabilities. Additionally, the COVID-19 pandemic substantiates the view of health as an essential aspect of our lives. Health risks are integrally linked to other types of risk, including our ability to be educated, to work, and to engage socially with our family and friends.

An alternative view states that global and domestic public health should orient toward the common good of securing the opportunity to flourish for everyone (Prah Ruger 1998, 2015). On this view, human flourishing, rooted in equal respect for all humans and encapsulating human capability, is a shared moral aim and common good for all persons (Prah Ruger 2006). Since capabilities are what people and societies are able to do and be, enabling human flourishing involves enabling people’s and societies’ abilities to be healthy.

Accordingly, this alternative view creates the conditions for all to be able to be healthy through both general and specific positive duties, as well as negative duties to not harm or diminish prospects for health capabilities (Prah Ruger 2012). There is a moral duty to reduce threats to and safeguard individuals’ and communities’ health capabilities, particularly their central health capabilities—the abilities to be free from premature death and avoidable morbidity.

Provincial globalism (Prah Ruger 2009) is the global health justice theory that provides a systematic account of principles and normative rules that grounds these duties. Justice entails the respectful and morally equal treatment of all people. Provincial globalism holds that central health capabilities are morally salient human characteristics, central to our common humanity (Prah Ruger 2012). Central health capabilities deserve respect, protection, and promotion because they are intrinsically morally salient, as well as instrumentally important for other human capabilities.

As the disruptions and tragedies of COVID-19 have shown, health capabilities are paramount and indispensable to our human functioning, particularly as all other human functionings and exercises of agency are premised on being alive.

Yet, according to provincial globalism, COVID-19 is only the latest data point accumulating in contrast to the current approach to global and domestic public health. Our collective collaboration is needed to create an effective global society oriented around promoting human flourishing and developing health capabilities in the common interests of all.

COVID-19 AND SHARED HEALTH GOVERNANCE: GOVERNING FOR THE COMMON GOOD

COVID-19 has proven, and shared health governance has systematized, that epidemics and pandemics are shared health threats that produce shared vulnerabilities. Producing effective and efficient global and domestic public health systems requires shared resources, shared sovereignty, and shared responsibility (Prah Ruger 2012). Shared health governance allocates specific roles and responsibilities to individuals, communities, governments, and international institutions based on their abilities. Public institutions and private actors collectively engage to co-produce conditions for the health and flourishing of all (Prah Ruger 2012).

Instead of relying on individualistic rationality, shared health governance employs social rationality to effectuate principles of global health justice. Rather than conceptualizing self-interest and other-regarding behavior as diametrically competing, social rationality recognizes that health is a collective interest of both self and other (Prah Ruger 2018, 102). Shared health governance achieves global health justice through actors’ genuine efforts in collective action, a mechanism enabled by an alternative set of fundamental assumptions. Actors who approach institutions, policies, and programs with narrow self- or national- interest, rather than the common good, fail to fulfill their moral duties of developing and protecting health capabilities.

Global and domestic actors are subject to duties of cooperation that arise from duties of developing and protecting health capabilities; their conduct must align with principles of justice. Actors must account for the cumulative result of their actions and inactions, as failure by omission to bring about the conditions for human flourishing still constitutes a moral failure.

Achieving health equity requires the authentic cooperation of interdependent individuals and groups to internalize their respective responsibilities, allocated based on functional capabilities and global health justice needs, and each play their part (Prah Ruger 2009). The voluntarily assumption of ethical duties both is consistent with values of health agency and improves the effectiveness of global health governance implementation. Ethical leadership contributes to voluntary assumption of moral obligations and moral success.

Sharing resources such as information, data, financing, best practices, genetic sequencing, and other scientific information is essential to solving shared health problems. Shared resources entail openness in the trade and supply chains necessary to create life-saving prevention, control, and treatment strategies, options, goods, and services. Shared resources are a critical and central component of shared health governance.

Shared sovereignty creates effective expectation for compliance through the individual and institutional internalization of ethical commitments and public moral norms. Duties are distributed according to the functional abilities of global, national, local, and individual actors and a comprehensive grasp of the actions needed to address global and domestic health problems. Under shared sovereignty, authority is functional instead of territorial (Scholte 2000).

