Impulsar la salud mundial en un momento de fractura de las asociaciones

BRIAN MATEO: Hello, everyone. My name is Brian Mateo, and I serve as deputy director of programs and partnerships at Carnegie Council. To begin, I would like to welcome you all to our second event in the Council’s Ethics Empowered: Leadership in Practice series, which convenes scholars and practitioners to discuss pressing moral issues, reflect on their careers, and offer insights to young leaders. During today’s panel we will be discussing “Advancing Global Health in a Moment of Fracturing Partnerships.”

It is my pleasure to now introduce our moderator for this event, Nicholas Bayer, senior communications manager for public engagement at Doctors Without Borders, and a Carnegie Ethics Fellow. We are also honored to welcome our guests Unni Karunakara, senior fellow at the Global Health Justice Partnership at Yale University, alongside Robert Klitzman, professor of psychiatry in the Vagelos College of Physicians and Surgeons and the Mailman School of Public Health at Columbia University.

As I join you from the Council’s Global Ethics Hub in New York City, I want to welcome you again and will now pass the program over to Nick.

NICHOLAS BAYER: Thanks very much, Brian. It’s a pleasure to be here with you, Unni and Robert, as well. We will have about 40 minutes of planned discussion questions for you and then we will make sure we save about 15 minutes at the end of the conversation to answer any questions from the audience.

Today we are here to talk about advancing global health at a time when multilateral partnerships and cooperation are fracturing. We are going to start with a big question to you, Unni: How did we get to this moment, and why are these global health partnerships fracturing?

UNNI KARUNAKARA: First of all, thank you for having me for this very important discussion. Things are evolving as we speak with new information every day, some of it the consequence of the current American administration’s policies but not just the policies of this government but other nations around the world also have a big role to play in this.

Let’s rewind a few years. To set the stage a little bit, in the year 2000, at the turn of the century, not one person in the continent of Africa was receiving treatment for HIV-AIDS from their public health care system, from their ministries of health, from their authorities. The big reason being that Big Pharma had priced drugs out of reach and HIV as a result had become a death sentence for poor people around the world.

In the first decade of this century activists started mobilizing, and together with humanitarian agencies like Doctors Without Borders there was increasingly a coalition taking on Big Pharma and challenging some of their practices and policies. Foundations also chipped in big time and governments also, for example, George W. Bush, a Republican president, established U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), which had a huge impact on the ground as well. As a result, today we have over 30 million people on HIV treatment around the world. This is what is possible when activists and civil society organizations and governments work together to address global problems.

That first ten years of the century we consider a “golden decade” for global health. Now we are at a point where multilateralism, as Nick pointed out, is fracturing, and we are increasingly unable to address critical global problems together, and we saw that during COVID-19.

I think 9/11 perhaps marked a moment when we entered a post-liberal age, and I say that because societies and states are increasingly securitized, and security concerns by and large trump any concern for human rights or humanitarian concerns. It is not just what happens in other countries; we see this playing out within countries as well, the lack of concern for human rights and also I would dare say a lack of empathy for the suffering of others. This is a huge problem.

COVID-19 highlighted in a big way how fractured we were as a global community. There was all this talk about global solidarity, but when push came to shove vaccines and essential lifesaving materials were hoarded by the rich and not shared with poorer communities and nations around the world.

Fabulous profits were made—you need to remember this—on the back of publicly funded research, the National Institutes of Health being the largest funder of medical research in the world. All of this is to say that what is happening at the moment is striking global health across the board, from research to development to our ability as a community of nations to deliver care around the world.

In addition to reaching limits of global solidarity, we are also reaching the limits of a globalized economy, and I say this because inequality is growing everywhere. It is no longer a matter of Global North and Global South; what we are seeing now is that there is a globalized minority of extremely wealthy people and a localized majority of people who are being left out of prosperity. This is as true in the United States as it is in other countries around the world.

We are reaching the limits of global solidarity, the limits of global economy, and planetary limits, and on top of that we have leaders who are unable to unite people. In many countries around the world dividing people is how leaders get their legitimacy and how they are able to stay in power. All of this is problematic, and it comes at a cost. All of the gains that we made during the first decade of this century are being rolled back at an alarming pace, and we need to be worried about how all of this is going to play out.

