Atuire and Hassoun International Journal for International Journal for Equity in Health (2023) 22:52 https://doi.org/10.1186/s12939-023-01830-9 Equity in Health REVIEW Open Access Rethinking solidarity towards equity in global health: African views Caesar Alimsinya Atuire1,2* and Nicole Hassoun3 Abstract When the COVID-19 pandemic first took the world by storm, the World Health Organization (WHO) issued a Solidarity Call to Action to realize equitable global access to COVID-19 health technologies through pooling of knowledge, intellectual property and data. At the dawn of 2022, 70% of rich countries’ populations were vaccinated but only 4.6% of poor countries (Our World In Data, Coronavirus (COVID-19) vaccinations, 2022). Vaccine nationalism and rampant self- interest grew and our ineffective global response led to new variants of concern - like Omicron - emerging. Rather than abandon the idea of solidarity in global health, we believe that the international community must embrace it. Solidarity, with its emphasis on relationality and recognition of similarities, could offer fertile ground for building an ethical framework for an interconnected and interdependent world. Such a framework would be better than a framework that focuses principally on individual entitlements. To defend this view, we draw on African relational views of personhood and morality. When humans are conceived of as essentially relational beings, solidarity occupies a central role in moral behaviour. We argue that part of the reason appeals to solidarity have failed may be traced to an inadequate conceptualization of solidarity. For as long as solidarity remains a beautiful notion, practiced voluntarily by generous and kindhearted persons, in a transient manner to respond to specific challenges, it will never be able to offer an adequate framework for addressing inequities in global health in a systematic and permanent way. Drawing on this understanding of solidarity, we propose pathways to respond creatively to the risks we face to ensure equita- ble access to essential health for all. Keywords Solidarity, Global health, Equity, Personhood, African philosophy, Faring Well, Fair allocation *Correspondence: Caesar Alimsinya Atuire atuire.ca@gmail.com 1 Department of Philosophy and Classics, University of Ghana, Legon, Accra, Ghana 2 International Health and Tropical Medicine, University of Oxford, Oxford, UK 3 Department of Philosophy, Binghamton University, Binghamton, NY, USA © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. 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Atuire and Hassoun I nternational Journal for Equity in Health (2023) 22:52 Page 2 of 11 Rethinking solidarity towards equity in global shaken to motivate resistance against Soviet dominion [7]. health1 During the heat of the anti-apartheid struggles in South Introduction Africa, solidarity was often invoked as a motivation for Solidarity has gained traction in recent times. The concept African countries to support the cause led by the African has been invoked to motivate various national and inter- National Congress [8]. In health and healthcare, success- national measures and initiatives to combat the COVID- ful national healthcare systems such as the UK’s National 19 pandemic. Yet, even though at local levels, especially Health Service (NHS) can be described as grounded on a in the initial phase of the pandemic, there were numerous notion of solidarity [9]. gestures of solidarity, from a global health perspective, the The COVID-19 pandemic has underlined the ways in calls to solidarity seem to have made little headway in the which everyone’s health is interdependent and intercon- face of vaccine nationalism and other forms of protection- nected. Whereas in past eras communities and popula- ism. As Gavin Yamey put it, the world’s attempt to come tions could remain isolated or relatively independent from together and distribute vaccines globally through COVAX, each other, today’s increasing interconnectedness means “was a beautiful idea, born out of solidarity… Unfortunately, that our health depends on others’ health and also on the it didn’t happen…Rich countries behaved worse than any- natural world given that many diseases (and likely SARS- one’s worst nightmares” [1]. The behaviour of some richer CoV-2) are zoonotic. Added to this, the current challenges countries, who by the way, also profess solidarity and adhere emerging from climate change, and environmental pollu- to initiatives like COVAX, has been described metaphori- tion and degradation, point to how our fates and the fate cally by the African Union special envoy Strive Masiyiwa in of the planet are all intertwined. Yet, interconnectedness the following terms: “Imagine we are in a village and there is and interdependence are only descriptive concepts that drought and there will not be enough bread and the richest do not possess the normativity required to establish the guys grabs the baker and they take control of the production equity needed for all to fare well and flourish. Historically, of bread and we all have to go to those [rich] guys to ask for a exploitation, injustice, and oppression have often been per- loaf of bread” [2]. He added: “It’s not a question of if this was petuated along the fault lines of interconnectivity and inter- a moral failure, it was deliberate. Those with the resources dependence. For example, the North