Every passing week in global health seems to put multilateralism to test. And in general, a stress test on our abilities to come up with solutions to unabating challenges sparked by the current pandemic.
Many of us have been absorbed in trying to understand the mechanics of this multi-dimensional response to COVID-19. But this week we take a step back to ponder on the big questions of justice, equity and ethics - fundamentals that underpin decisions on “who lives and who dies”.
We bring you a thought-provoking interview with Sridhar Venkatapuram, a global health academic and a political philosopher, who spoke to us describing the urgency of these questions in a long conversation during the summer. I hope you will take the time to read this important interview even as you may be dealing with the nuts and bolts of the logistics of making global health work against many odds.
What’s striking is that surely and inevitably global health is making space for sociologists, anthropologists, political scientists and philosophers. A fascinating power dynamic is underway, as technical and scientific domains find ways to work together with these “epistemic communities” as experts call this. You cannot keep politics out of health and you cannot keep philosophy out of politics. Read on.
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1. Story of the week
PHILOSOPHERS SEEK TO MAKE SPACE IN PANDEMIC RESPONSE
Sridhar Venkatapuram, is an Associate Professor at the Global Health Institute, King’s College London. He has spearheaded the Independent Resource Group for Global Health Justice (IRG-GHJ “URGE”), along with other philosophers and experts to address the some of the biggest questions of the times we are now living in.
You can also watch this recent event where these experts lucidly explain what they intend to do in getting organizations to discuss complex global justice matters and the ethical issues that this pandemic has thrown up.
He spoke to Geneva Health Files at length on how issues around allocation and distribution of medical products, for example, are being framed and why it is important to question the framing of these matters.
Q&A: Sridhar Venkatapuram, Associate Professor, Global Health Institute, King’s College London, and Chair of the Independent Resource Group for Global Health Justice
[GHF]: How would you explain to a lay person, what role can ethics play during the current pandemic? Have ethics being sufficiently integrated in our institutional response to COVID-19?
[SV]: To a lot people, ethics is an unknown quantity. There is a general lack of understanding or appreciation of what ethicists do, and what they don’t do. Ethics and bioethics do not mean the same thing.
In WHO, for example, ethics are used in two different contexts - one where it is about issues such as compliance, corruption, sexual harassment among others. That is a kind of professional ethics. Then there is a second area where people use the word ethics which is around research ethics. So, if someone is undertaking in some sort of research study, they have to submit a report to an Institutional Review Board or an Ethics Review Board.
WHO has a small ethics unit dealing with research ethics and increasingly beyond that. But there are concerns over whether this small ethics unit, and academics that are linked to it, is well-represented by relevant experts from different countries. Is there meaningful diversity in the representation of ethical traditions? So far, the bulk of the intellectual work of ethics group was being done by external collaborating centres because WHO does not have the resources. These collaborating centres have been overwhelmingly dominated by Anglo-American bioethicists. That is because, bioethics as field is professional and large in North America.
Well-funded universities, bring their research agenda to WHO and contribute to global ethics guidance.
Therefore, the ethics guidance produced by the WHO, risks being centered around what American ethicists deem as important, which may or may not be relevant to the world.
So, for example, what is interesting for these collaborating centres could be issues such as new technologies, big data, genome editing – which is great. But when it comes to the big public health problems, or understanding the social causes of health, or say how does trade impact, social inequality and health, how do economic policies impact on health – these issues do not get adequate importance. Typically, people working on these issues do not have a “collaborating centre relationship” with WHO. These kinds of issues, move into politics and political philosophy.
So, people who work on public health ethics, or have depth of knowledge of LMICs, have not be as engaged or involved in determining the ethics response to this pandemic.
We now know because of this pandemic that it's not just about research ethics. If you look back at the WHO meeting in February, the roadmap seemed to present ethics questions as to do with doing ethical research about SARS-Cov2. To be clear, this is not only just about public health ethics, but also about global health ethics, and global ethics in general. So when one country starts stealing the Personal Protective Equipment (PPE) of another country, what do we say about the ethics of that? Worse, what happens when we don’t say anything about it in terms of ethics?
How we should relate to each other across countries during a crisis or what do we say about the fact that a country failed in its ability and responsibility to notify the world quickly and clearly that there's something dangerous that's coming out of their country?
So, in order to fill some of the many gaps, we have been trying to get experts on public health and global health ethics involved in this process of a global response.
