Pandemic as revelation

ABSTRACT

This essay identifies three insights about global equity and justice in light of the COVID pandemic. It discusses the need for greater recognition of the role of the global order in the distribution of harms; the lack of capacity within global institutions to reason about social and global equity and justice; and the necessity to recognize and address racism as a driver of human deprivations and death.

KEYWORDS:

• Health justice
• capabilities approach
• pandemic
• global justice
• social determinants of health
• racism

But I think the second thing is that this is the nearest we have to a revelation even to atheists. Here, we suddenly see our vulnerability. We’ve been coasting along for more than half a century in unprecedented affluence, unprecedented freedom, unprecedented optimism. And all of a sudden we are facing the fragility and vulnerability of the human situation. And, at the end of the day, even without a faith in God, we have to say either we work together and survive, or we work separately and perish.

Rabbi Lord Jonathan Sacks zt”l, 17 March 2020

Introduction

At the time of writing, the COVID-19 pandemic is in its twenty-second month and continuing to produce enormous and diverse harms in all societies as well as to international relations and organizations. It was unusual that the world’s richest countries were the first affected with large-scale mortality from a new infectious disease outbreak. Usually, infectious disease outbreaks with significant mortality occur in low and middle-income countries (LMICs). However, given the hoarding of available COVID vaccines by the world’s richest countries, the unwillingness of pharmaceuticals companies to ‘share their recipes’ for vaccines, persistent inequalities within LMICs, and dysfunctional global governance, the pandemic’s death toll will soon likely be relatively much higher in LMICs. The LMIC deaths are being caused directly from COVID as well as by indirect or ‘knock-on’ causes. The Economist magazine estimates that, as of October 2021, 10–19 million more people have died around the world since the pandemic began than would have otherwise (The Economist 2020). This estimate is 4.5 times the official COVID death statistics. Moreover, the largest OECD economies are estimated to have lost billions of dollars from the decrease in economic activity, and the global economy as whole lost close to 4–6 trillion dollars over twenty months (The Economist 2021). While the absolute economic losses in LMICs may be smaller, the gains LMICs made in economic growth, health outcomes and the broader Sustainable Development Goals (SDGs) have been eroded, erasing years if not decades of efforts. One estimate is that about one billion people will be pushed back beneath the already very low global poverty benchmark line (Sumner, Ortiz-Juarez, and Hoy 2021). The loss of economic activity and new costs of dealing with the pandemic are forcing many LMIC governments once again to be overburdened by foreign debt servicing and wrangling for financial and other assistance from global institutions, foreign governments, philanthropists and others (‘Round Table Report. Responding to risks of covid debt distress’ 2021). This search for assistance is happening at a time when even the richest governments are cutting down foreign assistance, realigning their development assistance with national strategic interests and borrowing billions to deal with their own domestic crises.

The COVID-19 pandemic is indeed a rare event, not least for being a truly global experience; the global health crisis is profoundly shaped by hyper-globalization, affecting all societies and supra-national organizations and relations in significant ways. The only other modern comparison to the scale and global impact of the pandemic is the 9/11 terrorist attacks. The unusualness of global metropolitan cities, the richest countries and the most advantaged in society (e.g. national leaders, diplomats, business executives) being the first to be affected by the virus reflects which geographical locations and individuals are the most globally connected. What were previously considered to be advantageous positions and status turned into supreme vulnerabilities for both individuals and nations.

However, this truly global health crisis is not the only global crisis underway. There are also crises of the environment, economic inequality, authoritarianism, securitization of society and international relations, indigenous and minority group survival, migrants and refugees, 9/11 wars, population ageing, youth unemployment, and others underway. Despite all these multiple and inter-related global crises unfolding, the eminent thinker Rabbi Sacks identified the COVID pandemic as uniquely provoking a kind of biblical or transcendental ‘revelation’ for many people. According to Sacks, the revelation for many people is the ‘inescapably interlinked nature of our humanity’, which then motivates, especially for those in the West, taking actions that are more balanced between ‘I and we’ (2020).