NICHOLAS BAYER: Robert, could you give us some examples of multilateral cooperation in global health that worked well in the past, and what were some of the benefits, challenges, and opportunities of those multilateral cooperations?

ROBERT KLITZMAN: Great questions. I also want to thank you all for inviting me to speak today and be here with my friend and colleague Unni. I think these are extremely important issues and very timely obviously, in fact more timely each day.

There have been a number of wonderful examples. Unni mentioned PEPFAR, which was initiated under President Bush, and that led to literally billions of dollars of HIV-prevention medicines being brought to people in sub-Saharan Africa who otherwise could not afford them, and we know that the HIV pandemic was spreading particularly widely in sub-Saharan Africa. Up to 30 percent of young girls in certain areas in sub-Saharan African end up becoming infected by HIV. The fact that the United States was willing to make this kind of commitment to help the health of another country is crucial, and it was a wonderful example.

I should add, though, that as Unni suggested it was really AIDS activists who “named and shamed” multinational pharmaceutical companies to engage in this effort. I will return to this later, but activism has an important role potentially here. A nonviolent groundswell of support for global health and global health initiatives is very important and something we can all do at this point regardless of what goes on.

There have been a number of other examples including the World Health Organization (WHO). The United Nations was involved in many global health activities and working on social determinants of health, which are very important, and these by nature are multinational, global efforts to help the health of the world, particularly the health of more vulnerable people in poor countries in what used to be the Global South; there still is the Global South, although as Unni said the dynamics of some of that are shifting.

There are a number of other ways that there was support. The United States supported the HIV Prevention Trials Network, for instance, which I have been involved with for a number of years. That was a multimillion dollar effort to develop effective prevention treatments such as prep preexposure prophylaxis for HIV, to develop injectable prep, which is maybe something people only need to get once every six months rather than having to take a pill every day. Partners may not like that the other is taking a pill; a woman may not want her husband to know that she is afraid of getting HIV from him, but if she is able to get a shot once every six months or even less frequently than that she is able to protect herself. Those are interventions for prevention that were developed by the United States in many ways particularly to help people in other countries.

The Centers for Disease Control (CDC) in the United States also promoted global disease surveillance. Of course one reason this is important is because infectious diseases do not know national boundaries, whether it is influenza, COVID-19, SARS, West Nile virus, or avian flu. These viruses don’t know, “Well, when you get to the border of one country, stay in that country.” They go wherever the birds go. In past days, wherever the mice or rats went, that was where bubonic plague went.

Also, because we are more interconnected globally, you can literally get on a plane anywhere in the world and in 24 hours be anywhere else in the world. You travel along with any infectious diseases you may have and with the viruses and bacteria you may have, even if you may not be sick, so someone could get on a plane having been exposed to COVID-19 in China or Italy or wherever, and they could fly to Spain, the United States, India, or anywhere else and have the COVID-19 virus and not know it, get off the plane, and infect other people.

Because we live in that kind of a globalized world there are a lot of threats and a lot of need for global surveillance, not just looking at what is happening within the borders of my country but knowing what are the infectious diseases that are emerging in another country because those can spread to our country, and this goes back and forth, Global North to Global South, both ways.

Those are a number of examples, and just to be clear it involves disease prevention, surveillance of disease, treatment, and research, and in all of those activities there has been, as Unni was saying, for several decades a robust “global health ecosystem” if you will in which the United States would also train researchers who would come here from other countries. They would get training in the United States and then go back to their home countries and bring with them technical expertise in how to look for diseases, prevent diseases, assess the epidemiology of diseases that may be emerging, particularly infectious diseases, and then know how to treat them, spur research in terms of those activities, but also discover what are the obstacles to people getting treatment, whether they are economic, social, cultural, or geographical obstacles, and knowing how to overcome those.

These are all ways in which global health was truly global and in which there was a lot of multinational cooperation, and I think it benefited all countries. It was a win-win because if we are able to find out when diseases are emerging in other countries, let’s say in the Global South before they come to the Global North, those countries that were funding these activities in the Global North were able to protect themselves. Of course, people in the Global South benefited from expertise, medications, et cetera, that were then brought to those countries as well. It was a win-win, and as Unni said it is extremely important and is under threat, but I do think there are things we can do to try to strengthen it today.

