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Q. & A.
Imagining a Justice-Based Health System
By Isaac Chotiner
"We need a global master plan of public health. We need to figure out what the major public-health threats are," Jennifer Prah Ruger says.Photograph by Lucas Jackson / Reuters
Jennifer Prah Ruger, the director of the Health Equity and Policy Lab at the University of Pennsylvania, studies national and international public-health policies through a moral lens, examining the ways in which world leaders can insure more just health outcomes for their fellow-citizens, as well as for citizens of other nations—and how those two things necessarily intersect. Prah Ruger's work is influenced by her former teacher Amartya Sen, whose "capabilities approach" to economics—developed with the philosopher Martha Nussbaum—envisions a broad definition of human flourishing, one that transcends indicators like G.D.P.
Prah Ruger's most recent book, "Global Health Justice and Governance," published in 2018, examines international crisis responses to past epidemics, such as the Ebola outbreak of 2014. "Public health and health care systems capacity and governance vary considerably across the globe," Prah Ruger writes. "Like rapidly spreading contagions and global inequalities, this arbitrary patchwork of health systems is morally troubling." That work is especially relevant today, with the coronavirus pandemic straining health systems around the world, from China to Italy and the United States. In the U.S.—a country that is infamous for the unequal outcomes of its health system—hospitals find themselves overwhelmed with patients and short on medical equipment.
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I recently spoke with Prah Ruger by phone. During our conversation, which has been edited for length and clarity, we discussed how different types of health systems have responded to the current crisis, the area where the U.S. shines in keeping its population safe and healthy, and whether health care should be understood as a universal human right.
What have you been thinking about for the last couple of weeks, as this thing has spread, and how does the coronavirus fit into what you study and write about?
The first thing I've been thinking about is the underlying principles of justice and equity that we've been working on in our approach and in our lab. In the recent book that we just published, the underlying philosophy of human flourishing and the attempt to create the global and domestic conditions for people to have the ability to flourish is very relevant for the current situation. Flourishing is about enabling people to do and be what they want to do and be, and health is an instrumental and an essential part of that. So global public health that protects people's ability to flourish is an essential part of a just society—a global society and a domestic society.
And so what I've been looking for and trying to understand better, as you look globally but also domestically and in our own country, is how are we going about effectuating that or not. So I've been advancing a particular approach to that called provincial globalism, in which we look at the intersection or the commonalities between provincial or state or nation or local-based norms and values about equity in public health, and global foci on health and equity. Are those intersecting? Do we have a sense that, globally, we're really trying to work together, coöperate on the common good to insure people all over the world are able to be healthy, and protecting them and working collaboratively in coöperating? Or are we advancing the status quo in terms of a rational-actor model of global health governance, which has different nations and different countries and different interests advancing their own interests, rather than working together toward the common good of equity and health.
You're talking about flourishing, and one of the things related to that is something called the "health capability paradigm." What is that, and how does it fit into the broader idea of a "capabilities approach" to economics?
Well, the health-capability paradigm is a theoretical framework for justice and health, and that is at the domestic level. So, if you think about it in terms of an alternative to a free market, the free market is focussed on allocating goods and services in the economy at the domestic level based on people's preferences, or their desires for things. So, whether we're buying computers or phones or chairs or picture frames or whatever it is, we're advancing our interests in terms of our preferences for those goods and services through the free market. And we're regulating the market, to a certain extent, to protect consumers.
Alternatives to the free market are looking at a role for other institutions in promoting different goods that we have reason to value in society. The health-capability paradigm puts forward a framework that what we have reason to value—and what we have an interest in, societally and collectively—is people's ability to flourish and their ability to be healthy. So are the conditions in place? Are there public-health systems and structures that are in place that enable that? Is there a health-care system in place that enables that? Do we have the social conditions, and do people have enough income, and is that income distributed in an equitable way so that people have this opportunity? Are people educated, and do they have jobs?
