Social justice as a foundation for democracy and health

Governing for the common good

These successful countries use shared health governance to help prevent premature mortality and avoidable morbidity.8 Efficient healthcare and public health systems require shared responsibility, shared resources, and shared sovereignty. Private actors and public institutions engage collectively to ensure the health and flourishing of all. In shared health governance, genuine collective action brings about justice.

Narrow self-interest does not foster capabilities. The United States, United Kingdom, Brazil, and Russia, all democracies, have shown the failure of leaders who seek to deflect criticism or protect their personal and political interests. By contrast, the shared health governance approach in successful countries, rising above self-interest and focusing on the common good, has enlisted institutions and practices to ensure effective responses to covid-19.

Shared responsibility for scientifically grounded systems

Shared responsibility for scientifically grounded systems meets the moral obligation to act according to the current state of knowledge in pandemic preparedness. As the pandemic began, successful countries implemented rigorous systems of detection, contact tracing, isolation, quarantine, and social distancing. Taiwan, Japan, South Korea, New Zealand, Germany, and Austria all imposed a quarantine on people arriving from abroad.91011 Taiwan’s authorities arranged for special transport to take anyone arriving with a fever to healthcare facilities, which are accessible to all through Taiwan’s national health insurance.12 Healthcare is also universal, accessible to everyone, in New Zealand, South Korea, Japan, Germany, Austria, Denmark, Iceland, and Finland. While inequity in health is morally unacceptable, so far inequalities in infection and death rates as well as inequality overall seem to be lower in these countries than in unsuccessful countries. Successful countries developed and operationalised health and social systems necessary to prevent, reduce, and mitigate the collective risks emerging if marginalised, vulnerable groups lack social and health protections. The opposite occurred in countries such as the US that lack such systems.

Successful countries rapidly rolled out medically necessary equipment and supplies, tapped surge manufacturing capabilities, and targeted diagnostics and therapeutics. The Taiwanese, for example, built a reliable mass production process for masks within about a month.13

These were preplanned and scientifically based response plans. The collective capabilities of preventing, detecting, and responding to health emergencies were in place or honed expeditiously in these nations at the onset of the pandemic. This is because these nations and their citizens recognised and ethically implemented obligations to address the mutual interdependences and shared vulnerabilities posed by the coronavirus.

Successful countries also required cooperation from their citizens, who accepted and fulfilled their moral obligations to do so. South Korea and Taiwan, for example, had learnt from SARS (severe acute respiratory syndrome) that wearing masks protects people from both contracting and spreading infection,14 and mandated wearing masks in public places, including transportation.15 They controlled the supply and distribution of face masks centrally so all received masks to keep themselves and others safe.16 This is social equality at work.

The citizens of the successful countries cooperate with authorities and with each other because they are committed to doing their part for the good of the whole. The 2003 SARS pandemic prepared Taiwan, South Korea, Japan, and New Zealand for covid-19; the 2008 recession prepared Germany, Finland, Austria, Iceland, and Norway. Justice commitments to protect every citizen from premature mortality and avoidable morbidity were in place before the covid-19 outbreak.

Similar justice principles safeguard the economy. In Germany, for example, societal capabilities were built to ensure temporary employment insurance through the Kurzarbeit, under which workers accept reduced hours and receive 60-67% of their wages (with this proportion increased during covid-19) from the Federal Employment Agency, returning to full time work once the crisis is over.17 Austria has a similar short time work scheme,7 and New Zealand has access to financial support. Along with cultural norms of problem solving and long term planning, successful nations created social institutions to deal with shared threats and vulnerabilities, in good times and bad.

These governments and their people quickly and willingly came together to stop covid-19. Even before the pandemic, these nations had baked these shared commitments into their national health insurance systems. Well planned, reliable measures ensured that together leaders and people were doing everything possible to provide top quality healthcare services to everyone. This equity orientation has led to some of the lowest covid-19 incidence and death rates worldwide. Principles of justice are essential if political institutions are to work effectively for population health.

Rational, compassionate, and transparent public communication

Throughout the covid-19 response, authorities in successful countries have addressed their populations with transparency, honesty, reason, and compassion. They’ve sought to earn the trust of their citizens and their support in following guidelines. This approach has fostered national unity, the principles and practice of impartiality and objectivity are key. Regular news conferences have provided reliable, accurate information, and scientifically grounded guidelines for action.1819 Government officials made clear that every person’s life has equal value and the goal is to save everyone. These countries prize information transparency and accuracy, and news conferences acknowledged the disease’s scope and severity rather than covering it up.

This honest approach reassured the public and engendered confidence. Rather than false reports and inaccurate assertions, government officials proved themselves to be trustworthy public servants, motivated by duty and guided by data. Officials prepared well for public communications, with accurate facts and figures. Their citizens felt safe rather than fearful, observing government actions that were smart, effective, and responsible. Approval ratings for these officials have been high,20 and citizens have willingly submitted to the government’s authority. The Taiwanese, for example, believed government policies were orderly, efficient, and clearly justified.

Ethical leadership and trust

Successful nations enjoyed ethical leadership during the covid-19 pandemic. From the beginning, officials accepted responsibility and inspired others to embrace a shared purpose, to face a shared threat. They led from a sense of duty, not politics. Effective leaders do not politicise public health approaches for their own ends. They evince a deep respect for all. In Denmark, for example, citizens trust their government and leaders.

Of course, the countries that have successfully responded to covid-19 are not perfectly just; injustices exist and thwart flourishing. For example, South Korea and Japan remain patriarchal societies and also have unfair sexual orientation discrimination; racial and ethnic discrimination persists in Germany despite efforts to leave Nazism behind. Conversely, some equity oriented countries, such as Italy, fell short in fully protecting their citizens. Nevertheless, the successful countries are good examples of the justice framework and reflect characteristics identified as critical for a successful public health preparedness approach.

Democratic elections pressure politicians and parties to deliver on policies that are helpful rather than harmful, and to justify them, in order to meet people’s needs. But deep core values underlie countries’ policies and practices during and between times of crises. Just structures that foster security and express care and compassion are essential. A resilient society recognises shared risks and institutionalises shared safety, particularly for vulnerable groups. Justice was at work in nations that delivered resilient covid-19 responses. Justice, not politics, forms the foundation of what citizens owe each other and what leaders owe their citizens.