Accordingly, for functional and legitimacy reasons, national governments serve primary functions in achieving global health justice and have primary responsibilities for effectuating health equity. As a governance structure, the nation is well-situated for developing and sustaining equitable and efficient public health systems, self-determination, and collective action in public health. Nations such as the United States have ethical obligations to develop comprehensive, coordinated health systems capable of responding effectively to epidemics and pandemics. The scope of national obligations, in turn, defines global obligations. Supranational and subnational institutions execute functions to fulfill specific needs. Shared health governance fosters health agency and self-determination at both individual and collective levels.

COVID-19 has established that we are mutually interdependent upon each other’s abilities to collaborate in preparing for and preventing epidemics and pandemics. Shared vulnerabilities mean shared responsibilities. In shared health governance, mutual collective accountability is a multilevel, multi-actor, cohesive, and comprehensive framework for sharing power and responsibilities to address global and domestic public health problems. Mutual interdependencies requires mutual collective accountability.

Under mutual collective accountability, actors agree on joint work processes, target outcomes, and primary evaluation metrics. This creates processes for actors at all levels and of all sizes, particularly the groups most affected by a given policy, to engage meaningfully in health governance. Mutual collective accountability also necessarily implies increased effective and efficient resource use, because resource accountability frees up saved resources to put toward achieving additional social goals.

The world’s pandemic preparedness and response systems are as weak as their most vulnerable tie. “Collective security and the performance of international health systems in an increasingly globalized world are only as ‘strong as their weakest link’” (Global Preparedness Monitoring Board 2019, 20). As COVID-19 has shown, a disease in one place of the world threatens all of us. The world and the U.S. were not prepared for a speedy respiratory pathogen with pandemic potential. We failed to fulfill our moral duty to prevent and control COVID-19 as effectively and efficiently as possible.

Shared health governance and provincial globalism provide counterfactual paradigms to the chaotic and disordered ‘rational actor’ approach to public health. Shared health governance and provincial globalism provide the foundation for positive public health ethics, which advances systemic reforms that save lives and money, fulfilling our duty to reduce threats to and safeguard individuals’ and communities’ central health capabilities as efficiently as possible.

Positive public health ethics represents a change in moral attitude, one that shifts the focus from disease and risk factors to individuals’ and communities’ capabilities, their abilities to flourish and to thrive, and their health capabilities. On this view, governments, including the United States, need to reform risk management linked to epidemics and pandemics. They need systemic reforms to turn systemic fragility into systemic resilience.

POSITIVE PUBLIC HEALTH ETHICS: SYSTEMIC RESILIENCE VS SYSTEMIC FRAGILITY

Pandemic preparedness is a collective capability. It is the ability to anticipate, detect, respond effectively and cost-effectively to, and recover from, health events or conditions of an emergent or imminent nature. National governments humanely and efficiently fulfill their duties of effective prevention and control of disease outbreak, early detection, and accurate diagnosis by proactively anticipating and preparing for pandemic risks in the long-term. The dichotomous tradeoff between lives and the economy presented by some (Axios 2020) is illusory; developing capabilities and the economy are dual complementary, not contradictory, goals. Positive public health ethics explains why the obligation to cost-effectively prevent and control COVID-19 is a morally sound decision.

The risks of a pandemic have always been significant. 1483 epidemic events were tracked by the World Health Organization between 2011 and 2018 (Global Preparedness Monitoring Board 2019, 12); recent outbreaks, epidemics and pandemics such as Ebola, HIV/AIDS, H1N1, N5N1, Yellow Fever, SARS, and MERS represent numerous warnings and experiences to learn from.

The World Bank has estimated that a single flu pandemic could cost 4.8% of global GDP, a sizable $3 trillion (Jonas 2013, 2). Global institutions and national governments are well aware that systematic economic shocks create social and economic disruption, as well as shifts in demand and supply. However, the same paper estimates a comparatively small $3.4 billion annual cost to develop and implement effective and efficient pandemic preparedness systems in all countries, yielding annual benefits of $37 billion (Jonas 2013, 17). Similar to other issues in health, trying to cure pandemics is more costly than preventing them; the annual rate of return is estimated at 50–123%, with severe pandemic prevention yielding a benefit-cost ratio of 11:1 (Jonas 2013, 18; Pierre-Louis et al. 2012, 11). Pandemic preparedness has high economic returns (Prah Ruger 2020).