All of these conditions are necessary for people to be able to be healthy. And what are the principles of justice that apply to the health sector and health-care sector? And so we advanced an approach that looks at advancing a public-goods or common-goods approach to the health sector and health policy, as opposed to a private-goods or private-sector, market-based approach to health and health policy.
We have seen a lot of countries already ravaged by this pandemic. Some have health care that is at least relatively equitable—at least compared to most countries on earth—such as Italy, and others, like the United States, do not. Are there things that you're noticing from this pandemic about why it's so important to build as much equity into the system as possible?
Yes, I am noticing some real differences. What we have here is we have a set of natural experiments unfolding before us, right? You have a very good display of different kinds of approaches to public health domestically. And it's within the context of a global public-health system, or lack of a system. So, for example, we have the contrast between what we would call two typologies. The first is a more centralized public-health policy that has more of a focus on equity and health, and looking across the population, as opposed to a more decentralized public-health policy.
There are real differences between the two, generally speaking. Centralized public-health policy is more planned. It's more deliberate. It's more intentional. There are several steps along the way. Centralized governance and authority tends to be federally located in terms of decisional latitude and authoritative standards with national guidelines and triggers. The decentralized public-health policy tends to be very ad hoc, more patchwork, unscripted. It tends to be spontaneous and reactive, and there tends to be a lot of voluntary actors in the mix. And we're seeing in general a difference in, for example, the United States approach, which tends to be very decentralized, and countries like Taiwan or Singapore, which tend to be more centralized. Other differences are that under a centralized public-health policy you tend to have more uniform standards and uniformity in policies and practices.
So we had this huge variation in the decentralized standards with respect to testing, for example. In a decentralized approach, we have a lot of variations, considerable disorder, more disarray. It's a little bit messier. And so these are very different approaches to the way we look at public-health policies at the domestic level.
How have these approaches played out during different epidemics?
A good example of that is what we see on the part of a more centralized public-health policy, which is the case of Taiwan. The Taiwanese learned their lessons from SARS, from the prior major outbreak that we had, and, as a result of learning from that, their approach tends to be much quicker. They're much more alert, and they've been much more proactive to this current threat. In fact, they introduced a series of measures right away when they learned early about the severity of the respiratory illness that was coming out of the situation in China, and they started immediately inspecting passengers. They started some quarantine measures. They sent a team of experts, with permission from the Chinese, to fact-find and understand what was going on a little bit better. There was much more of a command, and a controlled set of actions that were introduced, and things were done very, very quickly. They also used technology, using mobile phones to assess people's locations, and tracking people, and also to report travel history.
On the other side, you see the United States, and some advantages to what we would call regulatory approach. So we are now learning that some of the origins of the coronavirus came from wet markets in China. And that's the current state of knowledge that we have. And we have in the United States highly regulated guidelines for the sale of different meat products in our food supply. And so we have an experience in the United States, over time, where we learned that the regulatory process is very effective. And it has been. We've had some outbreaks in the U.S. We've had E. coli, and we've had some salmonella and things like that. But for the most part we have been able to regulate our food supply in ways that have been effective for the public health.
So you're saying that we don't have the egalitarianism of care, or whatever the phrase might be, but we do have a certain amount of regulatory structure. Are there some countries that have both?
Sure. We are finding that in the European countries we haven't seen the major outbreaks that are stemming from this lack of regulation, in markets or other kinds of supply chains. But we also have a more egalitarian set of health systems and public-health policies there, as well. Of course, different European countries are different, but, more or less, in the European Union, you do find countries that have a steep basis of solidarity and reciprocity and, some would even say, rights with regard to health care and health insurance in those countries. And they do have a greater effectuation of equity and equity principles in the health sector and health policy.
Your book also talks about places that are not as rich, specifically the Ebola epidemic in Liberia. What did Ebola teach you about these issues that you're writing about, and specifically about health disparities?
We've learned a number of lessons from the Ebola epidemic. One that I think is very important is the recognition of the importance of public health and health-care systems. We know that, for example, in the United States, we actually did have cases of Ebola, but we didn't have the extent of the cases, and we also were able to treat the cases effectively. We do have high-quality health care in the United States when you have the ability to purchase it, or if you have a very expensive health-insurance plan through your employer, or other kinds of mechanisms, but mostly employer-related health insurance.
