Global Health Solidarity

Scarce resources, public health and professional care: the COVID-19 pandemic exacerbating bioethical conflicts - findings from global qualitative expert interviews

BACKGROUND

Since spring 2020, the SARS-CoV-2 virus has spread worldwide, causing dramatic global consequences in terms of medical, care, economic, cultural and bioethical dimensions. Although the resulting conflicts initially appeared to be quite similar in most countries, a closer look reveals a country-specific intensification and differentiation of issues. Our study focused on understanding and highlighting bioethical conflicts that were triggered, exposed or intensified by the COVID-19 pandemic in low and middle-income countries (LMICs) and high-income countries (HICs).

METHODS

We conducted qualitative interviews with 39 ethics experts from 34 countries (Argentina, Australia, Austria, Brazil, Canada, Colombia, Denmark, Ecuador, Ethiopia, France, Germany, India, Italy, Israel, Japan, Kyrgyzstan, Mexico, Nigeria, Oman, Pakistan, Paraguay, Poland, Romania, Russia, Singapore, South Korea, Spain, Sweden, South Africa, Tunisia, Türkiye, United-Kingdom, United States of America, Zambia) from November 2020 to March 2021. We analysed the interviews using qualitative content analysis.

RESULTS

The scale of the bioethical challenges between countries differed, as did coping strategies for meeting these challenges. Data analysis focused on: a) Resource scarcity in clinical contexts: Scarcity of medical resources led to the need to prioritize the care of some COVID-19 patients in clinical settings globally. Because this entails the postponement of treatment for other patients, the possibility of serious present or future harm to deprioritized patients was identified as a relevant issue. b) Health literacy: The pandemic demonstrated the significance of health literacy and its influence on the effective implementation of health measures. c) Inequality and vulnerable groups: The pandemic highlighted the context-sensitivity and intersectionality of the vulnerabilities of women and children in LMICs and the aged in HICs. d) Conflicts surrounding healthcare professionals: The COVID-19 outbreak underscored the tough working conditions for nurses and other health professionals, raising awareness of the need for reform.

CONCLUSION

The pandemic exposed pre-existing structural problems in LMICs and HICs. Without neglecting individual contextual factors in the observed countries, we created a mosaic of different voices of experts in bioethics across the globe, drawing attention to the need for international solidarity in the context of a global crisis.

Pandemic Risk and Standpoint Epistemology: A Matter of Solidarity

Current and past pandemics have several aspects in common. It is expected that all members of society contribute to beat it. But it is also clear that the risks associated with the pandemic are different for different groups. This makes that appeals to solidarity based on technocratic risk calculations are only partially successful. Objective 'risks of transmission' may, for example, be trumped by risks of letting down people in need of help or by missing out certain opportunities in life. In this paper we argue that a rapprochement of the insights of standpoint epistemology with pandemic science and pandemic policy making may be an important step toward making pandemic science more accurate and pandemic calls for solidarity more effective.

Solidarity and polarisation regarding COVID-19 and related risks - A thematic analysis of comments from an international survey

COVID-19 represents a risk to people's life and societies in their current shapes and functions, with institutionalised responses redefining everyday life. Crises in society can induce fear and tensions that can unite and divide people, inducing acts of solidarity and polarisation. The study explored articulations of solidarity and polarisation in relation to the COVID-19 pandemic and related risks. A Foucault-inspired thematic analysis was pursued on qualitative data from an international survey about COVID-19 and social media. The analysis resulted in four themes illustrating articulations of solidarity and polarisation related to the COVID-19 pandemic. The analysis showed solidarity and polarisation as each other's premise and contradiction. Socialisation into a ‘new normal’ was characterised by the balance between solidarity and polarisation as well as aspirations to enhance future solidarity. The study illustrated that social media functioned as social technology for control and manipulation towards social normalisation. However, it was also used to voice attempts to rectify (or overthrow) the dominant medico-political discourse and norms with own preferences, opinions and a functioning daily life. In short, the articulations and social media uses could be interpreted as expressions of power and counter-power.