In his reference to fifty plus years of unprecedented affluence, freedom and optimism, Rabbi Sacks was clearly referring to residents of rich countries and the West, and then, perhaps only to the advantaged within those geographies. And the concept of divine revelation provides a useful method to link powerful new insights regarding our inter-relatedness with justification for new social and moral behaviour about how we should relate to each other within and across societies. Sacks’ argument provides an opportunity for academic philosophers and practitioners of global ethics and justice to also ask: what new insights has the pandemic provoked for us? What are we going to do differently in applying our professional skills to theorizing and addressing this global health as well as other multiple, inter-related global crises?

Below I offer up three insights brought on by the pandemic from the perspective of a scholar and advocate of the capabilities approach (CA) to social and global justice. More specifically, I focus on how the CA should be applied differently or evolved in order to address (global) health equity and justice. Those who are unfamiliar with the CA, or who have a stronger affinity to alternative ethical approaches may still find the discussion informative. The three aspects I consider – analysis of the transnational plane, institutional capacity for ethical reasoning, and racism – are apposite to many other ethical approaches which are concerned with theorizing and realizing equity and justice for all human beings around the world, and for future generations.

Starting understandings and assumptions

I begin, however, making explicit three background understandings and assumptions. First, protecting and improving health and health equity, within and across countries, requires addressing the systemic/socio-structural causes of human deprivations and oppressions. Just like alleviating persistent (global) poverty is not just a technical problem to be solved in an indifferent social environment, alleviating acute and endemic disease and premature death in populations is also not a technical problem to be solved in an apathetic social environment. Despite what many globally advantaged individuals such as academic philosophers might think and experience regarding their own episodes of illness including COVID-19, suffering, impairments and deaths due to disease are thoroughly linked to social injustice. The status quo is what it is because powerful social actors and institutions benefit from extant harmful and unjust social conditions. In regard to this pandemic, anyone who states that the millions of people have died from COVID-19 because of a novel virus is only telling us a truncated part of the story. While an individual may become infected by the SARS-CoV-2 virus and then die from COVID, the causes for the individual’s exposure to the virus, their progression to disease and death, and the different levels and distribution patterns of infections and deaths in any given country or population group is significantly due to social politics, social institutions, policies, values and neglect. This is the appropriate understanding of ‘social determinants of health’ (SDOH) (Venkatapuram and Marmot 2009; Marmot 2006).

A natural experiment has been occurring whereby a novel and harmful virus has been introduced into the world, and we have been seeing how it spreads, causes harms, and is addressed in different ways within and across diverse nation-states. Each country did not contain distinct human bodies that could explain inter-societal differences, nor did each country have a unique virus variant. It is human and social actions and neglect within countries that are creating the diversity in effects across societies. Furthermore, what each country’s political, health and other leaders have been able to do or not do has been shaped to various degrees by the global social context – the processes, practices and norms of the society of nations, international institutions, non-governmental organizations and increasingly, individuals with state-like powers. The preeminent illustration is that of vaccine hoarding; most LMICs are not able to procure and provide COVID vaccines to their citizens and residents because of how the richest few countries are behaving, how some pharmaceutical companies are operating, and the broader impotence and failures of global institutions and governance.

Second, while a natural experiment is in progress, it is misconceived to refer to the pandemic, as some have done, as a natural disaster, a medical crisis or a tragedy. To restate, this is because everything – from the origin of the virus, to the local outbreak, to the transnational spread and then the spread within countries – has arisen through human actions and neglect. Calling it a natural disaster or tragedy obfuscates the social interactions and social choices and neglect in the causal chain of preventable deaths and suffering of millions of people. To call it a medical crisis shows the lack of awareness (or unwillingness) to recognize the broad social factors in the causal chain preceding the immediate exposure to the virus, and it points to the solution as something to be found in healthcare, or in natural and biological sciences, more generally.

A more accurate and comprehensive explanatory story would be that millions of people have died and still are dying because of inter-related social and biological causes of their constrained abilities to prevent exposures to a harmful virus, to prevent the progression to disease and to prevent death. Vaccines, pharmaceuticals, oxygen tanks and other healthcare commodities are hugely important because they protect or expand people’s abilities to avoid and mitigate harms from this pandemic. But, importantly, the causes of disease and death of individuals as well as the population distribution patterns are not wholly because of the lack of vaccines, therapeutics or healthcare. The place to look to explain why certain people died or suffered while others did not is in the socio-biologically determined abilities of people to prevent infection, progression to serious disease and death.

