Bioethics Forum Essay

Beyond the Covid Crisis—A New Social Contract with Public Health

Covid-19 is teaching us the stern lesson that economic well-being and health justice are two sides of the same coin. Measures to limit the spread of the disease and the loss of life have brought economic activity to its knees in many of the richest countries in the world. Public health measures like social distancing induce economic coma, and economic revival risks further assaults on the public’s health. These are the stakes in the pandemic now and writ large in climate change soon enough.

Here I want to turn attention from public health emergency response today to public health disaster preparation and planning tomorrow. This time, the failings of disaster planning are manifest in all countries seriously affected by Covid-19 especially in the United States, where the infrastructure of pandemic preparedness was deliberately dismantled.

What about next time? Will it be Keystone Kops or well-informed and judicious leadership inspiring trust? And there will be a next time, and a time after that. Zoonotic disease alone is a global sword of Damocles waiting to descend. Thousands of viral types are being exposed to naïve and rapacious human contact and stand poised for an evolutionary leap into our own bodies and lives.

To weather pandemics and restore the social contact that economic life demands, we need to sign a new social contract with public health.

One part of that involves disaster preparedness planning as an ongoing—not merely a periodic—activity. How we plan affects how we respond, and how tragic the ethical dilemmas of the response measures may be. I suggest that we rethink disaster planning so that it becomes a civic practice. If we do so, then a disaster preparedness planning process will come to be seen as an expression of the entire community about the value of the lives and health of its members. It is less like a commercial contract between seller (the experts) and buyer (the tax payers and those subject to the plan’s provisions) and more like a social contract, an agreement to be entered into by all that establishes commitments of responsibility for each.

A new social contract with public health requires a new form of civic thinking, a new ethic of public health citizenship. To bring about the institutional and behavioral change that emergency preparedness and response require, it is essential to see health as genuinely “public,” as something that involves us all, as a common good, not as a commodity we pay for and consume. The quality of our collective and individual health depends upon an intricate web of cooperation and interdependence. But, just as large areas of our society are food deserts where people lack access to healthy diets, so too large areas are civic deserts with virtually no organized and ongoing settings for deliberation about our common lives together. Of course, the analogy is not perfect. Food deserts tend to exist in low income and marginalized areas since nutritious foods are privately distributed as a market commodity. (The vital National School Lunch Program and Meals on Wheels nutritional programs for seniors are exceptions that prove the rule.) Civic deserts are created more by cultural and political attitudes of privatization and exclusion rather than by inequalities of wealth. Indeed, where food deserts exist, civic communities often form to combat that deprivation and other forms of environmental and health injustice. We shall deepen the tragedy that the Covid-19 pandemic has caused if we fail to find the leadership and political will to revitalize our democracies by enhancing opportunities for civic practice and civic engagement that is ethically informed. We require a new social contract with democracy itself, as well as a new civic conscience for public health.

Nonetheless, disaster preparedness planning offers one of those opportunities. It grows out of a social vision—backed up by epidemiological research— that sees membership in larger communities as the root of health and well-being. It also grows out of a political and moral vision—backed up by democratic experience at the local level—that sees in the activity of democratic participation and deliberation as a process of civic learning that has positive effects on us as a people, enlarging our imaginative capacity for a sense of justice, empathy, solidarity, and openness to cultural and personal diversity.

Disasters do not follow scripts. As a civic practice, emergency planning must focus, not only on steps to be taken in the immediate aftermath of a catastrophe, but also on upstream assessment and preventive measures and downstream recovery and mitigation. Planning is our sentinel canary in the mineshaft and our reconciler, healer, and comforter in the aftermath. Building codes and their enforcement in times of storms, floods, or earthquakes; the proper maintenance of the aging infrastructure of our cities when lead poisoning from municipal drinking water shows up—these and similar situations are integral components of preparedness planning, for they too protect lives and defend health. Loss of biodiversity and ecosystemic degradation should also come within the purview of planning, for they affect flood control, groundwater contamination, risk of exposure to zoonotic viruses like SARS-CoV-2, and the emergence of antimicrobial-resistant organisms.

From a civic perspective, it is not the final emergency plan document per se that matters so much as the planning process and activity itself, stretching over several years, and revisited periodically because risk horizons change. Emergency planning sets in motion a whole social complex—discussions, large meetings, small meetings, networks among officials and professionals, local organizing and educational activity, the creation of new communication channels, and the recruitment of specialized individuals, or the retraining of existing personnel.

In stressing civic considerations that I hope will be taken up soon and lay the groundwork for our next public health emergency, I do not take lightly the powerful opponents of aspirational civic life and civic learning in our democracy, nor the structural conditions of injustice and inequality that block these values. I don’t mean to suggest that emergency planning must wait until preexisting barriers to full inclusion, participation, and community involvement are overcome, or until broader social problems, like racism and poverty, are solved. Disaster planning must cope with society as it is, not as it could or should be.

Moreover, I do not mean to suggest that a civic practice of disaster planning will be the sole—or even the principal—instrument of social reform. Many other activities must converge on the problem of civic renewal and resilience.

Still, I believe that civically inspired emergency planning can contribute, not only to specific health and safety goals, but also to the task of reinforcing our social and democratic values. Successful emergency planning must tap a preexisting fund of civic responsibility and concern for others in need. Yet emergency planning can, and should, be an occasion to foster these outlooks and impulses, as well. Fear and self-interest will no doubt be strongly in evidence during any public health emergency. Public health leadership can aid communities in moving beyond these motivations to a sense of common purpose and solidarity.

Bruce Jennings is adjunct associate professor at the Vanderbilt University Center for Biomedical Ethics and Society, a senior fellow at the Center for Humans and Nature, and a senior advisor and a fellow at The Hastings Center, where he has co-directs a project on civic learning supported by the John S. and James L. Knight Foundation. He is author of Ecological Governance: Toward a New Social Contract with the Earth (West Virginia University Press, 2016) and “Disaster Planning and Public Health” in Hastings Center Bioethics Briefings. He also co-edited Emergency Ethics: Public Health Preparedness and Response (Oxford University Press, 2016).

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