What began as a group tasked with research ethics at WHO, quickly transformed itself into a group responsible for wider ethical issues on the pandemic. It also took some effort to get the membership be made public. But the group does not necessarily have the expertise on some of these big social and political choices happening at the national and global levels. This is where the politics comes in.
There are concerns by range of actors and Civil Society Organizations (CSOs) that the ACT Accelerator, for example, does not adequately recognize or account for the many ethical dimensions arising in each of its pillars. Rather the focus has largely been on logistics and operations. There is also very little information on who is on these different pillars, how they got there, and who is being asked to do what. There is a need for transparency on how these decisions are taken.
From a social and global ethics perspective, the lack of transparency is a problem because you do not distribute or you do not design distribution of life-saving goods in secret. A secret group of experts cannot decide who lives or gets helped, while others do not help and possible die. That would not be allowed to happen in most democratic societies, and it is certainly not what was envisioned in how the UN systems should world. Especially during a crisis, we must make sure that there is transparency, legitimacy, process, and outcomes and accountability.
Who should be taking the moral decisions on who lives and who dies?
Not enough people are challenging the ideas that are being handed down in some sense. There seems to be worry that scrutinizing what the ACT-A actors are doing will be seen as criticising the ACT-A, especially given the exceptional crisis ethos around all of it.
In political decisions about justice and equity, there is a need for transparency and legitimacy and publicity.
[GHF]: So, what are you trying to do about this?
[SV]: We are bringing philosophers and experts on ethics together. We need to really set the values for a world after the pandemic - we are rebuilding the world in some sense. We have to think about how do we articulate the rules now?
But no one's really raising these questions because everybody thinks it's all technical. It's all about money. Everyone is busy working away. But fundamentally these are really big questions.
The discussion about ethics and equity cannot be dominated by a few countries. There are big, powerful developing countries, but they do not necessarily talk in the language of values. There are not enough people who are able to engage in this kind of conversation.
We cannot keep talking only about say, human challenge studies or big data. We also have to discuss important questions on how we allocate vaccines or what is the right response of a government who has to choose between this or another epidemic? We must ask how governments are using data? How are we making choices between response to the pandemic and say, efforts to address maternal mortality, for example.
Why are we not talking about structural injustices in the context of this pandemic? The people who are dying are the ones that have always been at risk. How do we ensure that government policies on COVID-19 do not exacerbate structural injustices?
[GHF]: How do we judge whether ethical policies have had any impact on the pandemic?
[SV]: When we talk of ethics, we will have to see whether these discussions have had an impact on the policies that will be implemented. Will the policies truly reflect the global ethics agenda?
We must question if the best people, with the right expertise are framing the issues on ethics for this pandemic response? Perhaps it would make sense to use competencies across organizations to devise this.
The problem in global health is too many people think of themselves as benefactors. Because these are decisions that they are used to “giving” because it is not about themselves, but about “people over there” Unfortunately this mentality still exists. But during a pandemic, our futures are interdependent.
How do we ensure distribution so that it is sustainable and fair? In the current context, legitimacy is a profoundly important thing. Trusting scientific and technical people to take decisions about distributive justice may not be the right approach.
In this situation, there are many, many ways in which you can distribute a valuable good. There are many ways of approaching it. No single person or even a group of people can put forward the one right answer. So, you have to be able to provide an answer and the reasoning. And then see if the world will accept that and then make sure there's a process so that the world accepts it.
When a problem, such as the current one, is caused by social injustice, how do we address issues of distributive justice?
We are facing this really big event… in a way how nations think about each other and work with each other and the way the institutional actors work.
We now have to set the values, set the tone. We have to set the framework for how we are going to get through this and beyond this. This is a big global justice, global ethics, and global systems question. So, we are not just sort of dealing with how to distribute a vaccine, or issues of the ACT Accelerator. We are essentially setting up the way that we are going to work together as a global community in the future. This should be addressed at the highest levels, not just merely in the context of research ethics.
It is not just about the allocation framework, but we are talking about procedural ethics, and institutional ethics. If we can get this conversation going that you do not just impose this framework from the top - then I think it’s a win.
We must also ask questions on the role of member states in implementing and interpreting global guidance. What would it actually mean for this country in this context and does the guidance reconcile with local realities? And if countries are not thinking enough, then we need to think much more while working on global guidance.
How do we make sure that we don’t simply follow only guidance based on scientific expertise, but also think if it’s value-based. We should especially make sure that it aligns with the way that we think about equity and justice and fairness.
