• COVID-19
• Health policy
• Health systems
• Public Health

Calls for justice-oriented approaches to global health gained momentum and visibility during COVID-19. For many years scholars and community leaders have been discussing and debating the ideas of health equity and social justice,1 but with the COVID-19 pandemic the social and health injustices suffered by millions around the world came into a sharp relief in popular news media. Moreover, as it has been repeatedly stated, the pandemic and our responses both revealed and exacerbated injustices that have always been there. Rather than tinkering with the status quo, there is growing momentum behind advocacy for a new approach to global health and building a new global health architecture with fundamentally different foundational principles grounded in justice.

The calls for more justice in global health has been voiced even by stalwarts of the current global health system such as WHO leadership. At a July 2022 WHO press conference, Mike Ryan, Executive Director of Health Emergencies Programme, exclaimed, ‘We’re saying, yes, the response has been painful and there’s been great injustice, and the greatest tragedy will be to repeat that again in two, four, six or ten years’.2 He further noted, ‘…the solution for the next time is about the simple things, investing in primary healthcare, investing in communities, investing in social and health justice and not having so many hundreds, billions of people around the world who have no access to healthcare’.2 In order to consider such calls for greater social and health justice as more than activist or political rhetoric, we need to directly consider the questions, why and what is a justice-oriented approach to global health, and what would a global health architecture centred on justice look like?

Indeed, social and health justice may be vague and unfamiliar concepts and vocabulary for many global health professionals and leaders. However, there is a large body of philosophical and empirical literature on these topics. For example, in a well-regarded essay published 20 years ago called, ‘Why Health Equity’, Amartya Sen made a dual assertion that health equity must be a central concern for social equity and justice and conversely, ‘Health equity cannot be concerned only with health, seen in isolation…it must come to grips with the larger issue of fairness and justice arrangements, including economic allocations, paying appropriate attention to the role of health in human life and freedom’.3 Sen then goes on to argue, ‘what is particularly serious as an issue of injustice is the lack of opportunity that some may have to achieve good health because of inadequate social arrangements, as opposed to, say, a personal decision not to worry about health in particular’.3

What is relevant here for global health folks is that rather than focusing only on health status and healthcare, we must recognise the great injustice in inadequate or harmful social arrangements that constrain the opportunities of people to be healthy. Sen argues that we must distinguish between, ‘achievement and capability’ on the one hand, and the ‘facilities socially offered for that achievement (such as health care), on the other’.3 And so, if we follow Sen’s reasoning, a justice'-oriented approach to global health would mean we have to go beyond health achievement, to also encompass the capability to achieve health through addressing unjust social arrangements which lie within and beyond the healthcare and health systems. To not do that is to be willfully blind and tolerate great injustice.

However, when we examine the different future pandemics initiatives underway (eg, the pandemic fund, the draft pandemic treaty, 100 days Mission and others), they seem to espouse narrow, patchwork solutions rather than address the endemic and acute injustices which the pandemic exposed. This raises questions about what lessons have actually been learnt over the last few years, and how much of these future pandemics efforts actually reflect a justice-oriented approach. To be fair, at least in some of the documents there are references to ethical principles such as equity, human rights and inclusiveness. Yet, these and the larger issues of ‘fairness and justice arrangements’ are dealt tokenistically at best. That is, justice and equity language is being used as political rhetoric rather than substantive framing ideas.

The need to prepare globally for the next major epidemic or pandemic is undeniable. But the diverse future pandemic discussions and superficial ethical rhetoric may be diverting attention from, or even co-opting the advocacy momentum for a fundamental rethink and rebuilding of both health systems and broader systems for health, nationally and globally, that are grounded in principles of justice.4 Of course we need to put justice at the forefront in future pandemic responses, but we need to have a justice orientation in addressing overall health of populations on an ongoing basis. Justice-oriented systems for health, particularly those which address the needs of those with the most restricted opportunities to be healthy, of the most marginalised and vulnerable on an ongoing basis would, in fact, best prepare us to address the next pandemic (if and when that may happen).

The consideration of the future pandemic preparedness efforts is clearly also related to how we understand the frequently used term ‘resilience’ from a justice approach. Resilience in public and global health literature is often explained as the capacity of health systems to absorb shocks, internal or external. As COVID-19 and Ebola before it exposed, for many countries, the concept of resilience is a mere apparition. There are very weak or no systems in place at all in many countries to be resilient with. Unless there is a shift in thinking which addresses inequities in investments and capabilities of health systems within and across nations, very little can be achieved. And, importantly, these least resilient countries are due to experience shocks that are very real such as rising burden of diseases due to climate shocks, conflicts and other local events while the next pandemic is hypothetical.

While particular approaches to justice may clarify the what and how in global health, even the basic link to justice as an idea has value. As Carvajal states so well, the idea of justice provides a ‘non-parochial view’, meaning that we are pulled out of a deeply contextual, narrow or myopic perspective, and it helps us focus on the ‘actual lives people live’.5 Global health has become dominated by metrics and agendas distanced from the actual lives of people. Whether it is healthcare packages, financial flows, disease control priorities, health metrics or the like. COVID-19 has revealed how the ignorance of the quality of and fairness in actual lives of people everywhere can make what should have been a controllable situation into global devastation.

Making a step-change in global health and not repeating past mistakes requires us to challenge the dominant discourses, question entrenched power holders and rethink and re-vision, “…what health is, how it is created and distributed, and why it is valuable to human beings’'.6 In particular, our collective failure to recognise and challenge ideological neoliberalism, while also reaffirming it within the context of the so called ‘new architecture’ impedes us from truly making progress on fairness, equity and justice in global health. While some safeguards being offered are notable, they offer a mere fig leaf of protection against the challenges we are facing. Let us remember that even after 3 years of the pandemic, we still do not have the basic patent waivers from Big Pharma companies and their host countries. While such companies continue to collect billions in pandemic profits millions of people around the world are suffering and dying. The Economist magazine estimates that over 27 million people have died so far from the pandemic,7 while official statistics state 6.9 million have died directly from COVID-19.8 We must ask the question, why was it that even the most powerful leaders of governments and institutions were not able to address these injustices? Were they unable or unwilling? And how would a fundamentally new architecture address these injustices and truly build back better?

In responding to criticisms that she was complicating things, the Black feminist Audre Lorde said, ‘There is no thing as a single-issue struggle because we do not live single-issue lives’.9 Similarly, we in global health need to reflect on our fixation on narrow interventions and outcomes as we look at a world beyond the pandemic and imagine one which can robustly respond to the plethora of existential issues that are confronting humanity. Now is the moment to purposefully pause and reflect. We need to grasp this window in time as an opportunity to build national and global systems for health grounded in the ideas of justice and fairness. It would be a lost opportunity if we try fixing just the events that led to the last pandemic. We must have the courage to create anew, and not make the same mistakes or follow the same old scripts if we are to truly embrace a justice approach to global health and beyond. The alternative is that unjust systems do eventually fall, sometimes quite dramatically.