To illustrate, many people in the richest countries were able to avoid disease and death for many months without a vaccine because of their socially supported abilities to prevent getting infected while continuing to live their lives albeit in a constrained manner. They stayed at home and continued to work or were financially supported through government programmes. Food was made available to them in the shops, public utilities were still made to function, and they had supportive technologies such as internet, phone and television. In fact, many people in rich countries amassed large amounts of financial savings during lockdowns. In the United Kingdom, over £185 billion went into personal savings accounts in the first twelve months of the pandemic (Hickey 2021; Partington 2021). Aside from having selective social protection and more money to do more of what they want to do, such individuals also now have the socially created benefit of being vaccinated so that their bodies are able to prevent progression to serious illness and death as they begin to expand their social interactions.

To understand this pandemic as a natural event, or that the necessary and sufficient solution is medical care, ignores the socio-structural and biological antecedents in the causal-chain of disease as well as non-disease. Furthermore, framing it as a medical crisis with a biomedical solution also hinders mounting a robust effort at preventing deaths in societies where there is no vaccine by minimizing the enormous supportive role of non-pharmaceutical social and policy interventions. Such a truncated biomedical perspective also restricts, perhaps purposefully, deliberations on the scope of possible actions for preventing and mitigating resurgent waves from declining vaccine protection or new variants, future pandemics and local epidemics.

Third, in the face of the pandemic, the CA’s analytical and normative framework has been reaffirmed. In familiar philosophical terms, going back and forth between the practical realities of the pandemic and the CA’s framework through a process of seeking reflective equilibrium results in affirming the CA’s perspicacity, relevance and action-guiding properties. To illustrate, in surveying the levels and distribution patterns of COVID disease and mortality within and across countries, the picture generally reflects the levels and distribution patterns of basic capabilities of individuals. By far, the people that have died the most are older people who are the most biologically and socially excluded, or in CA terms, those with the most constrained capabilities. The distribution patterns do not reflect particular inherently genetic vulnerabilities as some had tried to argue in trying to explain the disproportionate deaths of racialized and ethnic minority groups. They reflect long-standing socially created constrained capabilities. Furthermore, the distribution patterns of COVID deaths parallel pre-existing societal distribution patterns in health outcomes and their antecedent basic capabilities. For example, Michael Marmot showed the pandemic deaths in the UK mirror closely the pre-existing social gradient in health inequalities (Marmot et al., 2020; Marmot and Allen 2020). These long-standing health inequalities and social gradient in health, he argued before the pandemic, reflect inequalities and social gradient in basic capabilities (Marmot 2017).

The larger estimated 19 million cases of excess mortality from all causes can also be understood in terms of the levels and distribution patterns of basic capabilities. That is, these excess deaths and their population distributions cannot sufficiently be explained by individual biology, behaviours or proximate harmful exposures. Millions of people have died beyond the normal pre-pandemic levels because of starvation, of lack of access to non-covid healthcare, of non-covid diseases, of violence and of yet to be tabulated reasons. What is common behind all these individually diverse ways people have been dying is that their basic capabilities – likely to have already been constrained – have been extinguished, largely by harmful and unsupportive social contexts further impacted by the pandemic.

Furthermore, the rapidity by which hard-won gains in health outcomes in LICs have been erased also shows how precarious achievements in discrete health outcomes like disease prevalence levels, immunization rates, DALYs, and so forth can be. Discrete health outcomes stand in contrast to creating, protecting, and expanding health capabilities of individuals, families and communities through transforming socio-biological contexts, from the local to the global. The health achievements that were much-lauded pre-pandemic and produced through large-scale, metric-driven and cost-effective programming now seem akin to economies of superficial prosperity. One of the CA’s central tenets is that for both ethical and instrumental reasons, it is the capabilities of persons, and not functionings or discrete outcomes that should be the target of analysis and interventions. This guidance from the CA goes far in helping explain the rapid erosion of discrete health outcomes from the sudden shock of the pandemic.