Atlantic Slave Trade, pushed their way to the front of the queue and took control and its accompanying racist agenda, were only made possi- of their production assets” [3]. Solidarity, it seems, is turn- ble by a more interconnected world arising from the Euro- ing out to be a weak driver for equity in the allocation of pean explorations in the Americas and Sub-Saharan Africa resources to combat a global pandemic like COVID-19. in the late fifteenth century. For an interconnected world Solidarity, a notion present in European and Catholic to be a fairer world, we believe an ethical framework capa- political discourse for over a century, is a somewhat late ble of embracing all the interconnected parties is required arrival in mainstream bioethical and global health dis- [10]. So, as we become increasingly aware of our intercon- course [4]. Bioethicists and global health experts are more nectedness, there is a corresponding need for tools that can at home with notions like justice, often understood from embed ethics into these relationships. We see solidarity, a liberal viewpoint as fairness, and concern for individual adequately conceived, as an attractive candidate for pro- freedom. Some claim that these concepts, which generate moting fairness in an interconnected global health space. negative and positive duties, lend themselves better to for- Rather than abandon the idea of solidarity in global health mulating enforceable legal frameworks that can hold peo- as ineffective, we suggest taking a fresh look at the concept. ple, organizations, and nations accountable. Solidarity on This paper offers a conception of solidarity we hope will be the contrary, often appears, “as a rather opaque term” [5]. useful in practice, though we do not defend the claim that Yet, despite these apparent conceptual weaknesses, there we should have solidarity here and only aim to provide a are historical examples of how solidarity has contributed new way of thinking about solidarity. We draw on African to making important socio-political changes. The concept relational views of personhood and morality in articulat- of black solidarity, expressed by authors like Frantz Fanon, ing our proposal. In this view, humans are conceived of William E. Du Bois, and Kwame Nkrumah, was important as essentially relational beings and solidarity occupies a in the pan-African movement that accompanied the drive central role in moral behaviour. Relationality and solidar- to end colonial rule in Africa [6]. In Poland, the fight against ity are not unique to African thinkers. Conceptualizations communist rule was led by the Solidarnosc movement. In of humans as relational beings can be found in the Asian the Czech Republic, Patočka appealed to a solidarity of the traditions as well as contemporary pro-communal think- ers in the Western tradition like Charles Taylor, Michael Sandel, and Alasdair MacIntyre. There is also a rich and 1 A thank you to our colleagues at the Independent Resource Group for long tradition of work on solidarity dating from Durkheim Global Health Justice, Oxford and Kings College, Noa Mizrachi, and the Global Health Impact Team for incredibly helpful comments and discussion. [11] to more recent works by Wiggins [12], and global A tuire and Hassoun I nternational Journal for Equity in Health (2023) 22:52 Page 3 of 11 health-focused works like those of Prainsack and  Buyx bioethics literature. On their account, solidarity “com- [13], Gould [14], Jennings and  Dawson [15], Dawson and prises enacted commitments to carry costs – in the widest Verweij [5], and Kolers among others.2 We focus on Afri- sense of the word – to assist others with whom a person can conceptualizations because they add to the current dis- or persons recognise similarity in a relevant respect”. They cussion by arguing that solidarity is a primary ethical duty believe solidaristic “practices are enactments and expres- that arises from the way human beings are and ought to be sions of who a person is, and wants to be” [13]. In the rather than an instrumental or axiological means to assist salient African philosophical traditions from which we those who are worse off. Secondly, appeals to solidarity will draw, however, solidarity is not just an “expression of during international health emergencies are often made in who a person is, and wants to be” but an expression “of favour of assisting lower-income countries, most of which who a person is and ought to be” [13]. Thus, solidarity is are found in Africa. Such international projects, like the not merely desireable or an ‘axiological value’ [13] but an ACT-Accelerator, bring together people and countries who expression of personhood. In this section, we look at the may have different understandings of solidarity. One way to notion of (moral) personhood in African philosophy and avoid talking past each other is to have a better understand- the concept of solidarity that emerges from it. ing of each other’s conceptualizations and expectations. Understanding each other’s conceptualizations and expec- Relatedness and moral obligation tations is a good starting point for defining shared action- One of the most cited texts in African philosophical reflec- able goals.3 We conclude by applying our conception of tions on personhood is Kenyan, Mbiti’s [16] claim that ‘I solidarity to evaluate the COVID-19 response and how we am, because we are; and since we