Reducing pandemic risk benefits all countries and all individuals, it is a global common good. The moral obligation for pandemic risk reduction, however, falls uniquely on governments because they are best situated to manage and coordinate across sectors and across local, national, and global levels. Yet, the U.S. and other countries neither valued nor prioritized pandemic risk reduction, focusing disproportionately on current patients over future patients.

The current state of knowledge (Mahjour et al. 2019) in pandemic preparedness is clear. Whole-of-society preparedness, relative to the high human, health, societal, and economic costs of a pandemic, is an inexpensive set of activities. Key components of a socially rational, positive public health ethics approach to cost-effective systemic pandemic resilience include the following.

First, systemic pandemic resilience requires scientifically-grounded risk assessments and rigorously tested response plans. All national governments must regularly run simulations to effectively hone and update response plans. Health security action plans should be fully financed domestically or through international assistance on an as-needed basis. As of 2018, 64% of countries reported preparedness levels on the WHO’s Health Emergency Protection Index that correspond to “urgently needing” or “requiring effort” to strengthen and sustain preparedness capacities for preventing, detecting, and responding to health emergencies (Mahjour et al. 2019, 13).

Preparedness plans in all countries should identify systemic gaps to prepare for worst-case scenarios in advance of outbreaks. This requires research and development (World Health Organization 2016) investment and planning for targeted and expeditious diagnostics and therapeutics, non-pharmaceutical interventions, medically necessary equipment and supplies, broad-spectrum antivirals, surge manufacturing capacity, and innovative vaccine development and manufacturing (Chawla et al. 2018).

Positive public health ethics requires a change in moral attitude toward shared responsibility for innovating, developing, and implementing shared systems that protect every person’s ability to be healthy. Shared responsibility entails the collaborative and timely sharing of resources, information, pathogen samples, specimens, sequences, data, and medical countermeasures. We must change our values and moral outlook to prioritize the research, development, and implementation of broad-spectrum antivirals, new therapeutics, and a universal influenza vaccine. Egg-based technology for influenza vaccine and production, which dominates 88% of the global market, remains virtually unchanged since the 1970s (Chen et al. 2020). We must also effectuate national and global tools and systems to prevent and prepare for epidemics and pandemics, capable of global information-sharing; identifying and sequencing novel pathogens; and expeditiously producing, testing, approving, and manufacturing vaccines.

Second, preparedness requires truthful, transparent, and consistent public communication. High-quality communication in urgent and non-urgent times primes the public to act based on factual information and motivation, instead of from anxiety and fear. Singapore’s and Taiwan’s COVID-19 public messaging exemplify effective public communication (Barron 2020). Risk communication as well as community engagement to understand and incorporate community needs in all stages of planning and implementation are critical for public trust. People must trust public health and government officials and each other, regardless of religious or cultural affiliation. Social cohesion is critical for public health, as mutual collective accountability rests on everyone feeling responsible for, and doing, their part. Including adolescents and young adults is particularly important so they accept and take ownership of their roles and responsibilities.

Third, all governments must coordinate centralized national responses that integrate security and risk management systems with distinct roles for various sectors, departments, and agencies. Systems-building and engagement across the whole-of-society and whole-of-government is necessary. Consistent investments, in advance, are required to keep outbreaks from escalating into disasters. For example, Singapore’s long-standing inter-agency task force paved the way for a rapid and coordinated response strategy to COVID-19 of contact tracing, quarantine, isolation, national testing, and public communication (Hsu and Tan 2020). An agency, board, or commission could co-ordinate high-level multi-sector simulations to maintain effective preparedness.

The COVID-19 pandemic challenged the U.S. in all these necessary pandemic-preparedness activities, exposing a fragile system that led to a rapid growth of cases. A resilient system also detects cases in a timely fashion through robust rapid testing supported by strong laboratory and surveillance capabilities, including comprehensive and frequent monitoring and repeated assessments. A resilient system rapidly engages due to well-rehearsed organization, training and programs of testing, contact tracing, isolating and quarantining practices, integrating across public health and health care. A resilient system develops its capabilities to prevent, control, and mitigate all types of public health emergencies, by involving the community and engaging stakeholders from multiple sectors, including the private, government, and civilian, to build trust and solidify mutual collective accountability.