Giving global guidance is one thing, but trusting that countries will do the right thing is another. The whole of point of legitimacy is once you make policies, people will carry it forward. But without safeguards built in to ensure equitable access and justice, the guidance risks not getting implemented the way it should be. Having an allocation framework is fine, but in my opinion, WHO is not preparing for a world, where countries will not respect policies on fairness in delivery and distribution of vaccines.
In the coming weeks, Geneva Health Files will look more closely on how ethics have guided response to the pandemic at international institutions.
If you want to read more on some of WHO’s work on these issues so far, see below.
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2. What we found interesting this week:
I. The Emergency Authorization passport for drugs?
It appears that “Emergency Authorization” is hastening regulatory processes for drug companies more than ever during this pandemic.
We were somewhat intrigued to see this:
Vaccine makers can skip U.S. inspections: Bloomberg
“FDA regulations don’t require what’s known as a pre-approval inspection for products seeking emergency use, said Jerry Weir, director of the Division of Viral Products in the FDA’s vaccines office. Weir spoke last week at a meeting of FDA advisers to discuss standards for Covid-19 vaccines…”
While the story also adds that vaccine developers will need to share more details of their manufacturing process, it does raise some questions. (For example, according to Bloomberg, an FDA database shows Moderna has never been inspected by the FDA).
Clearly something we will be trying to wrap our heads around in the coming days. Regulatory intelligence geeks, please help us understand this.
II. Consultants Vs Public Good
Read this brilliant parsing of Rudy Guiliani’s impact on public health as seen in the context of his advisory roles to his clients including Purdue Pharma and Ranbaxy.
‘Where is Rudy?’: Inside Giuliani’s checkered track record as a pharma consultant by Ed Silverman at Stat. He concludes:
“...At the end of the day, though, Giuliani is like any consultant who wants to get paid for giving advice or fixing a problem. But he is no public health expert and, whether he is working for Trump, Purdue or Ranbaxy, his first interest is his client — not the public good.”
We must keep this in mind, while examining the role of consultants in public health. Get in touch with us, if you want to talk about this.
3. We are also watching:
America’s exception, at WTO
US holds up Ngozi Okonjo-Iweala appointment as WTO Director-General: The Africa Report
At a critical time for the world steeped in the current pandemic, the US continues to hold back crucial processes at WTO, this time by opposing the nomination of Ngozi Okonjo-Iweala for the top job at the international trade body. The reasons for the lack of American support for the former Nigerian finance minister, is not yet clear. (U.S. is the only WTO member to oppose this appointment.)
What happens next is anyone’s guess. To what extent can the U.S. influence the final process remains to be seen. The General Council of the WTO is expected to meet on November 9, post American elections. If the US continues to block the consensus on the matter, WTO will find itself at an impasse. This could then open the door to a vote.
See our previous story on the elections here. We quote excerpts from what we wrote earlier:
To understand the importance of consensus, look no further than 1999. Incredible as it may sound – in 1999, countries could not agree on a candidate. Eventually, both served a three-year term each. (Mike Moore – 1999-2002 and Supachai Panitchkpakdi – 2002-2005).
“The atmosphere then was opaque and poisonous. Countries would not want a repeat of that”, a source familiar with the events of 1999 recounted.
So, WTO is no stranger to a politicised election process for appointing its director general.
See below as stated in a 2002 document titled “PROCEDURES FOR THE APPOINTMENT OF DIRECTORS-GENERAL”:
Recourse to voting as a last resort:
.. If, after having carried out all the procedures set out above, it has not been possible for the General Council to take a decision by consensus by the deadline provided for the appointment, Members should consider the possibility of recourse to a vote as a last resort by a procedure to be determined at that time. Recourse to a vote for the appointment of a Director-General shall be understood to be an exceptional departure from the customary practice of decision-making by consensus, and shall not establish any precedent for such recourse in respect of any future decisions in the WTO.
The coming days could see “frenzied activity” according to WTO officials.
In a report, U.S. State Department cable signals support for South Korean in WTO race, Politico said:
“If Okonjo-Iweala emerges as the last woman standing at the HODs, the phones at the State Department and the White House National Security Council "will be ringing off the hook" urging them to persuade Lighthizer not to block her way, the former U.S. trade official said. That could even include a call from Nigerian President Muhammadu Buhari.”
Upcoming World Health Assembly
On-going at WHO: Emergency Committee meeting on the pandemic
Fifth Emergency Committee meeting on COVID-19 under the International Health Regulations (2005) (IHR) is being held today, 29 October.
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