Articulations of antimicrobial resistance in trade union financed journals for nurses in Scandinavia - A Foucauldian perspective

Antimicrobial resistance (AMR) in bacterial infections is a growing threat to humanity and a challenge to healthcare systems worldwide. Healthcare professionals have an important role in preventing AMR and the spreading of infections. This article focuses on trade union financed journals for nurses in Scandinavia studying how the journals articulate AMR to its readership. A systematic literature search over an eleven-year period was conducted, using web-based national trade union financed journals, searching for 'bacteria' and 'resistance'. A thematic analysis, inspired by Foucault's concepts of power and governmentality, was made of 131 texts to understand, which kind of practices, strategies and policies the journals frame regarding AMR. The time period studied resulted in the recognition of four separate themes: the horror scenario, the 'dangerous' other, healthcare professionals as a source of resistance development and AMR as a field of research and producer of research qualifications. The study concludes that the journals tend: to present AMR in apocalyptic terms with more research and pharmaceutical industries needed for avoidance; to point out problems in other countries, populations, and sometimes nurses' working conditions, but primarily with other professionals' behaviour; and lastly, to present the nurse as a good fairy and disciplinator of doctors.

Does the COVID-19 pandemic threaten global solidarity? Evidence from Germany

The global COVID-19 pandemic poses challenges to the economy, politics and public health systems of developed and developing countries alike. However, the latter are less well placed to cope with adverse effects. In particular, important advances towards sustainable development might be reversed. Tackling the pandemic and its effects therefore requires global cooperation as well as solidarity in the form of development assistance. Yet, support for development assistance among donor publics might be dampened by individual health-related and economic worries as well as decreasing trust in government during the pandemic. Against this backdrop, we investigate the possible effect of pandemic-induced worries on public support for development assistance as well as the moderating role of moral considerations and trust in government. Drawing on literature on aid attitudes, and using survey data for Germany provided by the COVID-19 Snapshot Monitoring (COSMO) project from April 2020 (N = 1,006), our analyses show that neither health-related nor economic worries are associated with less support for providing development assistance during the first wave of the pandemic. However, we observe a marginal interaction between health-related worries and trust in government in predicting support for development assistance. For those with high levels of trust in government the effect of worry regarding the loss of friends or relatives on support for development assistance is positive, whereas it is close to zero for those with low levels of trust. We conclude that at the peak of the first wave of the pandemic there was little need for concern by policy-makers endorsing development assistance as neither form of worry correlated negatively with public support for development assistance and trust was high. However, when worries recur and trust in government simultaneously decreases, public support for global solidarity may wane.

Relational solidarity and COVID-19: an ethical approach to disrupt the global health disparity pathway

While the effects of COVID-19 are being felt globally, the pandemic disproportionately affects lower- and middle-income countries (LMICs) by exacerbating existing global health disparities. In this article, we illustrate how intersecting upstream social determinants of global health form a disparity pathway that compromises LMICs' ability to respond to the pandemic. We consider pre-existing disease burden and baseline susceptibility, limited disease prevention resources, and unequal access to basic and specialized health care, essential drugs, and clinical trials. Recognizing that ongoing and underlying disparity issues will require long-term correction efforts, this pathway approach is nonetheless helpful to inform ethical responses to this global pandemic. It can facilitate international cooperation during the pandemic to reduce the disparate burdens among different regions without imposing significant burden on any particular contributor. The pathway approach allows international stakeholders in various social positions to respond to different components of the pathway based on their respective strengths and resources to help break the cycle of global health inequity. Guided by the ethical principles of relational and pragmatic solidarity, we argue for a coordinated global division of labor such that different stakeholders can collaborate to foster equitable healthcare access during this pandemic.

Crisis Nationalism: To What Degree Is National Partiality Justifiable during a Global Pandemic?