So, to summarize, addressing health inequalities and crises requires addressing background socio-structural injustices; the pandemic is socially created and not just a medical crisis nor a natural disaster, or a tragedy. The CA remains a useful analytical and normative framework when confronted with the practical realities of the pandemic. I now turn to present three aspects made visible from the unfolding pandemic and the global response that motivate modifying or evolving the CA.

Global institutions, processes and actors

How nations, international organizations and non-state actors and others have acted over the first twenty-two months of this pandemic illustrates that the current global architecture, or world order, cannot deliver equity and justice across or within societies. Indeed, as some have done pre-pandemic, it could be argued that the current global system is geared towards producing and exacerbating global inequity. Again, the most current and acute example of the dysfunctional global system is how the few richest countries in the world have been subverting the one and only global cooperative mechanism, the Access to COVID-19 Tools Accelerator (ACT-A/COVAX), and procuring vaccines for their own citizens at all costs, and then hoarding millions of vaccine doses above their own needs. The systems, norms and processes in place at the transnational level have failed to uphold even minimally decent relations between societies and other international actors even when there is an existential crisis affecting every society produced through inter-relatedness and inter-dependencies. As the UN Secretary General stated to global leaders present at the General Assembly in September 2021, ‘we’ may have passed the science test, but we get an F in ethics (United Nations Regional Information Centre for Western Europe 2021). While the unfairness and injustice in vaccine procurement and hoarding by rich countries is understood by people worldwide, what is less recognized is the role of the global order in the spreading of the pandemic, and the breadth of injustices in the responses to the pandemic, including and beyond vaccines.

CA advocates, often concerned with extreme poverty, have been relatively more cognizant of the impact of the global architecture and institutions on the lives of individuals (e.g. IMF’s structural adjustment programmes; regional financial crises, global development agendas, metrics, etc.). Nevertheless, much of the focus of the CA and the related scholarship on human-centred development has been on individual capabilities, and at the local and national levels. CA scholars, in the main, have not paid enough attention to the breadth of actors, institutions, legal regimes, processes and norms operating at the transnational level, and how their impacts work their way down to the level of individual, human bodies. The pandemic has made visible how quickly a harmful virus can be carried across national borders by human beings, and how it can be spread quickly within a city and country, eventually leading to deaths of people in homes and hospitals. The pandemic insight here is not just about the specific global and societal pathways of this particular virus. It is also about the existence of discernible transnational pathways that deliver both harms and benefits to individual human beings throughout the world. And that these transnational pathways are governed, supported or neglected by global institutions, actors, processes and norms.

Macro-economists have previously used the term ‘contagion’ and have drawn from epidemiological reasoning to trace the inter-related impacts of global and regional financial crises as well as identified the role of global institutions in exacerbating or mitigating the harms. And, increasingly, social epidemiologists and political economists have been identifying the transnational pathways that enable trade-regimes, political conflicts, illicit financial flows and other phenomena to produce harms in terms of disease and premature deaths in individuals and groups within nation-states. In contrast, CA advocates have largely focused on individual and national level analysis, ignoring the transnational plane, both in empirical research and normative reasoning. They have left the empirical and normative aspects of the supra-national global causal chain of individual capabilities, and the role of the world order on those pathways, under-examined.

Expanding the scope of the CA outward beyond the local and national is urgently needed. This is because there have been few calls for reform despite the clear visibility of the harms that can be spread through and by the current global architecture, and which is unsuitable for securing the health (or just life) of the vast majority of human beings. Instead, deliberations are currently under way for better preparedness for the next pandemic, focusing largely on better identification, reporting and coordinated management of new pathogen outbreaks. The calls for reform are likely to come from leaders of LMICs who have become emboldened by the injustices of this pandemic. For example, the President of South Africa’s articulation of the lack of access to vaccines for most Africans as ‘vaccine apartheid’ intimates an entrenched and actively designed system to exclude people, particularly non-whites (Winning 2021).

