The global response to the COVID-19 pandemic has been marred by a widespread failure to embed ethics in policymaking. The consequences have included vaccine hoarding by rich countries and the deaths of millions of people around the world. Governments have followed a simplistic narrative of science and finance teaming up against a virus and delivering a silver bullet in the form of a new vaccine, rather than recognizing that a health emergency reflects patterns of inequality within and across countries and other social factors that need to be addressed. Given the interconnection and interdependency of globalization, ethics must be incorporated in global health policy as a primary consideration, not an afterthought.

“To do better with the next pandemic, as well as with persistent health inequalities, requires facing up to and learning from the profound ethical shortcomings of the various national and global responses to the COVID-19 pandemic.”

In September 2021, United Nations Secretary General António Guterres stood before world leaders gathered for the UN General Assembly in New York City. Describing the state of the world 21 months into the COVID-19 pandemic, he noted that a majority of people in the wealthier world were already vaccinated, while over 90 percent of Africans were still waiting for their first dose. “This is a moral indictment of the state of our world,” he stated emphatically. “It is an obscenity. We passed the science test. But we are getting an F in ethics.”

Guterres’s rebuke trenchantly captures the remarkable distancing between science and ethics, particularly the concern for equity, in the global response to the pandemic. At the same time, the secretary general’s use of “we” was likely jarring to many in the audience. It implied that all the world leaders at the gathering had a meaningful role in producing, and thus were partly responsible for, this morally deplorable state of world affairs.

In contrast to this suggestion of collective responsibility, a few months earlier, in May 2021, South African President Cyril Ramaphosa described the unfolding situation as “vaccine apartheid.” He revived not-too-distant memories of apartheid in South Africa, as well as a world segregated along racial lines, an architecture of world order enforcing white supremacy and structural domination of everyone else—in other words, the era of colonialism and imperialism. Ramaphosa’s fierce language also gave voice to growing alarm and frustration at the disconnect between the rhetoric of global solidarity and cooperation coming from various leaders of the world’s richest countries and international organizations, and the reality that the same wealthiest countries were hoarding the extant and future global supply of COVID vaccines. Moreover, people were dying in the rest of the world because of limited supplies of tests, personal protective equipment (PPE), medical treatments, and basic medical supplies such as oxygen.

Dishonesty, unbridled self-interest, hypocrisy, mistrust, racism, neglect, marginalization, and inequity are emblematic of immoral relationships and institutions. However, for some theorists and practitioners of international relations, morality has little purchase when it comes to the protection of national security or pursuit of national self-interest in a global arena of competition and conflict. Even some political philosophers whose egalitarian theories of social justice start from the foundation of the moral equality of persons cease their moral reasoning at their national borders.

Such thinkers conceive of social justice as a system of principles or rules for distributing the benefits and burdens of social cooperation. Given that the world contains diverse societies with fundamentally incommensurate moral values, over which horrendous wars have been fought through the ages, the eminent philosopher John Rawls proposed that we would do well to begin by theorizing the demands of social justice within our own society first, imagining that it is the only one in the world.

The long-standing school of realism in international relations, and mainstream philosophers’ uncertainty or skepticism about moral relations with societies that are disconnected and fundamentally different from “us,” can go a long way toward explaining the continuing global devastation that the pandemic and responses to it have caused. But what is confounding is that nations and the world order are in disarray because of a global health emergency. Global health—as an academic discipline, a conglomeration of health institutions, and a field of practice—was seen just a few years ago as a beacon of international cooperation, multilateralism, and public–private innovation, clearly expressing the ethics of beneficence and global equity. No society was too remote or too different to be outside the scope of global health research and practice. Whatever moral and cultural differences may exist between societies, most individuals and all societies value good health.

Spending on development assistance for health programs—mainly, funds going from rich to low- and middle-income countries—grew from $8 billion per year in 1990 to $40 billion in 2019, according to the Institute of Health Metrics. The growing scale, reach, and positive impact of global health over those three decades led to its being seen as a plausible model or cornerstone for building further global cooperation in other domains, such as trade, regulation of illicit financial flows, climate change negotiations, and migration. Global health leaders were increasingly part of elite discussions among presidents, corporate chief executives, and billionaire philanthropists.

Ethics has been relegated to a role of supporting science.