NICHOLAS BAYER: That is some helpful context to help us wrap our heads around this complicated topic. I appreciate that. That is going to help us lay the foundation to talk a little bit about some of the ethical implications of this breakdown in multilateralism.

Unni, as you spoke earlier, you mentioned a lack of empathy that is seemingly more frequently in the communities around us. What does this mean for humanity ethically, and how can global health professionals who believe in the ethics of medical care try to address this issue?

UNNI KARUNAKARA: I mentioned empathy in particular because a certain billionaire recently made fun of people with empathy as “being weak.” I think it is important to take note of the times we live in, when people in positions of power are very publicly against empathy and expressions of solidarity.

Having said that, I have been a humanitarian worker for close to 30 years now. There are four principles of humanitarian action, the first one being the principle of humanity. It simply states that all people are worthy of respect and deserve a life of dignity. For all of us in this discussion today there is no debate; I think that is something we all believe in.

However, increasingly today this principle of humanity has to be underlined in all of our engagements with people in power, politicians, and countries because the reality—and we see it play out every day—is that there are some people who are more deserving than others, some people have more rights than others, and some people are increasingly being left out of not just their civil rights but also economic prosperity. That is the time we live in.

The former high commissioner for refugees, Sadako Ogata, in the 1990s said, “There are no humanitarian solutions to humanitarian problems.” Humanitarian action is emblematic of failure. We provide assistance and go to places where we work because politics has failed in a big way: communities are not able to live side by side in peace, governments are not responsive to the needs of people, or the United Nations is unable to broker peace between warring nations. There are many levels of political failure that humanitarian action responds to.

The responses to these problems are not technical. They have to be political, but when politics fails, humanitarian action and overseas development assistance are a necessary response in the face of political failure.

It is not just that there is a lack of empathy. Humanitarian workers and global health professionals around the world are under attack. In some of the crisis situations that I have worked in and where war is raging at the moment, health workers are under attack. Four out of five Security Council members have been part of coalitions that have bombed health facilities and health workers in the past decade, and there is no outrage. There is just impunity.

What is worrying for me is that these violations of international humanitarian law are being normalized with little respect for international norms or the lives of people. In the past things were not perfect, but there were always laws or rights that we could appeal to when demanding justice or demanding access to people living in conflict areas, but that is increasingly difficult.

Humanitarian workers are also being criminalized. Just a few years ago the government of Italy took Doctors Without Borders to court for saving the lives of drowning people in the Mediterranean. In the United States providing assistance to people in Somalia at one time was criminalized, and we all know what is going on in the Middle East at the moment. These are difficult times, and I think the first thing we have lost is empathy and a sense of our collective humanity.

NICHOLAS BAYER: Robert, based on where we are right now, do you think we are prepared to face another global pandemic like COVID-19? What are the ethical considerations for addressing global health threats like this, acknowledging as you did earlier that there are inequities in access to medicines?

ROBERT KLITZMAN: I think unfortunately we are not well prepared for dealing with another COVID-19-type pandemic. If anything, we are less prepared than we were a year or two ago. I think that is horrific and will have devastating consequences.

Of course, we don’t know when the next pandemic will be. There may be a COVID-26 or COVID-27. It could just be a slight mutation in an existing virus that could overcome whatever immune defenses we each have in our bodies, particularly if we got vaccines, and we don’t know when and where this will happen. The number of such pandemics has been increasing in recent years because in part of global travel, as I mentioned. It used to be that if a disease broke out somewhere it stayed in that area, whereas we know with pandemics now and in the past they travel with humans as humans travel.

In terms of the ethics, there are several key principles. I run a Master’s of bioethics program at Columbia, and we have a number of courses online and in person, and we emphasize several key principles. One is the rights of individuals, respect for individuals, and I will come back to that in a moment and how and why that is important here.

Another is benefits. We want to benefit as many people as possible, we want to avoid risks and avoid harming people, and we believe in social justice and certainly not increasing the gaps between the haves and have-nots, and trying particularly to help people who are more vulnerable to disease.

In this case, as I mentioned, the risks are extreme. There are risks of infectious diseases spreading as we saw with COVID-19 and we saw with severe acute respiratory syndrome (SARS), avian flu, and HIV, so we want to minimize those risks.