The agitation for reforming the international order is likely to keep growing given the growing reach of the decolonization movement, the return of racial undertones to global politics, and a drip-drip approach to making vaccines available to LMICs extending the pandemic for years. What is still missing in all of these movements is the explicit identification of how transnational processes and actors enabled the spread of the virus and consequent deaths, and the diverse forms of inaction and neglect of the many factors that could be acted upon at the supra-national level to protect and expand the health capabilities of people. Greater recognition of the global pathways’ importance at the individual level would also do something beyond identifying the moral and physical harms created by global institutions and actors. It would help move us toward establishing the protection and promotion of individual human health and well-being as the central moral purpose of global institutions and governance. The CA as an analytical framework for assessing individual well-being and an ethical approach asserts the centring on individual human well-being at a societal and local level; that the right purpose of public policy and action is to protect and expand people’s basic capabilities to plan, pursue, and revise their diverse plans of life. This normative position needs to be asserted more clearly regarding all the different parts of the system of global governance.

Institutional capacity for reasoning about equity and justice

A second dimension the pandemic has illuminated is that most global health and development institutions do not have the internal capacity, and specifically staff, to reason explicitly and rigorously about social and global equity and justice. This first became evident in the design and setting up of ACT-A, the only coordinated global response to the pandemic. The ACT-A was created with the aim of pooling global resources in order to rapidly develop, manufacture and distribute pandemic response ‘tools’ including vaccines, diagnostics and therapeutics (three pillars). Of the hundreds of people that were involved from diverse backgrounds that met weekly from April 2020, there were no explicit roles or involvement of trained ethicists across the pillars. The one issue that seemed to be prominently recognized as an ethical concern was the question of how to distribute or allocate vaccines, given there would not be enough for everyone initially, if and when effective ones are produced. And so, the one place where ethics was explicitly considered was in a working group of the Strategic Advisory Group of Experts on Immunization (SAGE) inside the World Health Organization. The SAGE Working Group on Covid-19 Vaccines was tasked with determining the ‘best use’ of pre-licenced vaccines. Under this remit, the group produced allocation principles for vaccines across and within countries – the WHO SAGE Values Framework (World Health Organization 2020). In that committee, there was only one recognized expert in bioethics. And the possibility that ethical expertise aside from bioethics may be needed for deliberating on allocating vaccines across and within nation-states was not recognized.

The necessity for broader ethical reasoning such as is found in political philosophy including accounts of distributive, social and relational justice became more visible to some within global organizations after the uprisings first in the United States, and then in other countries, against racial injustice. These uprisings brought greater attention to the fact that racialized and ethnic minority groups were dying more from COVID because of long-standing socio-structural factors undermining their health, making them more vulnerable to infection, disease and death. National pandemic responses, healthcare triage in hospitals and vaccine distribution principles could be challenged if they are blind to increased vulnerabilities to death because of unjust socio-structural causes such as structural racism. And yet, bioethicists and vaccine scientific experts are usually not skilled in ethical reasoning about social structural causes of disease and death, or how to balance these social justice concerns with epidemiological reasoning during a pandemic.

While SAGE may have produced an ethical principles framework, the formula or allocation framework for vaccines that was actually used across countries by COVAX was apparently produced by management consultants working with GAVI. It was estimated that about 20% of national populations of most societies work in healthcare, so countries that were greatly dependent on the COVAX facility to get vaccines would receive doses up to 20% of their population size, in periodic tranches (GAVI The Vaccine Alliance 2020). Rich countries which would initially put in more money in order to prime the pump for research and development of vaccines would be able to get larger shares. As of October 2021, COVAX has failed in its aim to deliver vaccines to the world, and LMICs in particular. The leadership largely blames manufacturers, while others blame COVAX’s lack of transparency, inclusion of LMICs and community organizations in decision making, the fundamental design of COVAX including its reliance on the charity of rich countries and so forth (Goldhill and Furneaux 2021). Of the few LMICs that have received vaccines, they have gone largely to the elites and professionals and not to the most vulnerable. This means that ACT-A/COVAX has neither been able to deploy strong ethical principles, particularly regarding equity, across countries nor within countries.