are, therefore I am’. This might better prepare for and respond to pandemics. If one is a cardinal point in the understanding of the African view endorses our view of solidarity, it should be clear that bet- of [hu]man” [16]. Within the ubuntu philosophical tradi- ter pandemic preparation and response requires combat- tion, South African Ramose [17], similarly appeals to the ting artificially as well as naturally created scarcity; we must saying that motho ke motho ka batho; umuntu ngumuntu respond creatively to the risks we face to ensure equitable ngabanye bantu, (a person is a person through other per- access to essential health for all. sons). Drawing from the Ghanaian Builsa—a Savannah ethnic group of West Africa—tradition, Atuire et  al. [18], A conception of solidarity: an African perspective highlights how persons are defined as nurbiik, meaning a The African view we present offers a framework in which son or daughter of a person thus, inextricably relational. For practicing solidarity is an expression of being human; a the Builsa, a human being is considered as one who matters view that we believe provides a new perspective, and that to someone [18]. Relationality would seem essential to the can shape the ongoing debate about what we owe to oth- notion of personhood. Put another way, African philosoph- ers. What follows considers first the notion of person- ical traditions posit relationality as a given; personhood hood within African philosophy and then a conception of cannot be conceived of without relationality. Wiredu [19] moral personhood or dignity that draws on this account underscores this position by recalling the Ghanaian Akan and grounds the conception of solidarity we advocate. By saying that onipa firi soro besi a, obesi onipa kurom (when African conceptions we mean the views that are commonly a person descends from above, she descends into a human expressed by African philosophical writers. This does not society). mean that such views are not present in other philosophical Reflecting on these conceptions, Metz [20] teases out traditions, nor does it mean that all Africans subscribe to an Afro-relational conception of personhood. In his view, these views. The views we present are the salient ideas we unlike Aristotle’s Categories, relations are essential to the find among the African philosophical writers. That is, we definition of an object and persons, in particular: “the are drawing some common strands from diverse traditions essence of any concrete, natural object is, at least in part, that differ from one another in some important ways. necessarily constituted by its relationship with elements An initial iteration of our conception of solidar- of the world beyond the thing’s intrinsic properties” ity is closest to Prainsack and Buyx [13]  account in the [20]. He posits this against “the Anglo-American, and more broadly Western, philosophical tradition,” where “the self or person is usually identified with something 2 We do not discuss John Paul Sartre and Edmund Husserl’s conceptions of internal, either a soul that contains mental states, a brain solidarity because this would require going to great lengths to explain why that contains mental states or, most common these days, the phenomenological approach, with its starting point as the object that appears to consciousness, differs from the approach the African authors we a chain of mental states themselves, some of which are draw on take. self-aware” ([20], p. 215). Metz’ account echoes Nigerian 3 See: Amartya Sen, Reasoning and Disagreement, Isaiah Berlin Lecture, 2011. Menkiti’s [21] claim that whereas most Western views of Oxford Podcasts: https://i tunes. apple. com/u s/ itunes- u/t he-i saiah- berlin- lectu re/ id3817 00653 human “abstract this or that feature of the lone individual Atuire and Hassoun International Journal for Equity in Health (2023) 22:52 Page 4 of 11 and then proceed to make it the defining or essential such we still owe duties such individuals because they are characteristic which entities aspiring to the description humans. Atuire [24] draws on the concept of a privation ‘[hu]man’ must have, the African view of [hu]man denies to say that cognitive or psychological impairments that that persons can be defined by focusing on this or that limit the capacity to become a fully morally responsible physical or psychological characteristic of the lone indi- are accidental and do not alter the nature of a being, thus vidual”. What emerges from these various positions is a duties owed to all humans are also owed to such persons. relational view of personhood whereby persons emerge What is more, a truly relational ethic that prioritizes the out of a web of relations. faring well of all points to doing more to assist those Moreover, drawing on the views of Akan philosophers whose capacities are limited. like Wiredu and Gyekye, who see these relations as On this view, Molefe [25], affirms: “Put simply, to be a extending to all humans, the conception of solidarity in good human being I am required to exercise my duties to the context of health crises like international pandemics, others. The best way to focus on what is morally best for we suggest that all humans are part of one global com- me as an agent is to focus on bettering the humanity of munity. That is, the conception of solidarity we offer is others”. properly cosmopolitan. We start from a conception