How do we do that? Multinational cooperation is one way to do it. There are other ways: education, prevention, investing to try to reduce social determinants of health such as poverty, lack of clean water, and lack of housing, all of these other things that we can help with in terms of infrastructure. If we don’t help, it can lead to more disease or exacerbate more disease, so we want to reduce the risks.

We also want to increase the benefits. If we have good treatments here and they can be made inexpensively and help other people, we should do that. We should help other people as much as possible, and this notion of “We’re here partly to help others” certainly is a core element of all religious traditions, Christianity, Judaism, Islam, Buddhism, etc. That is a good thing in and of itself, but it also makes us feel good, and from a utilitarian perspective, if we help others and reduce risks we reduce risks of infectious diseases coming back to haunt us.

There are also infectious diseases that we now have treatments for but which are now becoming treatment-resistant. We now have treatment-resistant tuberculosis and treatment-resistant bacterial infections, a number of different kinds of infectious diseases.

We also believe in, as I mentioned, autonomy, respecting individuals and respecting individual rights. An important element of the United Nations’ Universal Declaration of Human Rights, which was signed onto by all countries of the world, is that there is a right to health. I would argue that ethically people in the developing world, lower- and middle-income countries as well as wealthy countries, all have a right to health. This is partly what we owe each other, but it is also an inherent human right, so ethically we should be doing what we can to help the health and well-being of people in other countries.

A fourth principle is social justice. We believe in reducing and not exacerbating the gaps between the haves and have-nots. Unfortunately there may always be some gaps. In an ideal world, of course, there wouldn’t be. That is not the reality we live in today, but we certainly want to reduce those gaps rather than increase them.

Fortunately when we have multinational cooperation about health we can work to reduce those gaps, and when the United States ends the United States Agency for International Development (USAID), cuts back on the CDC, or threatens to stop funding WHO and the United Nations, those gaps will undoubtedly increase rather than decrease. Ethically that is a problem.

In all these ways it is important ethically that we try to aid each other and help global health as a whole, and I would argue in terms of process one key element of that is transparency: If a government says, “Look, I’d love to help out but I just can’t,” it would be important to know how that government is spending its money. Unfortunately there is a lot of corruption in different levels of different governments all over the world, and sometimes if there was less corruption there would also be more money for healthcare in various countries, so transparency is important to be able to know how we can best use whatever resources may be available, and unfortunately that too is limited sometimes.

NICHOLAS BAYER: Robert and Unni, this question is for both of you: How do we advance from here and how can we prepare for what comes next? From your perspective what are some of the bright spots or productive places where we can focus our energies going forward?

UNNI KARUNAKARA: I usually leave my students depressed at the end of my lectures, but it is not all doom and gloom. This moment presents a lot of opportunities as well. This is a moment to reshape assistance and solidarity.

Multilateralism and overseas development assistance in the past generally helped, but they were controlled and directed by a few powerful countries and powerful foundations, and they had the power and the ability to set global health agendas and global health spending, so the poor countries where the disease burden was had very little control over what they could spend the money on.

A lot of people think of COVID-19 as a “decolonizing” moment. COVID-19 laid bare what we probably knew or felt all along, that global solidarity was dead. There is a retreat from multilateralism and globalization. A lot of countries and regions are saying: “We need sovereignty over critical supplies, our own drug-producing capacity, our own supply chain capacity. This reliance on rich countries has to end, and we have to build our own capacities.” It is a retreat from globalization, but it is important for the poorer parts of the world to have this capacity so that in times of crisis they do not always have to rely on rich countries. That is one.

Even if multilateralism is dead in New York and Geneva, there are a lot of regional groups such as the African Union, the Association of Southeast Asian Nations (ASEAN), and Brazil, Russia, India, China, and South Africa (BRICS), to name a few. They all see this as an opportunity because also it is no longer a unipolar world. The United States is not the only show in town, so this is a moment for a lot of countries to assert themselves in groups and change the narrative, so to speak.

A much-needed reform of the United Nations has been kick-started. That might be one of the positive fallouts, though not intended, of the United States defunding the United Nations to a large extent so that it has to reform because, let’s all admit it, there was a lot of fat that needed to be cut. That is underway, but I hope those in power at the United Nations and also the Member States make the right decisions on what to cut, what to keep, and how to restructure it in a way that is lean and efficient.