Aside from ACT-A operations having a minimal role for ethics and ethicists, the organizations involved such as GAVI, the Global Fund, the EU, FIND, UNICEF, the Gates Foundation and the Wellcome Trust also do not have staff who have expertise in ethical reasoning about specific cases or general principles of global and social equity and justice. In fact, ethics is itself a confounding concept to many within these large international organizations. One type of confusion stems from the term ‘ethics’ often being used within these international organizations in reference to issues of regulatory compliance, anti-harassment, anti-corruption, reputational risk and other related issues. An ethics officer within these organizations is most often an individual in charge of educating and monitoring staff, projects or partners on these kinds of issues.

Perhaps another reason for the lack of capacity and skills to recognize, deliberate, and educate about global and social equity and justice may be the fact that ethical guidance regarding the behaviours of nation-states and other actors engages with international politics. That is, the major and minor actors in the current global system may not welcome ethical constraints on their behaviours, particularly by organizations that they fund, govern and meant to have in their service. The results of that tension are apparent in the fumbling use of ethical rhetoric (‘solidarity’, ‘vaccine equity’, ‘vaccine apartheid’, ‘moral failure’, etc.) by many leaders of global institutions.

One important casualty of the lack of institutional capacity for ethical reasoning is global public deliberation and consequent lack of legitimacy of policies and decisions. The dominant framing of the pandemic as a biological health crisis demanding a scientific solution elevated scientific and financial expertise and reasoning. However, as Guterres said, world leaders have passed the science test but get an F in ethics. The fail marks are deserved not just because of the current situation of vaccine inequity and exacerbated global economic and social inequity. It is also deserved for the non-transparent, small-cabal driven process that produced the outcome. To put it another way, even within the domain of healthcare, most rich countries recognize the need for transparent and deliberative discussions involving relevant stakeholders in making difficult distributive decisions. Those discussions are often guided by or informed by state-of-the-art knowledge about equity and justice in healthcare, and increasingly about social determinants of and inequalities in health. The process of fair deliberation produces more informed discussions and serves to justify the decisions, particularly in cases of life and death. In comparison, what we have seen in the ACT-A response is technocratic and scientific expertise that has not even successfully produced its intended aim, thus failing to achieve both epidemiological goals and ethical justification.

CA scholars take great pride in the impact of the approach on many global agendas as well as the references to the approach by many global organizations. The annual Human Development Report of the UNDP stands as an important example of how the CA and human-centred development has become embedded within an international organization. However, the production of the Report’s annual Human Development Index and references to in speeches are quite different from institutional capacity within organizations to apply the CA, and the more general capacity for ethical reasoning about equity and justice.

Racism and white supremacy as a fundamental cause

The third dimension made more recognizable by the pandemic is that racism around the world and within the system of global governance is a fundamental cause of structural violence leading to disease and preventable death (locally and globally). The CA as well as social and global justice philosophy more broadly has not explicitly or meaningfully recognized or addressed racism as a significant phenomenon in the world. This should be particularly embarrassing for CA scholars because Amartya Sen, one of the few non-white eminent social justice philosophers, has written frequently on racists and racism in his work. A scenario appears in his seminal 1981 article, The Impossibility of a Paretian Liberal: there, Sen discusses the conflicts of rights at play in the example of needing to break into a house to call your friend Ali in order to save him from being attacked by a racist (Sen 1970). In the essay ‘Reason before Identity’, Sen writes of personal experiences of racism including experiencing police abuse in Cambridge, and when a UK border official could not easily recognize him as the Master of Trinity College given that he wrote ‘Master’s Lodge, Trinity College’ as his UK address (Sen 1998).

Sen’s writings also contain less explicit references to racism that are more directly relevant for public policy. For example, Sen refers to ‘Government house utilitarianism’ in describing the governance of colonial administrators. That is, decisions were made by a few white-European men who assumed positions of beneficence, omniscience and, perhaps, omnipotence while determining the policies for the greater good of colonial subjects. The thoroughgoing rejection of utilitarianism by Sen is not only because of its conceptual and ethical deficiencies. It also seems to be rejected because of its historical role and potential continued use to aid white supremacy and colonial mentality. The relevance of this worry to the pandemic is not difficult to see. Think about the calculations some government officials were doing regarding achieving high levels of population immunity through infection, mistakenly called ‘herd immunity’. They were calculating how many people and which people would likely die in the process while the greater population would survive. In most of the worst-affected rich countries, the people that would likely die included older people, those severely impaired, as well as racialized and ethnic minorities made vulnerable from long-standing health disadvantages or facing more intense and frequent exposures to the virus because of their ‘essential work’. Anti-racist activists, as well as others, saw racism underlying the utilitarian-epidemiological calculations.