of The main thrust of African ethics according to Wiredu our relationships to others in a theory of moral person- ([19], p. 194), “would seem generally to be of a human- hood and claim that these relationships require us to istic orientation”. This, he continues, is sustained by the sympathetically put ourselves in each person’s shoes to fact that the most common formulation of morality cen- stand in solidarity with them and collaborate creatively tres around the expression, onipa na ohia (it is a human to ensure that we all fare well enough together. There being that has value). The saying can be interpreted both are, of course, other possible ways of thinking about as “all values derive from human interests’ and ‘human fel- solidarity but we explain in the paper why we prefer this lowship is the most important of all human needs” [19]. one to some of the main contenders in the literature on Wiredu proposes a moral imperative: “In all inter-per- bioethics. sonal situations put yourself into the skin of the other and see if you can contemplate the consequences of your pro- A normative conception of personhood posed action with equanimity” ([19], p. 198). African concepts of morality emerge against this back- The notion of solidarity we outline below is grounded drop of what it means to be a person. Given that per- on this moral framework in which to be a person means sons are relational beings, morality is that which creates to be-in-relation and to be moral means promoting one’s and fosters the conditions necessary for members of own well-being by ensuring that others also fare well and the collective to be able to fare well enough. Thus, enough. Thus the Akan saying, “If you do not allow your according to Wiredu [22], ‘a certain amount of altruism neighbour to reach nine you will never reach ten” [23]. is absolutely essential to the moral motivation’. As Mbiti put it, “only in terms of other people does the individual Defining solidarity become conscious of his own being, his own duties” the Drawing on the African frameworks that we have set out, act of becoming conscious of one’s personhood entails an we propose the following definition of solidarity, broadly: assumption of duties [16]. The fulfillment of these duties, a sympathetic and imaginative enactment of collaborative which are mostly other regarding virtues, is what consti- measures to enhance our given or acquired relatedness so tutes the moral notion of personhood. that together we fare well enough. The key to understand- African theorizations of personhood focus more on the ing what this kind of solidarity requires, then, is under- moral notion of personhood. Thus, on some accounts, standing our given interrelatedness and how we can live personhood becomes a human ideal to be achieved. Men- well enough together, but first we must explain how we kiti ([21], p. 172), describes moral personhood as “some- should sympathetically and imaginatively collaborate to thing which has to be achieved, and is not given simply achieve this goal. because one is born of human seed”. Also, Gyekye [23], makes the claim that personhood is typically “earned Sympathetic in the ethical arena: it is an individual’s moral achieve- Solidarity, as Prainsack and Buyx point out, entails a rec- ment that earns him the status of a person. Every indi- ognition of similarity with others in a relevant aspect. vidual is capable of becoming a person inasmuch as he It does not, however, stop at a recognition of affinity, it is capable of doing good and should therefore be treated requires sympathy (syn--with, together and pathos--pas- (potentially) as a morally responsible agent”. Against the sion, suffering, emotion, feeling) [13]. Sympathy entails objection that some humans may be incapable of becom- recognizing, and to some extent identifying with the ing fully morally responsible agents, Gyekye suggests that other. In the present case of the COVID-19 pandemic, A tuire and Hassoun International Journal for Equity in Health (2023) 22:52 Page 5 of 11 assisting low- and middle- income countries will thus not does not become solidarity until these feelings are trans- be motivated by the fear that if persons from economi- formed into concrete actions geared towards ameliorat- cally poorer countries remain unvaccinated, new variants ing their condition. can appear that will render the vaccinations in the high- A common characteristic of the creative and imagina- income countries inefficient. Such a view is ultimately tive dimension of solidarity is the capacity to generate about protecting oneself within a world of inextricable new groups or new forms of relationships within exist- global interdependence. It simply sees the well-being ing groups to respond to challenges. When this happens, of others as instrumental and may even allow for forms the common goal of the group becomes what Taylor [29] of vaccine nationalism when the interconnectedness calls an executive goal. For example, a group of travel- becomes unnecessary or of little value. Solidarity points lers on a train that breaks down before arriving at a des- more in the direction of seeing the other as another self tination may establish a solidaristic group to assist each whose well-being is conjoined to our own. We empathize other to arrive at the desired destination by, say, coming with others putting ourselves into their shoes in deciding together to hire a bus