And so having high-quality care is good, and we want that, but we want that for everybody on an equity-based or justice-based system, so we're able to get people diagnosed and information is shared in a transparent and factual way.
We've learned that there are a lot of misinformation campaigns there. Certainly, there was misinformation being spread in the Ebola epidemic, about the way it was spread, and what would happen, and who people could and couldn't be around, and things like that.
Another set of lessons is in terms of development assistance for health. We know that there has been a rapid increase over decades in the investments in health worldwide. There has been a lot of money going into global health, and going from donor countries, either multilaterally or bilaterally, to countries that have weaker health systems. The question is: How effective is that investment? Where is it going? And is it locally owned? Are countries able to develop their health systems and a horizontal capacity? Not just disease-specific, so not just for tuberculosis, or AIDS, or malaria. Are they able to develop their health systems and their health policy in a horizontal capacity, so that they can adjust the resources that they have for any particular epidemic that confronts them? That is a very important part of what we're learning and understanding, and certainly what the book addresses.
The last part is the importance of the security piece of it. That's why we see now a greater emphasis in the sustainable-development goals on universal health coverage and universal health insurance. Again, that's across the entire health system. It's not just for a particular disease.
What is your ultimate vision? It seems like it would be some global health system or set of rights, along the lines of the way a lot of people talk about universal human rights, which would be enforced with some sort of international legal system. What would be that vision, and what have you seen so far? Because, obviously, we do have the World Health Organization.
The World Health Organization is an important institution. It's our main United Nations-based organization focussed on health. It is a state-based organization, so it gets its authority from the states around the world. It's an international organization, and so states provide their interests and support through the World Health Assembly and that kind of a governance structure.
Unfortunately, the World Health Organization, however, is funded through internal support that is based on particular donors and interests, and seventy-five per cent or so is not based on the multilateral pooling system. So, in other words, the ability to make decisions collectively and to put resources toward those decisions collectively is about twenty-five per cent of what the World Health Organization is able to do. That severely compromises the institution. And what we see is other vested interests and other groups having a lot of power and influence through the organization in a way that is inconsistent with global health equity. So an alternative approach is looking at global health equity from the perspective of all individuals on the planet, over the whole entire seven billion people on the planet, and trying to figure out what kind of a structure, privileges, and conditions that individuals live in, regardless of where they are.
And we advanced two different infrastructures for that. We advanced the Global Health Constitution, which is a moral constitution, which is a set of principles of justice and health that sits above the World Health Organization. It's a coördinating mechanism. It sets global standards and moral standards for the world, and it puts the World Health Organization in the context of all the other different organizations, N.G.O.s, nation-states, individuals themselves, in this collective exercise toward global health. The second institution that we advanced is a Global Institute of Health and Medicine. This institution is an independent organization that is scientifically based, and the reason that we need an institution like that is exactly relevant for the current situation: we need a global master plan of public health. We need to figure out what the major public-health threats are. And, by the way, emerging and zoonotic diseases are some of the most recent public-health threats.
What have you made specifically of the W.H.O. response to the coronavirus?
I think that what we've seen is that there's been a significant underinvestment globally in what we have seen from the latest emerging threats. They're coming from animals. And we know that. We've got SARS, coronavirus, Ebola. And yet we're underinvesting in the science toward understanding what diseases are prevalent in animals, the scientific basis for the development of treatments and vaccines, and the coördination across different countries toward those endeavors. We do have some investment in it. We have some investment globally. We have some investments, for example, in the United States. We have a whole unit on that at the C.D.C. But we need to recognize, now more than ever, given this latest pandemic, that this is a major area for investment going forward.
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Isaac Chotiner is a staff writer at The New Yorker, where he is the principal contributor to Q. & A., a series of interviews with public figures in politics, media, books, business, technology, and more.
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