This may partly explain why a handful of men leading prominent global health organizations believed that they could design, mobilize support for, and deliver a single, coordinated global response to the COVID-19 pandemic, namely by creating and running the Access to COVID-19 Tools Accelerator (ACT-A). Established in April 2020, the ACT-A initially had three pillars: financing and delivering diagnostics, treatments, and vaccines, respectively. The vaccine pillar, known as COVAX, was the best known of the three.

The aim of COVAX was to rapidly invest in research and development for new vaccines, negotiate prices, and deliver them to all countries. Countries that initially put in money would get priority access and larger amounts than countries that did not. That was the balance between science and equity.

Starting in early 2020, the originators of COVAX sought to galvanize global funding for the ACT-A pillars, and create legitimacy for the new entity, by involving international organizations such the World Health Organization (WHO) and UNICEF and obtaining the political sponsorship of powerful nations such as France, Germany, and the United Kingdom, as well as the European Union. (The United States was a nonstarter because President Donald Trump had shown his aversion to global cooperation and international organizations and his willingness to break global norms. Russia and China also did not participate in the ACT-A.)

Yet the leaders of the world’s richest countries, while mostly stating their support for ACT-A, were independently financing vaccines for their own populations and purchasing them directly from pharmaceutical companies. Rather than being the single source for COVID vaccines for the entire world, as its founders had envisioned, COVAX became just another buyer standing in line—and even then it was a latecomer, with only funding pledges in its wallet.

As Ramaphosa highlighted in early 2021, the richest countries had signed purchase orders for extant and future supplies of diverse kinds of COVID vaccines, and in amounts many times more than their own citizens would need, even accounting for multiple doses. This was a textbook example of hoarding as well as realist international relations. Now, three years into the pandemic, ACT-A is a shell and is likely to be dismantled soon.

The way a few rich countries subverted COVAX and hoarded global vaccine supplies played a big part in the global devastation that is still underway and that has fundamentally shaken up the world order, but this was not the only significant cause. The current global total of COVID-19 deaths is estimated to be around 6.4 million, while excess mortality due to the pandemic is around 23 million, according to the Economist. That means close to 23 million people have died over the past three years who would otherwise be alive if not for the SARS-CoV-2 virus as well as the effects of national and global responses and neglect.

The distinction between direct mortality and excess mortality is important. Whereas vaccine procurement efforts sought to prevent COVID morbidity and mortality, other social policy choices and neglect at the local, national, regional, and global levels have produced indirect mortality that continues to accumulate, with consequences in multiple dimensions of individual and social well-being that will be felt for generations. The current direct death toll might have been lower with vaccines more widely available and better infection control policies and medical care, but that is only part of a set of big questions: How might the number of excess deaths and the many more people suffering long-term disease and disability and other devastating harms have been lower? And how can we contain those consequences and help people recover from them going forward?

Two competing narratives, or perhaps paradigms, may help make sense of this pandemic and the mind-boggling totals of lives lost and harms inflicted so far. The first is a story about how a new virus appears and begins to multiply, causing death and devastation. Biological science and finance are the main protagonists in the response, working together under the immense pressure of daily mounting deaths and motivated by the noble purpose of saving lives. Contending with immense scientific uncertainty, they emerge with a silver bullet—a new kind of vaccine—to slay the virus. Ethics and equity enter the picture after this discovery, once it is realistic to think about how fairly the silver bullet should be distributed. This heroic narrative plays out not only during sudden health crises, but also during normal times. A particular kind of ethics is expressed in the selection of which health care is provided to whom in order to have the greatest impact on disease burden.

An alternative view rejects this narrative that frames a novel virus’s emergence as a sudden and natural or biological event. Instead, the second perspective identifies social choices and neglect as factors in the emergence of a novel virus in a particular locale, and in why and how it spreads within and across countries. In addition to pointing out the social causes of the differential spread across individuals and populations, this narrative also considers the diverse impacts of both extant and potential social responses to containing the virus and its harms. The role of ethics in this second perspective, tracking social choices and neglect, is prominent and thoroughgoing.

Ethics is often described as answering the question of how we ought to live. Thus it discerns goodness or badness, rightness or wrongness, in the individual and collective human actions that produced the conditions from which the virus emerged, in the pathways by which it spread across and within countries, and in the social responses it has elicited from the local to the global level. The role of ethics, in this second narrative, is not limited to deliberating on how we ought to distribute the silver bullet, or ensuring that the scientific research that produces the silver bullet is conducted according to established bioethical principles. Ethics is intertwined with the emergence and pathways of causes, disease levels, distribution patterns, differential experiences, varied consequences, and possible social responses. This is what is meant when health equity is described as multidimensional. And health equity is not just applicable to emergencies—it is also applicable to human health during normal times.

