By Sridhar Venkatapuram
As we amplify, further develop, and advise in the realizing of health justice, there would be much benefit in clarifying the basic units of moral concern.
This call for more specificity relates to both who is the primary unit of moral concern (individuals, communities, nation-states, etc.) as well as what it is that we care about in relation to them (i.e., liberties, resources including health care, basic needs, respect, opportunities, capabilities, relationships, etc.).
In the current context of the COVID-19 pandemic, where vaccines have become the preeminent goods of value worldwide, I focus my discussion here on how distributing vaccines equitably at the level of geographical units such as districts or nation-states may obfuscate or tolerate injustices, as well as provide suboptimal control of the pandemic.
The COVID-19 pandemic has brought to the fore a greater public and institutional understanding that, in addition to the injustices that occur in access to and in the experience of receiving (life-saving) health care, there is much injustice in the causes that create the need for health care in the first place.
A pivotal shift happened in public understanding that the disproportionate deaths of racialized and ethnic minorities from COVID-19 in the U.S. and other rich countries has less to do with any unique biological susceptibility and much more to do with the harmful social conditions that such individuals and groups experience during their life course, and sometimes, over generations. Racism and white supremacy, for example, in their various forms, some of which are embedded in basic social institutions, have now become clearly recognized as a cause of disproportionate health vulnerability of racialized and ethnic groups.
Scholars and advocates increasingly use the term “structural injustice” to capture the concern for the unjust social/structural causes of ill-health that occurs outside of the healthcare setting. This term complements the fourth principle of bioethics, justice, which is usually understood to encompass fair distribution of health care.
Recognizing and naming structural injustice is an important first step. But a critical next step, determining what health justice demands in response to all of the various kinds of structural injustices, remains unresolved. If basic social institutions and practices are causing unjust harms and deaths, mitigating, preventing, or compensating for those unjust harms requires transforming social institutions, practices, norms, and values. But where does the work begin, particularly in a pandemic?
One novel and precedent-setting response advocated by the U.S. National Academics of Sciences, Engineering, and Medicine (NASEM) was to use “disadvantage weights” in the phased distribution of vaccines across the country, at a time when supplies were scarce.
After prioritizing certain population groups across phases based on epidemiological, biological, and other social concerns, NASEM advocated using a social vulnerability index. Prior to the COVID-19 pandemic, the U.S. Centers for Disease Control and Prevention developed a social vulnerability index using 15 census variables to identify the census tracts that are likely to need particular support during disasters and disease outbreaks. The NASEM report proposed that 10% of total federal allocation of vaccines be reserved for the top 25% of the most deprived census tracts within a state, and local authorities should make special efforts to deliver vaccines to these high-vulnerability areas.
Such an effort is profoundly important in moving toward health justice during this pandemic, and the use of “equity weights” will impact health policy making beyond vaccines and the pandemic.
At the same time, vaccine prioritization at the level of U.S.-census tracts should sit uncomfortably with Anglo-American liberal political philosophers and others who are used to asserting the individual human being as the primary or ultimate unit of moral concern. To be more clear, prioritizing a geographical unit like a census tract in order to address longstanding structural injustices causing health vulnerabilities ignores individuals who have been equally or even more socially disadvantaged outside those areas. Showing respect for the moral equality of persons would require providing them a reasonable justification.
A similar kind of geographical equity exercise is happening at a global level with the distribution of vaccines. Grossly limited numbers of vaccines are being distributed to low- and middle-income countries. There is little tracking of the distribution within each country. While these countries have little infrastructure to track the recipients of vaccines according to age, ethnicity, socio-economic status, and so forth, it seems fairly clear from second-hand accounts that it is the elites and socially connected that are getting the few vaccines. This includes both first and second doses. Providing COVID-19 vaccines to those who can push to the front of the line neither serves the epidemiological goals of containing infections and deaths very well, nor does it address the social injustices that cause vulnerability to serious illness and death from COVID-19.
I have been arguing for a long time now that every individual’s moral right to health capability requires addressing harmful structural factors, no matter where we find them. It is individuals who have the moral right to health capability.
I am not claiming that moving to more granularity beyond census tracts or national borders will be easy. But not following through on the basic principle that justice demands we assist individual human beings who are socially disadvantaged and experiencing structural injustice (and not geographical units), we will continue to ignore or tolerate the suffering of those who have legitimate claims of justice. In a way, this makes such individuals worse off than before our efforts to address structural injustice, as they are now recognized, but their justice claims are ignored.
Sridhar Venkatapuram, MSc, MPhil, PhD, FRSA, Hon FFPHm is Associate Professor of Global Health & Philosophy at King’s College London, Deputy Director, King’s Global Health Institute, and Director, King’s Global Health Education & Training.