Are countries especially entitled, if not obliged, to prioritize the interests or well-being of their own citizens during a global crisis, such as a global pandemic? We call this partiality for compatriots in times of crisis "crisis nationalism". Vaccine nationalism is one vivid example of crisis nationalism during the COVID-19 pandemic; so is the case of the US government's purchasing a 3-month supply of the global stock of the antiviral Remdesivir for domestic use. Is crisis nationalism justifiable at all, and, if it is, what are its limits? We examine some plausible arguments for national partiality, and conclude that these arguments support crisis nationalism only within strict limits. The different arguments for partiality, as we will note, arrive at these limits for different reasons. But more generally, so we argue, any defensible crisis nationalism must not entail the violation of human rights or the worsening of people's deprivation. Moreover, we propose that good faith crisis nationalism ought to be sensitive to the potential moral costs of national partiality during a global crisis and must take extra care to control or offset these costs. Thus, crisis nationalism in the form of vaccine nationalism or the hoarding of global supplies of therapeutics during a global pandemic exceeds the bounds of acceptable partiality.

Solidarity is for other people: identifying derelictions of solidarity in responses to COVID-19

The role and importance of solidarity for effective health provision is the subject of lengthy and heated debate which has been thrown into even sharper relief by the COVID-19 pandemic. In various ways, and by various authorities we have all been asked, even instructed, to engage in solidarity with one another in order to collectively respond to the current crisis. Under normal circumstances, individuals can engage in solidarity with their compatriots in the context of public health provision in a number of ways, including paying taxes which fund welfare state initiatives, and avoiding others when ill. While there has been significant engagement in solidarity worldwide, there have also been high profile examples of refusals and failures to engage in solidarity, both by individual agents, and governments. In this paper I examine the consequence of these failures with reference to the actions of the current British government, which has failed to deliver an effective response to the crisis. This failure has effectively devolved responsibility for responding to the crisis to people who are simultaneously more vulnerable to infection, and less able to do anything about it. I argue that such responses represent mismanagement of a public health crisis, and a rejection of important democratic and egalitarian norms and values.

A Global Ecological Ethic for Human Health Resources

COVID 19 has highlighted with lethal force the need to re-imagine and re-design the provisioning of human resources for health, starting from the reality of our radical interdependence and concern for global health and justice. Starting from the structured health injustice suffered by migrant workers during the pandemic and its impact on the health of others in both destination and source countries, I argue here for re-structuring the system for educating and distributing care workers around what I call a global ecological ethic. Rather than rely on a system that privileges nationalism, that is unjust, and that sustains and even worsens injustice, including health injustice, and that has profound consequences for global health, a global ecological ethic would have us see health as interdependent and aim at "ethical place-making" across health ecosystems to enable people everywhere to have the capability to be healthy.

Pandemic Surveillance and Racialized Subpopulations: Mitigating Vulnerabilities in COVID-19 Apps

Debates about effective responses to the COVID-19 pandemic have emphasized the paramount importance of digital tracing technology in suppressing the disease. So far, discussions about the ethics of this technology have focused on privacy concerns, efficacy, and uptake. However, important issues regarding power imbalances and vulnerability also warrant attention. As demonstrated in other forms of digital surveillance, vulnerable subpopulations pay a higher price for surveillance measures. There is reason to worry that some types of COVID-19 technology might lead to the employment of disproportionate profiling, policing, and criminalization of marginalized groups. It is, thus, of crucial importance to interrogate vulnerability in COVID-19 apps and ensure that the development, implementation, and data use of this surveillance technology avoids exacerbating vulnerability and the risk of harm to surveilled subpopulations, while maintaining the benefits of data collection across the whole population. This paper outlines the major challenges and a set of values that should be taken into account when implementing disease surveillance technology in the pandemic response.

Do solidarity and reciprocity obligations compel African researchers to feedback individual genetic results in genomics research?

Background

A key ethical question in genomics research relates to whether individual genetic research results should be disclosed to research participants and if so, which results are to be disclosed, by whom and when. Whilst this issue has received only scarce attention in African bioethics discourse, the extension of genomics research to the African continent has brought it into sharp focus.