The first narrative—focused on science, finance, and silver bullets, with equity as a late-stage consideration—has dominated national and global responses to the COVID-19 pandemic. The primary equity concerns have focused on the distribution and manufacturing rights to vaccines once they are developed. This approach was visible at the first WHO R&D Blueprint meeting, in February 2020, intended to coordinate a global research agenda for COVID-19, where ethics was given a supporting role—assisting scientists to do research ethically, rather than to begin preparing to address all the ethical dimensions of the crisis. The first time ethics was raised in public discourse during the pandemic was in debates over principles for allocating emergency room beds and ventilators in rich countries.

The fair distribution of lifesaving health care goods and services, and the conduct of scientific research, are indeed weighty ethical issues. Yet there were, and still are, far more numerous ethical issues at stake than these. Some are even more significant, such as issues related to social equity and justice—particularly the roles played by social choices (including political choices) and neglect. Sporadic debates that arose during the lockdowns, framing these policy decisions as pitting the economy against public health, individual liberties against public health, or the lives of the young against those of the old, show how inadequate it is to assume that the primary role of ethics in a national or global health emergency is to assist in distributing lifesaving goods or upholding certain principles in doing research.

If the ethical dimensions of these issues are tethered to social actions and neglect, from causes to consequences and possible responses, the social dimensions need to be widely recognized and acknowledged. To put it another way, a random event or natural disaster has no morals. A large tree branch that falls and hurts a child is neither morally good nor bad, nor does it have moral rights and duties. But depending on who the child is and where the event occurs, that child may have a claim to assistance—and there may be moral duties on others to provide that assistance. However, unlike a falling branch, socially created crises do have ethical properties. If we—whether we are leaders, experts, or just citizens or inhabitants of planet Earth—have created a crisis through our actions or neglect, we are morally responsible for the resulting harms and have diverse obligations to correct or mitigate those harms.

Given such profound ethical implications of recognizing the role of social choices and neglect, it may be understandable that politicians, experts, and leaders of nations and international organizations would prefer the first narrative of pandemics as a matter of natural events, heroic science, and silver bullets. It may be that such individuals are not just unwilling, but even unable to recognize the thoroughgoing social dimensions of health emergencies, as well as endemic health inequalities, because the consequent ethical implications would require dramatic reforms and would directly threaten the social, political, economic, and perhaps even racial architecture that sustains their position, power, and interests. But scientists have a lot of agency in determining whether they uphold the heroic narrative that obfuscates the social dimensions and ethical implications of the causation, distribution, and consequences of disease and death—as well as possible responses.

Biomedical interventions are only part of the solution.

It has by now become commonplace to hear that the COVID pandemic has revealed and exacerbated preexisting inequalities, from the local to the global level. Despite the political rhetoric and the initial panic driven by simplistic mathematical modeling of the coronavirus’s spread and mortality, not all individuals or population groups are equally exposed to health risks or vulnerable in the same way, have the same experience of disease or medical care, or face the same nonhealth consequences. This also holds true during normal times. Diversity in individual biology and in how individuals are socially situated directly determines the inequalities in people’s abilities to protect themselves and mitigate the harms and other consequences of disease, if they survive.

Such patterns of unequal abilities to protect health, often reflected in disease distribution patterns across individuals and groups, are measurable, accessible, and widely known in both scientific and policy circles. In the United Kingdom, Michael Marmot and colleagues stated in their 2020 report, Build Back Fairer: The COVID-19 Marmot Review, that the UK’s COVID mortality distribution patterns were utterly predictable, tracking existing population health inequalities. In the United States, health capability distributions, or health “disparities” as they are called, are tracked by race as well as by state, county, and even postal code. Underneath the aggregate number of roughly 1 million deaths due to COVID in the United States, the distribution patterns follow preexisting patterns of disease and health capabilities. Excess mortality in the United States is also likely to follow the same patterns, as are long-term disabilities and the harms to other dimensions of well-being.

In contrast, in many low- and middle-income countries, health data is patchy or lags behind because of weak infrastructure. Nevertheless, there is some understanding of the levels of population health and distribution patterns, and the diverse social conditions that constrain the abilities of certain groups to protect their health.

