24 August 2020
“Historically, pandemics have forced humans to break with the past and imagine their world anew. This one is no different. It is a portal, a gateway between one world and the next.” – Arundhati Roy1
Inspired by these words, we try to imagine ‘another world’; one which puts everyone’s health and human rights at the center. For us to do that, we need to start with introspection about the world we wish to leave behind and ask ourselves some tough questions. For we, those working on health and human rights in global spaces and beyond, need to reflect on our values, our standards, our institutions, our mechanisms, and ask if we are fit for purpose. Can we seize this opportunity to rebuild anew, without first taking a mirror to the sheer savagery of the injustice on display around the world—and our role in it? The obvious answer is—NO. Unless we realign our values, we risk dragging ‘the carcasses of our prejudice and hatred’ into the new world.
With the waning of, or growing ennui from the shock of the pandemic, the world seems ready to slip back into ‘avarice’ with little thought. The reversal of the temporary but refreshing drop in carbon dioxide levels is evident, as is the greed of big pharma, and the onslaught on the global commons. Are we going to continue with the absurdity of our present or ‘…walk through lightly, with little luggage, ready to imagine another world’?1
In the WHO Constitution, world leaders proclaimed ‘the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being.’2 The true meaning and purpose of this statement while never fully realised have never seemed more distant. It took just a few weeks of the COVID-19 pandemic for the gains of decades to begin to erode. In the past months, millions have been pushed back into poverty; catastrophic consequences have been borne by the elderly; women and girls have suffered unspeakable levels of violence and been denied essential services, and we are witnessing what could well be a lost generation of children. All of which is needless and all of which was preventable. The question, therefore, is how did it all go so horribly wrong?
Over the last several decades, there have been significant, though uneven, advances in recognising health as a human right. Addressing discrimination and inequality have largely been accepted as critical for people to attain and maintain their human rights to health.3 There is a general acknowledgement, at least discursively, that an individual’s ability to manifest their human rights has a direct bearing on their health and vice versa.4 Consequently, there have been significant strides in the development of normative aspects, on a range of global health topics, as well as tools for monitoring health from a human rights perspective.5
These advances have, however, been paralleled by regressive tendencies. The operationalisation of health within countries is often undermined by arguments that the specificities of national contexts justify the abdication of human rights responsibilities, resulting in policy incoherence and uneven implementation of international norms and standards.6 Macrolevel politics and ruling ideologies have had profound impacts on the provision of services, and ultimately individual realisation of health.7 Patterns of financing and funding for global health significantly determine not only normative developments but the implementation of interventions on the ground.
Global health work continues to pay lip service to human rights in setting global and national development priorities. Yet the structures do not embrace health as a human right, as intrinsic to the capability of individuals to achieve a life they value.8 In failing to embrace what human rights offer, we lean towards simplistic solutions to otherwise complex global health issues, rooted deeply in social, cultural, religious contexts. COVID-19 is a stark example of this failure, both in the events leading up to the pandemic as well as in the responses. But COVID-19 is not unique in revealing an ecology of sickness and mortality based on social determinants of health.9 Failing to explicitly address human rights concerns not only continues to jeopardise the response to this pandemic, but the future of global health. The time is now to rethink health as a human right, that is premised not just on our collective conscience, but our collective responsibility.
To rethink global health, we have to start by reimagining health as a ‘global common’. So much of our world is premised on the notion of the individual that we have trouble understanding that some of the most crucial wealth we own is collective and social.10 Many scholarly writings, reflecting on the determinants of the current pandemic, point to our failure to approach global health as ‘commons’ as the beginning of our collective descent. Market structures and capitalistic models of development which justified everything, from fracking to unfathomable use of fossil fuels, to the systemic perpetuation of inequities, have systematically unravelled the concept of the ‘commons’. Add to that the abandonment of global leadership and the withering trust of populations in political leaders, the very glue that might have held the commons together, has been relinquished.
Sad as this may be, it is not new. For at least a generation, the archetype of ‘commons’ has been tainted by the narrative that it is invariably a tragedy.11 This view argues that commons would fall apart, as eventual overuse would destroy the resource. The pandemic, and the litany of failures that led to it, is evident.