One last thing I will say is that this is also a moment to shift the center of gravity especially in global health because a lot of the time global health discussions were happening in the North in places where people could not even get visas to attend meetings. Coming to the United States or coming to Europe was a big hassle for grassroots activists and people who had important stories to tell and important issues to discuss.

We are now going to see for sure a period where discussions are going to move out of the United States and Europe and into places where people can attend and sit at the table where decisions are being made. That was not always the case before. I hope we are seeing movement toward a more equitable and more just way of global health decision making.

One last thing is that there are increasingly Southern thinkers and Southern nations articulating that social spending should not rely on overseas development assistance anymore and that there needs to be tax-based financing of healthcare, education, social security, et cetera. Easier said than done, but I hope these are all good starts and we don’t waste the moment. “Never waste a good crisis,” as someone said. We can use this crisis to change the way aid worked in the past, redirect it, and reshape it in a way that works for people in poorer parts of the world.

NICHOLAS BAYER: Robert, what are some of the bright spots from your perspective or some of the places we can focus our energies?

ROBERT KLITZMAN: I agree with everything Unni just said, but to build on that a little bit I think one low-cost intervention is education. In a lot of countries that have relied on, say, HIV prevention through medication, education and other modalities can help. The notion even that we are going to try to reduce the HIV pandemic in sub-Saharan Africa mostly through a technological fix of giving medication is not a bad thing in and of itself, but it is just one modality that could potentially be used.

There are studies that show that 30 percent of young girls in certain areas of sub-Saharan Africa end up becoming HIV-infected. There are also studies that show that if we pay parents to have the kids stay in school they are much less likely to become HIV-infected. That is, if young girls stay in school they see they have other futures. They can have a career and get a job, get older and rather than being out there and potentially being exposed to HIV. That itself can help prevent HIV.

Getting young girls to stay in school does not need to happen because of money from the West or from the Global North. Within countries, as Unni said, there can be a rethinking and reprioritization of certain resources to help education in that case as a way to prevent HIV but also education about infectious diseases and about how health could potentially be improved. Again, these are not replacements for medication and medical interventions, but they are a modality that perhaps in many areas could potentially be strengthened.

Another actually is artificial intelligence (AI). We know that AI has transformed many things in the West, but there is work being done using AI to help with mental health. Having a mental health bot is not as good as having an in-person psychotherapist, but it is better than nothing. There is a question whether AI could be an inexpensive way to communicate about health and in some ways provide health services and encourage HIV prevention. These are all things that are being explored and could potentially be used more given that there are fewer millions or billions or dollars being given to certain countries. Those are two ways.

One reason that the United States gave money for PEPFAR and USAID is not just altruistic; there is also the notion of soft power, that countries like the United States wanted to develop alliances and allegiances with other countries and helping healthcare in those countries was a way of exercising soft power. I don’t mean to be instrumental about it, but other countries may want to step into that.

China, for instance, may realize that soft power is important—it is not very much on their radar now, but potentially looking forward if the United States continues to stay out of this arena—other countries may realize the importance of soft power and therefore provide support for healthcare in other countries, maybe in the form of treatment in terms of educating researchers and providers in one’s country who can then go back.

Other countries may want to do that more as well. The European Union or countries like South Korea or Japan as well as China could attract researchers and providers from the Global South for training who could then go back to their countries and help healthcare there. I think there are various things that could be done.

Lastly, I mentioned activism earlier. I want to be clear that I don’t mean violent activism; I am thinking about it in the spirit of Gandhi and Martin Luther King, Jr. Nonviolent naming and shaming or using other methods like that could also be helpful, such as if people in the United States made efforts to say: “We’re going to exercise our power as citizens, through voting in the midterm elections and elsewhere to persuade our country to engage more in these activities because of the many benefits both to other countries as well as to ourselves.”

Huge numbers of Americans, in many elections half of Americans, don’t vote. If there are efforts through volunteerism to get out the vote, get people to vote, and to educate people, these are all things that could help “turn the dial,” so to speak.