Despite the availability of such knowledge about inequalities in health capabilities—and previously documented findings about how this has played out in pandemics like HIV and epidemics like Ebola, Zika, tuberculosis, and malaria—when the COVID-19 pandemic began, many nations, starting with China, took a fairly simple biomedical perspective focused on the virus and generic biological bodies. That is, every human body was considered to be equally vulnerable to exposure, infection, and death. The Chinese government’s implementation of lockdowns in cities with millions of inhabitants was unprecedented in terms of scale, but it was also based on scientifically unproven assumptions.

Historically, infectious disease outbreaks have been dealt with through a “contain and control” approach. Those who are infected or thought to be infected are separated from the uninfected to contain the spread of the virus. In a small, localized outbreak, this can be an effective, efficient approach since it involves relatively few people. But as infections spread across people, time, and geography, the cause of contagion is no longer just the harmful organism. Human behaviors, shaped by social factors—cultural, legal, economic, political—start to influence the course of the outbreak. It becomes more necessary to identify how human diversity and social forces (from local to global scales) are affecting the spread and population distribution of infections, and then integrate that evolving knowledge into the containment response. An effective response entails addressing both the biological and social factors driving the spread of infections, and it requires social cooperation, since infections spread from one person to another within societies and across national borders.

China’s approach of locking down large cities well after infections were spreading widely reflects an absolute denial of the importance of human diversity and of social factors affecting the behaviors driving the spread. Officials thought that what could be done to a few individuals in a small outbreak could be done to millions of people, simply scaled up to apply to entire populations, with the same results. This reasoning is where the biomedical perspective fails profoundly. Though the quarantines may have curtailed infections to some extent, they also spread infections outward to other countries as hundreds, perhaps thousands, of infected people fled China to escape lockdowns, quarantines, or other restrictions.

The initial China lockdowns, the early disease dynamics modeling that gave no consideration to inequality in risk or abilities, and the WHO’s “test-trace-isolate” mantra all focused narrowly on the biology of the virus and individual human bodies. This contributed to the rapid lockdowns of entire countries across the world. They were all, like China, scaling up the contain-and-control approach to entire populations, a strategy that had no precedent and was scientifically unproven.

This approach also contributed to the focus on individual-level biomedical interventions, notably vaccines, and other commodities such as tests, masks, other PPE, and medical treatments. These biomedical interventions have been hugely important in addressing the pandemic, but they are only part of the solution. Richer analyses of human diversity and social drivers of the local and global spread of infections, and good modeling of social distribution patterns, could have informed much better lockdown policies and highlighted the importance of social cooperation. In particular, rather than largely focusing on policies protecting the average healthy citizen, governments could have been compelled to pay much more attention to protecting the most vulnerable—older people, those who have biological or psychological impairments, and socially excluded groups.

To put it another way, had some of the earliest affected countries known that infections would largely lead to the deaths of older people, minority groups, and others who were biologically and socially vulnerable, would they have implemented the lockdowns? Or implemented them in the way they did? The types of scientific knowledge that were called on early in the pandemic, within countries and in international organizations, and the attention given to the social dimensions versus the biomedical approach, have resulted in stark differences in the pandemic’s impacts in different societies. Too many failed to incorporate ethics and equity in planning and implementing pandemic responses, contributing to over 23 million deaths so far.

In light of the enormous role of social actions and neglect in the pandemic, and the profound ethical issues intertwined with them, one might have expected ethicists to have been greatly involved in the responses at the national or global levels. But the dominant perspective within and across nations, including international organizations, relegates ethics to a role of supporting science and late-stage consideration of how to distribute science’s products.

Take, for example, the formation and ongoing operations of ACT-A and COVAX. Starting in early 2020, each ACT-A pillar was led by two organizations, while diverse experts, government officials, and community service organizations worldwide were called upon to contribute to its work. In frequent conference calls, various aspects of the initiative were discussed, including financing, effectiveness, and operations. Yet no trained ethicists have been directly involved over the past three years.

From the start, however, it was recognized that there was a need for ethicists to consider the distribution principles COVAX should use for vaccines, if and when they appeared. Since demand would greatly outstrip supply, some reasoned that ethical principles were needed for “vaccine allocation.” At one point, it seemed that a group within the WHO, called the Strategic Advisory Group of Experts on Immunization (SAGE), had been given responsibility for developing an ethical framework for COVAX. A SAGE Working Group on COVID-19 vaccination was formed—it included one or two bioethicists, but mostly comprised vaccine experts. They produced a document that presented allocation principles to be used across and within countries.