The various social movements that are mobilizing in the COVID response have been making visible how racism and white supremacy is embedded not only in national institutions but also in global institutions and agendas. For example, one study was produced showing how the leadership of many international health and development organizations is largely white men, and to some extent, white women (Abimbola et al. 2021). The concern pre-pandemic was that the lack of leaders from LMICs would produce agendas and policies aimed at LMICs not sufficiently reflecting the issues and reality on the ground in LMICs. The pandemic has provoked a new argument: that exclusion of non-white people from leadership positions of global organizations is an expression of racism and white supremacy and a continuation of the colonial mentality and reasoning (Kumar 2021). That is, the government house of colonial rule has moved and been reconstituted at the global level. It now operates with the same kinds of people and conceptual tools, and in a more diffuse way across a network of hubs in Washington DC, Seattle, Geneva, Berlin, and so forth.

This revelation of racism and white supremacy being embedded in global institutions and health and development agendas does not diminish the need to recognize their impacts at the national and local levels. The persistence of health inequalities resulting from the domination and oppression of indigenous people, religious and ethnic minorities, and others cannot be understood or addressed without recognizing racism as a fundamental factor. Significant literature already exists on racism in the evolution of epidemiology, public health and medicine. And significant research also shows how racism is evident in healthcare delivery, health outcomes and the drivers of health inequalities. The pandemic has brought to light how racism is inadequately recognized and addressed, despite that racism and its harmful impacts are so pervasive from the inter-personal level all the way to global institutions.

Revelations and actions

A revelation is not an insight into a minor truth. The term points to something significant about our individual and communal lives. And a proper revelation should motivate us to change our thinking and action. Rabbi Sacks was not wrong to think the pandemic can serve as a revelation provoking profound insights for us individually as well as for societies and the global community. From the perspective of a philosopher of global equity, my revelation has been that the present global architecture, actors, values and dynamics are dysfunctional and cannot protect or deliver even a minimal level of health and well-being to the majority of human beings in the world in contrast to what it delivers to those in a few rich countries. The above discussion has pointed to three aspects of this dysfunction. First, that the current global order has a significant role in distributing benefits and burdens, specifically life-threatening harms, to individuals throughout the world. This needs to be more thoroughly recognized and assessed against conceptions of equity and justice. In particular, CA scholars need to more thoroughly recognize the supra-national factors determining the capabilities of individuals within societies and specific locations. Second, the lack of capacity within global organizations (of all kinds) for ethical reasoning about global and social equity and justice is a contributor to the dysfunction and unsuitability of the current global order for promoting and protecting even minimal human well-being. This has to be highlighted and addressed. Third, racism and persistence of white supremacy as a fundamental driver of human deprivations within and across countries must be recognized and addressed directly by global ethics scholars, particular those applying the CA.

Acknowledgements

I would to like to express my thanks to the editor for the opportunity to contribute this essay. I would also like to thank organizers of the HDCA Global Dialogue 2021 for the invitation to speak on how the multiple global crises underway motivates applying the capabilities approach differently to global health.

Disclosure statement

No potential conflict of interest was reported by the author(s).

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Notes on contributors

Sridhar Venkatapuram

Sridhar Venkatapuram is Associate Professor of Philosophy and Global Health at King's College London and Deputy Director of King's Global Health Institute. Sridhar's career began in the early 1990s as the first researcher at Human Rights Watch to focus directly on health-related human rights violations (HIV/AIDS in India). Sridhar is known for helping establish the area of ‘health justice’ philosophy, for engaging with and advising public/global health practitioners, and for amplifying ethical reasoning in public/global health education, research, and practice. His book publications include Health Justice: An Argument from the Capabilities Approach (Polity Press), Vulnerable: The Law, Policy and Ethics of Covid-19, and Routledge Handbook of Philosophy of Public Health (forthcoming). He can be found at @sridhartweet.