I also think that overall history is cyclical. We are in a very bad spot now. The world has been in bad spots in the past, and through these kinds of efforts there have also been changes. I am hopeful that at some point we will be in a better spot, and these kinds of efforts can help us get there in the meantime and get us there as well.

NICHOLAS BAYER: I will ask one final question to both of you: What are some resources or articles that you can recommend to audience members who would like to learn more and engage more with this topic?

UNNI KARUNAKARA: As I said earlier, this is playing out in real time. A good thing is for people to read the news, but of course we live in a “post-truth” world so you have to triangulate your news sources. I would suggest Health Policy Watch, Devex, and a few other websites and publications like that which give you a blow-by-blow account of, for example, how the International Treaty on Pandemic Prevention, Preparedness, and Response (Pandemic Treaty) was being negotiated. They just signed the Pandemic Treaty, but it is still not fit for purpose. Like Bob said earlier, if you have a pandemic next year or the year after I think we might find ourselves in the same place that we did a few years ago. There are sources like that which students should explore, read, and understand which will help you get a grasp of what is playing out before our eyes at the moment.

ROBERT KLITZMAN: I think there are some examples partly from the past that might be able to inspire us and help us not to lose hope. Paul Farmer was a hero of mine and an incredible human being—I had the privilege of meeting him a few times, and I think Unni worked very closely with him for a number of years. His example of what could be done outside of government funding is truly remarkable. He inspired many healthcare providers around the world to offer their time to help with healthcare in other countries. There is a book about him by Tracy Kidder called Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, a Man Who Would Cure the World, which tells part of that story.

What would Gandhi do today? What would Martin Luther King, Jr., do today? I have always found watching the movie Gandhiinspiring, just to see what one man can do using nonviolent action to help in that case get the British Empire out of India and get India to be independent.

There are examples such as Albert Schweitzer of what one individual can do as a doctor going into another country and helping. That story is complicated for various reasons, but there are examples that have been written about that can inspire us to not give up and realize there are things each of us can do as individuals, even if the United States government is less involved than it should be.

NICHOLAS BAYER: We have some great questions from those tuning in online today. We will take the first question from Vivian in Uganda: “In some contexts in Africa where leaders often face competing pressures from global powers, local communities, and national interests, how can young leaders ethically navigate decisions that involve tradeoffs between economic development, democratic values, and humanitarian principles?”

UNNI KARUNAKARA: I have lived in Uganda and know a little bit of the context there, but I will talk about my own experience. India in the past years has been under tremendous pressure to sign free trade agreements with the European Union and the United States, very often through the demands of Big Pharma to lower the intellectual property standards in India. Every time they have come close to signing away access to healthcare and health rights in the country the only thing that stopped them was people turning out in large numbers outside parliament. When people mobilize and come in large numbers outside parliament or outside where negotiations are happening it becomes very difficult for those in power to do that.

Of course there are tradeoffs but human lives, human rights, and access to healthcare should not be traded away. I don’t see how that can in any way be in the best interests of citizens in any country. I think the best thing for all of you to do is educate yourselves, understand what the issues are, and turn up in large numbers to pressure your politicians and policymakers to ensure that the right choices are being made for all of you.

ROBERT KLITZMAN: A few thoughts on that. Thank you for the question; it’s a great question.

In bioethics as I was mentioning earlier there are certain basic principles: What are the benefits? How can we maximize benefits for the most people, long term, short term, and reduce risks? What are people’s rights? What are justice concerns?

In terms of tradeoffs from a utilitarian point of view one should try to aim for the greatest good for the greatest number. That often is not done. Often governments focus on what they can do to help the wealthy people or the elites.

From a rights-based point of view—people have rights to health, etc.; that is obviously a general background—I agree with everything Unni said. I would also add writing about these issues. News sites all over the world, let alone websites, let alone social media give young people an opportunity to express their views in ways that can go viral and have widespread impact. I would encourage young people also to write about what they feel and think, put it on social media, submit opinion pieces to local news organizations as well as The New York Times, The Wall Street Journal, the BBC, CNN, and The Guardian, global news organizations.

The perspective of a young person in Uganda saying, “These are the issues and the difficulties we are facing, and here is what’s happening on the ground,” would be of great interest to many people. One advantage of AI and social media is that one can get one’s point of view across. I would encourage people also to get that out partly to educate others.