Nevertheless, the actual principle that was used by COVAX—that every country initially would receive vaccine doses to cover 20 percent of its population size, over time, in tranches—was reportedly developed by a management consultant working for the Global Vaccine Alliance (GAVI). The reasoning apparently was based on an estimate that around 20 percent of all national populations are health care workers. Since these workers were essential to managing COVID-19 patients and holding health care systems together, each country would initially get enough vaccines to cover them. But it was left up to governments to choose whether to vaccinate health care workers first.

In early 2020–21, it was surprising that ACT-A engaged so minimally even with bioethicists, even though it was steered by health organizations. More troubling has been the marginalization and lack of consideration of the broader ethical issues intertwined with the multiple dimensions of the pandemic. This has been evident not only on ACT-A’s part but everywhere.

The pandemic has made visible the interdependency of societies.

The spread of deadly infections makes visible the current interconnectedness of all human beings on this planet. Despite long-standing awareness, debates, and experiences of globalizing trends, globalization was largely understood as a phenomenon of trade and finance, or perhaps a clash of cultures. But a virus passed from person to person across borders makes globalization tangible. Every person’s vulnerability as a result of being interconnected is immediately palpable. Global interconnectedness helps transmit direct and deadly harms alongside many of the good things it brings, such as faster travel, freer exchange of ideas, and greater economic prosperity and poverty alleviation.

A related but distinct aspect of the pandemic is how it has made visible the interdependency of societies. This should give pause to the realist school of international relations. It also poses a challenge for many Anglo-American global ethics and justice philosophers, who until now have viewed the world as a group of distinct, self-contained entities, and have focused largely on the possible extension of rights and obligations across national borders, particularly between rich and poor countries. To simplify, many of these thinkers have focused on the question: What do we owe to distant strangers, particularly the poorest? That was a narrow question and the wrong one to ask.

The COVID-19 pandemic challenges this initial framing of the main problem in global ethics in a few ways. The pandemic has emphatically shown that all persons on this planet are interconnected across borders—and through those interconnections, we are made vulnerable to grievous harms and death. Moreover, it is likely that we have also passed on harms to other people in other countries. By not quickly shutting down major international airports, for example, wealthy countries—which have considered themselves benevolent actors in global ethics—likely enabled the rapid spread of the virus to other countries, particularly low-income countries that have suffered enormously as a result.

Beyond receiving and transmitting harms, it is fairly well evident from the basic epidemiology of the pandemic that no single country, or even group of countries, can contain the pandemic by itself. No country can control the virus within its own borders and remain protected unless all other countries also control the spread within their own borders. Interconnectedness and interdependency make global coordinated action necessary to contain the pandemic everywhere. And this requires not just the cooperation of a few governments; all countries must cooperate in order to protect every country for as long as necessary. Notions of benevolence or even humanitarianism are not the appropriate ethical resources to draw on in this situation.

The necessity for, and benefits of, cooperative action at a global level have previously been identified in the context of many other global issues, such as climate change, nuclear proliferation, and the illicit drug trade. But the distinctiveness of this pandemic is that along with making more prominent the interconnectedness and interdependency of all human beings, it produces a sense of urgency due to the imminent threat to bodily health, possibly leading to a quick death for millions of people. Social interactions within and across borders will be even more necessary for societies to recover from the economic and social devastation.

It is the recognition of jointly living on this planet, and of having intertwined destinies, that compels us to ask: How should we live together? This is the mainstay of the philosophy of social and global justice, particular theories of social contract, and distributive justice. It may not matter if other societies have different moral values; we can grievously harm each other, we have done so, and we continue to do so to varying degrees. The role of ethics and ethicists in this shifting global order is to provide moral guidance for the political processes and structures that distribute benefits and burdens across societies. Their role cannot simply involve identifying how to distribute health care or conduct scientific research. And, unlike human rights law, which has historically focused on the relationship between governments and their citizens, the scope of ethics can encompass a whole range of diverse actors that operate at the transnational global level.

Ethics is the right register from which to address issues regarding the world order and the place of health within it. The dominant narrative of heroic science and finance joining up to save humanity may produce valuable goods, but it also enables and sustains immoral relationships within and across societies. Starting with the question of how all societies should live together in interconnectedness and interdependency allows all to more honestly identify social factors and neglect in the causation and distribution of harms, including infectious diseases.

To do better with the next pandemic, as well as with persistent health inequalities, requires facing up to and learning from the profound ethical shortcomings of the various national and global responses to the COVID-19 pandemic. The deaths of 23 million people, and the untold suffering of millions more, demand that we get the ethics right as much as we try to get the science right.