This pessimism may persist, in part, because the notion of the commons is frequently confused with an open-access regime, in which a resource is essentially open to everyone without restriction. Therefore, without the ‘social infrastructure’ that defines the commons—the cultural institutions, norms and traditions—the only apparent value left is private profit for the most aggressive appropriators without any incentive to invest in the resource because someone else may gain from the returns.12
The same is true for global health. Healthcare systems are held and managed under different property regimes, often with complete disregard of the basic tenet, that global health foremost is a ‘global common right’ and healthcare systems a ‘common pool resource’.13
As we strive to create another world, we must start by challenging how we understand ‘commons’, and build a narrative for the collective, recognising the power of exogenous variables such as moral and social norms, and the significance of the commons to those who do not hold the strings of power. Equally importantly, we must rebuild public trust, because it is not just addressing the pandemic that is at stake, but the whole future of global health.
To ensure we are fit for purpose for a new world, we need to take a deeper look at our institutions, our mechanisms. The questions that arise are not about a single institution or mechanism, but about multilateralism as a whole, and about the member states who are the ‘masters’ of these institutions and the bedrock on which multilateralism is premised.
The history of the United Nations (UN), and the League of Nations that preceded it, provides critical context. Many blame the failure of the League of Nations, on general weaknesses within the organisation, such as the voting structure, and incomplete representation among world nations. The League was also paralysed by the absence of the USA, already a significant power. As paradoxical as it may be, the same pivotal country is now systematically disengaging from multilateral institutions and agreements. The situation for the UN today, however, is more complicated. Not only is this a time of rising nationalistic demagogues as leaders, with narratives restricted to ‘me’ first; the system also struggles with structural weaknesses, block politics and a voting structure which privileges certain countries over others. Member states can rightly be criticised for reducing the UN to a fig leaf that they hide behind, but also a whipping mule.
Despite rallying calls for global solidarity, as COVID-19 has shown, we are NOT all in this together. Siloed and isolated positions do not work. No one is insulated, and no issues are unconnected. The pandemic has brought into sharp focus the interconnectedness, the indivisibility and inalienability of the human rights agenda from the global health, global development and global peace agendas. Time is now to show real leadership, seize the opportunity and bring these agendas together to deliver a truly sustainable future, one that truly leaves no one behind.
The need for an in-depth review of these institutions today is more acute than ever because the way we strengthen and reshape them will not only determine our collective future but that of generations to come. For any such review to be genuinely transformative, however, it must start with a review of the member states and their conduct domestically and within these institutions.
John Locke explained the notion of the social contract as one ‘where people in the state of nature conditionally transfer some of their rights to the government to better ensure the stable, comfortable enjoyment of their lives, liberty, and property’.14 The pandemic has shown people around the world willing to give extreme deference to the state and readily accepting severe restrictions to their freedom of movement for weeks and months at a time. However, hundreds and thousands of lives have been lost, sometimes because of authoritarian leadership and their inability to accept scientific evidence and willingly subject people to needless suffering and death. The question becomes, therefore: is the current social contract tenable? From the grass roots to the national to the global level, as governments fail to provide ‘stable, comfortable enjoyment of their lives, liberty, and property’, this question is now universal.
As the elite went into their burrows and hid for months largely unscathed, the ‘common person’ not only bore the burden as ‘essential workers’ but many died needlessly. The demand for an equal social contract premised on the fundamental values of human rights for all human beings, equal participation and voice and not deference, is required. We need collectively to answer the question: is it time to renegotiate the social contract? The stakes are high, and we cannot afford to get it wrong.
We go back to our original question: are we ready to imagine a new world? To answer yes, we must first fathom the courage to ‘shed the baggage’, the prejudices of the past and reimagine a narrative which puts our collective health and human rights at the centre. Through this essay, we hope to initiate a discussion that can help us build back for the better. In the words of Jonathan Mann, ‘time is now for us to come together as “equal partners in the belief that the world can change”.’15