UNNI KARUNAKARA: I want to also recognize that we live in times when turning up in large numbers is easier said than done because governments are increasingly restricting the space for people to turn out in large numbers. I fully understand the context, let’s say, in Uganda or even in the United States now. If you stand up for certain things, you could get into big trouble. Writing is a good way. I would still insist that we have to be courageous enough to turn up and turn up the pressure on politicians.

ROBERT KLITZMAN: To put those two things together, someone told me a story a few years ago, before President Xi was in charge of China, that you only needed three people to have a protest in China: two people to hold up the sign and one to take the picture and put it on social media saying that there had been a protest. It doesn’t take a lot of people, and getting the message out there on social media can help spread awareness.

NICHOLAS BAYER: We have two questions, both interested in talking about the COVID-19 pandemic and human rights from opposite sides.

The first question is: “To what extent is the West’s refusal to impose lockdowns the way that China did during COVID-19 based on human rights considerations? I am wondering if this implies an overemphasis on human rights by not locking down.”

On the other hand, the second questioner asks: “In the context of the COVID-19 pandemic or future pandemics, how can we ensure that human rights are upheld globally, especially for people who might have to cross a border at some point or might not be able to lock down?”

UNNI KARUNAKARA: My feeling is that human rights played a very small role in Western countries deciding to lock down or not. First of all, there was hubris. With all of the money and all of the capacities that Western countries had they still failed spectacularly—most countries did—in their response to catch up and sort it out. That is one thing.

The second thing is that the main reason for not wanting to impose lockdowns was economic but also political. In the United States many states’ policies were dictated by politics and not really by science. That was the other thing we saw during COVID-19 as well, an anti-science sentiment that dictated a lot of policies.

That is by no means only a feature in U.S. society. Social media is a double-edged sword and can also be a place where disinformation and misinformation can be spread in a big way.

There are international guidelines on how countries can restrict rights for a certain period of time. The Siracusa Principles allow nations to restrict rights of individuals for a small period of time, but it is also incumbent upon nation-states at the time that they restrict the rights of individuals that they do it with as minimum an amount of inconvenience as possible, and those rights have to be restored at the earliest possible moment, so there are mechanisms that exist, but of course none of this was considered not just during COVID-19 but also during the West African Ebola outbreak and how entry of people into the United States was restricted and how different states in the country had very different policies as to who to quarantine and who not to quarantine. None of it was based on science; it was largely dictated by local politics.

ROBERT KLITZMAN: I agree with everything Unni said. The push for lockdowns was based on concerns initially about how to prevent spread of the disease, and I think they made sense in an ideal world from a public health point of view. As Unni said it became at a certain point, “How long does one do a lockdown for?”

We know that the U.S. red states—conservative Republican states—had less lockdown because of political reasons, and they had a higher rate of COVID-19 as a result. Often it was not the elite; it tended to be poor people and people of color who were the ones getting COVID-19, whereas wealthy white people were the ones making decisions and supporting fewer lockdowns. There is a lot of concern now that lockdowns had a lot of “unintended consequences” in harming educational achievement and abilities among young people who for three years in many cases were going to school from bedrooms or living rooms at home or wherever they were doing school from, so it is complicated.

In all fairness I would say that lockdowns occurred at least initially when very little was known about the virus and when there was a lot of fear and panic, so it made sense. At a certain point, the question became how long do we lock down, why, where, et cetera.

Part of the problem is education. A lot of people in this field—also the anti-vax movement in the United States and elsewhere—don’t understand the need for public health preventive measures so they oppose lockdowns. A lot of people in the United States opposed vaccines and still do. Of course, we now have Robert Kennedy, Jr., as the head of the Department of Health and Human Services, who has argued that vaccines cause autism.

I don’t want to get into all that, but I think there is a lot of disinformation, and I agree with Unni that social media is a double-edged sword. I think we should try to use the good edge if we can as much as possible given that it is going to have another side.

I want to comment on that, by the way. Education is crucial, but healthcare providers can also be a source of good information: If every doctor and nurse said to patients, “Look, vaccines do help people,” we could combat some of the disinformation. I think that could happen in the United States as well as other countries.