Methods

In this qualitative study, we examined the views of adolescents, parents and caregivers participating in a paediatric and adolescent HIV-TB genomic study in Botswana on how solidarity and reciprocity obligations could guide decisions about feedback of individual genetic research results. Data were collected using deliberative focus group discussions and in-depth interviews.

Results

Findings from 93 participants (44 adolescents and 49 parents and caregivers) demonstrated the importance of considering solidarity and reciprocity obligations in decisions about the return of individual genetic research results to participants. Participants viewed research participation as a mutual relationship and expressed that return of research results would be one way in which research participation could be reciprocated. They noted that when reciprocity obligations are respected, participants feel valued and not respecting reciprocity expectations could undermine participant trust and participation in future studies.

Conclusions

We conclude that expectations of solidarity and reciprocity could translate into an obligation to feedback selected individual genetic research results in African genomics research.

Sharing Solidarity Experiences to Overcome COVID-19

Solidarity in the general sense means unity or agreement of feeling or action, especially among individuals with a common interest; or mutual support within a group. There are different ways of standing in solidarity in different kinds of literatures. One of the most important ways is to advocate. Advocacy is a win-win strategy and a process of supporting and enabling people to express their views and concerns. In the end, I think sharing different types of solidarity can be one of the drivers that stimulate the solidarity itself, and I call on everyone to contribute to this sharing. I hope that this solidarity, which began in the world with the beginning of COVID-19, will not end with its end and will last forever because our world needs coexistence. This may be the only gift to the world from COVID-19.

Discourse on the idea of sustainability: with policy implications for health and welfare reform

Sustainability has become a major goal of domestic and international development. This essay analyzes the transitions of normative ideas embedded in the notion of sustainability by reviewing the discourses in the representative reports and literature from different periods. Three sets of ideas are proposed: inter- and intra-generational equity, stability of public systems, and a sense of solidarity, which confirms the scope of community and functions as a precondition for the previous two ideas. This essay uses the case of a health system in a hypothetical country to illustrate that, besides securing financial sustainability, a genuinely sustainable public system must also meet the three normative ideas of sustainability. This essay also finds that these three ideas may create intrinsic tensions within the prevalent policy-making model-democracy. The pursuit of sustainability is not only the responsibility of a democratic government, but also a shared moral obligation of the body politic.

Solidarity and Responsibility in Health Care

Some healthcare systems are said to be grounded in solidarity because healthcare is funded as a form of mutual support. This article argues that health care systems that are grounded in solidarity have the right to penalise some users who are responsible for their poor health. This derives from the fact that solidary systems involve both rights and obligations and, in some cases, those who avoidably incur health burdens violate obligations of solidarity. Penalties warranted include direct patient contribution to costs, and lower priority treatment, but not typically full exclusion from the healthcare system. We also note two important restrictions on this argument. First, failures of solidary obligations can only be assumed under conditions that are conducive to sufficiently autonomous choice, which occur when patients are given ‘Golden Opportunities’ to improve their health. Second, because poor health does not occur in a social vacuum, an insistence on solidarity as part of healthcare is legitimate only if all members of society are held to similar standards of solidarity. We cannot insist upon, and penalise failures of, solidarity only for those who are unwell, and who cannot afford to evade the terms of public health.

Thinking ethical and regulatory frameworks in medicine from the perspective of solidarity on both sides of the Atlantic

This article provides a concise overview of the history of scholarship on solidarity in Europe and North America. While recent decades have seen an increase in conceptual and scholarly interest in solidarity in North America and other parts of the Anglo-Saxon world, the concept is much more strongly anchored in Europe. Continental European politics in particular have given rise to two of the most influential traditions of solidarity, namely, socialism and Christian ethics. Solidarity has also guided important public instruments and institutions in Europe (e.g., welfare, healthcare, etc.). Despite the much stronger affinity of continental European societies to solidaristic thinking, we argue that solidarity has much to offer for addressing societal challenges on both sides of the Atlantic and beyond. After proposing a working definition of solidarity that highlights its utility for guiding policy and practice, we give an example of how a solidarity-based perspective can shape instruments for the governance of data use.