Fourth, a strong One Health system (One Health Commission 2020) should underpin all pandemic preparedness efforts. One Health involves multi-sectoral, local, national, and global collaboration to optimize health for people, the environment, and animals. A One Health system supports early and effective contagion control by reinforcing cross-system human and veterinary health coordination. One Health planning, along with whole-of-society preparedness, are high-return low-cost approaches to managing pandemic risk.

Fifth, international coordination with international organizations and other countries is critical. Taiwanese officials, for example, traveled to China in late January on a COVID-19 fact-finding mission that contributed to Taiwan’s early and effective control of the virus (Sui 2020). Moreover, every national government, including the U.S., is responsible for full implementation of the International Health Regulations (IHR) (World Health Organization 2020). The IHR commits domestic resources and pools funding to strengthen all countries’ health systems as a critical move for national and global security. Development assistance for health must be directed toward preparedness, strengthening national health security action plans for the most vulnerable, insecure, and complex contexts. The global community must respond with clear roles, responsibilities, and rules in coordinating among countries and the private sector. Proactive institutionalized structures and processes for governance and accountability through shared health governance presents an opportunity to permanently change global and domestic rules.

Last, and arguably most importantly, accountable and unified high-level leadership during crises as well as between crises prepares and strengthens a country to act swiftly and decisively. Leaders create and direct the political will that is necessary for resilient public health systems. Political will from the very top, and through all sectors and levels, is a critical determinant of resilience. Moral responsibility lies with leaders, who are responsible for developing, financing, and implementing resilient national and global preparedness systems through evidenced-based measures that reflect the current state of knowledge (Global Preparedness Monitoring Board 2019; Workie et al. 2019). Three operationalizations of evidence-based preparedness measures include the National Action Plans for Health Security (NAPHS) and Pandemic Influenza Preparedness (PIP) Framework, developed by the WHO, and the Global Health Security Agenda (GHSA), developed by the United States and global partners including the WHO.

The responsibility to enact and invest in pandemic preparedness prior to potential outbreaks falls with national and local leaders. Spending is evidence of both leadership and political will. Leaders at local, national, and global levels have the moral responsibility to exemplify proactive action, rather than reaction, to protect all people equally by establishing the systems to prevent, detect, and control potential disease outbreaks. Leaders must lead and direct actions across sectors to successfully implement national preparedness measures.

Leaders must engage locally, nationally, and globally in the essential collective functions of preparedness, early detection, response, and recovery to ensure trust and social cohesion. Countries like the U.S., as well as other wealthy states—G7, G20, G77—must lead by example to create trust and shared governance across the world.

Morally responsible leadership in building and operating a resilient systematic prevention effort both reduces pandemic risks and produces considerable health, social, and economic benefits. We have failed to build and operate resilient pandemic preparedness systems, and we do so with hubris and obliviousness. The current approach of repeated emergency responses represents a moral failure to act responsibly. During a disease outbreak, everyone is at risk. Partitioning off and privileging the wealthy and well-connected is impossible. Yet despite the high benefit-cost ratio, governments continue to disregard preparedness. We must change our moral point of view to an alternative set of values and priorities. Positive public health ethics, by contrast, is driven by ethical leadership.

CONCLUSION

In conclusion, systemic fragility is an obstacle to the ability to be healthy and a failure of global health justice. A fundamental reorientation for nations, international organizations and multinational corporations is required to sustainably address these failings and shift to an alternative approach.

Failed pandemic preparedness represents a critical barrier to flourishing. Leaders must act morally and shift from repeated emergency responses to resilient individuals and communities. The latent fragility that the COVID-19 pandemic has uncovered, leading to cascading human and social harms, is the result of unjust global and domestic health systems. Inequitable global and domestic priorities and structures have revealed a world that has neglected to enact the lessons of mutual interdependencies and shared vulnerabilities. While good-hearted people all over the world are reaching out to support each other in this tragic time of adversity, our leaders and policies have failed to mirror those same values of self-sacrifice, discipline, and care. The current approach to pandemic preparedness is broken; it is a morally deficient mindset that requires a transformation to correct the injustices our world has experienced from COVID-19. It is time to reconsider what we value and create a stronger and sounder version of ourselves and our communities. Positive public health ethics has the potential to lead us to a more just and sustainable world.

Additional information

Funding

The author acknowledges funding, in part, by the Vice Provost for Research University Research Foundation at the University of Pennsylvania, and thanks Kara Zhang for research assistance.