NICHOLAS BAYER: We have time for one more question from the audience: “In light of these fractured partnerships, how can we improve data sharing and communication between countries in West Africa”—I would say between all countries—“to effectively monitor and respond to things like COVID-19, mpox outbreaks, and other future outbreaks?”

UNNI KARUNAKARA: This is precisely the sticky point in the Pandemic Treaty that has just been signed. Negotiators were unable to reach a satisfactory agreement on how to share biological samples and how to share data. There is a requirement on affected countries to share information, but there is no corresponding responsibility on other nations to provide vaccines and other tools necessary for survival.

Big Tech is the big resource that we all have and which can be monetized for huge profits, so with data sharing I would put the ball back into the court of countries that data is a resource they should guard zealously and should share but with adequate protections that should be put in place to safeguard their interests. Big Pharma benefiting from data from poor countries while not sharing the benefits of that data, research, and vaccines that are produced should no longer be acceptable. Global health governance and especially how we govern AI and data is a big issue we should all engage with in the coming years.

ROBERT KLITZMAN: I want to come back to ethics. I agree with what Unni said, and generally I always agree with Unni because he is a tremendous moral force and is inspiring. Unni, you may think your lectures are undue doom and gloom, but my students—I have Unni speak every year in my class—are inspired by him as a moral force. For that we are extremely grateful.

As various treaties are being written and as political leaders and others are considering these issues, ethics is crucial. The role of moral suasion is every important. If a group of leaders coming together to ask if they should share people from health departments in different countries or whoever is at the table, everyone may get very protective and territorial about their own data: “Why should I share my data?”

Coming back to ethical arguments, the notion of what is the greatest benefit, the greatest good for our country and for other countries, not only short term—“Yes, I may be protecting myself now and you are not going to get my data”—but in the long term think of all the benefits if you were to share data and find out what is going on in the country next door to you which may spread disease into your country. What are the risks of not doing that?

If we say, “We are each going to keep our down,” there are costs to that. What are the costs? Yes, there may be fear of costs with sharing, but what are the costs of keeping it in the long or short terms? If all countries agree and one country doesn’t and that country doesn’t get the benefit of seeing the data from other countries, the countries sharing their data will benefit more than that individual country.

What are people’s rights? If you want to stay in power, I would argue that if you help the people in your country you will probably be able to stay in power longer than if you don’t help the people in your country.

These are moral arguments. One reason we have bioethics—and I emphasize this in the program I run—is because technology, healthcare, and diseases given global travel are rising exponentially. There are more and more questions: We have more and more powerful interventions and vaccines, but who is going to get them? They are expensive; how do we reduce the costs? These are not medical questions per se but ethical, legal, social, and political policy questions, and being aware of these issues is important.

At the same time, seeing the role of ethical argument can persuade people and policymakers to think beyond the narrow sense of what is in their best interest and to think of long-term benefits for them, for other people, and for their citizens. Risks and justice concerns: How would they want to be treated? I think ethics can play a key role in many of these discussions now and moving forward.

UNNI KARUNAKARA: I have one anecdote regarding the greater good. A few years ago, when India was negotiating a free trade agreement, one negotiator told me: “It is not health ministers negotiating health between countries.”

The negotiator said: “It was a decision whether we should drop Section 3(d) of the Indian Patents Act, which has a huge impact on Big Pharma. They were being offered a seat in the Security Council: “If you give in on the patent law, we will support your seat on the Security Council.” So “greater good” is very subjective. It depends on where you stand. The greater good for the common person is not the same as the greater good for policymakers and politicians.

That is why the Universal Declaration of Human Rights is so important because 70 years ago we all bought into it, and it still holds true to a great extent. Going back to these universal frames of rights and ethics is ever more important now than before.

ROBERT KLITZMAN: One last thought is the importance of transparency. If everyone in India knew that they were hurting themselves in terms of public health in order to give person A a seat on the Security Council, they might not have agreed with the decision.

NICHOLAS BAYER: I am sure we could continue this conversation for many more hours because there is so much to talk about.

Thank you so much, Unni and Robert, for lending us your time and your expertise today. We appreciate it. Thank you so much to all of you who joined us today live. We are grateful for your thoughtful comments and questions in the chat, and we appreciate you tuning into this special session of Ethics Empowered: Leadership in Practice.

With that, we will close. Thank you so much. Have a wonderful day.