or some other means of transport. what they need to flourish, in part, because their flourish- Such a group may even assist travellers who need physi- ing is part of our own [26, 27]. cal or economic help. However, once the executive goal of arriving at the destination has been achieved, the group Imaginative may cease to exist as a solidaristic group. For other types By imaginative we mean that solidaristic initiatives often of executive goals, say healthcare or worker’s rights, soli- go beyond the established channels of social welfare to daristic groups can, over time, become institutionalized. find paths to assist others. Often solidarity requires crea- When this happens, as the initial trigger that catalyzed tive resolve - a fundamental commitment to overcoming the establishment of the group recedes in individual and apparent tragedy [28]. Solidarity can be institutional- collective memory, solidarity can feel imposed or coerced ized and even codified into legal mechanisms as we see if motivations are not constantly renewed. This happens in national healthcare systems where all are expected to especially in large solidaristic groups like nationwide contribute to the health needs of fellow citizens through healthcare systems or social welfare programmes. taxation. Institutionalized solidarity still leaves room for other forms of solidarity to be practiced at interper- Enhance intrinsic and acquired relatedness sonal and community levels. These latter forms which Whereas solidarity can be borne out of transient condi- can be spontaneous, or transient, and often require going tions like a train breaking down, there are other types beyond established channels to assist others, or each of solidaristic groups that are born out of the intrinsic other, in achieving a desired goal. Examples of such forms human relatedness that we have described above. This of solidarity during the COVID-19 pandemic include type of solidaristic exigency is not transient; it is a per- shopping for members of the community who are in iso- manent requirement for human flourishing. Arguably, lation, clapping for healthcare and frontline workers at an health and access to healthcare fall under this exigency established time and day, and many other gestures [28]. since they are important for flourishing. The specific Nevertheless, the imaginative and often spontaneous modalities or institutions that are created as a response to character of solidaristic initiatives do not make solidarity the solidaristic exigency can change and need to adapt to optional or supererogatory. The normative requirement be better attuned to achieving the desired goals. What is is to find paths to assist so that we all fare well enough constant is the requirement of solidarity as a framework together.4 Where there are no established routes or when in which relatedness is not just a descriptive reality but the existing channels are inadequate or inefficient, it one that is a normative requirement to ensure fairness, takes imagination to find novel pathways. equity, generosity and compassion. It is a moral obliga- tion because it makes us more human as moral persons. Enactment of collaborative measures And, becoming more human, in the African view, which Sympathy and imagination alone do not suffice to estab- we take as the starting point for our argument, is a moral lish solidarity. Solidarity is an action orienting concept, duty. Solidarity embraces justice because it ensures that thus, feelings or attitudes need to be transformed into we fulfill our duties towards others by recognizing our real measures or gestures for solidarity to occur. Feeling common humanity that is grounded, in part, in the rela- sympathy for members of marginalized communities in tionships we stand in to others. India or Brazil who have little access to COVID-19 tools Faring well enough together The notion of faring well enough together is grounded on 4 the idea of our human interrelatedness. Faring well thus For more on what faring well enough together might require see [26, 27]. Atuire and Hassoun International Journal for Equity in Health (2023) 22:52 Page 6 of 11 becomes both an individual and communitarian enter- physical health. It refers to a person’s physical, prise. Ideally, to fare well together requires imagination social, psychological and spiritual well-being. If any and sympathy to put ourselves into others shoes and of these aspects of a human’s life is in a state of dis- consider whether we would be content to live their life. ease, then she cannot claim to have alaafia. (…) A As reasonable, caring, and free people we ask ourselves person who is not healthy or who is ill is in a state of whether there are any serious reasons to doubt the per- dis-ease and needs to be reinstated wholly [31]. son can live their life well enough considering their his- tory, psychology, social relationships, values and so forth. If we focus our attention on the holistic and rela- We should empathetically consider whether we would be tional view of health put forward by Omonzejele and content living another’s life in order to reach a judgment the notion of disease by Gbadegesin as a condition of about whether their lives are sufficiently good [27]. We being ill-at-ease, we begin to understand why it is com- believe that reasonable, caring and free people should put mon in Africa for persons to recur to both biomedical themselves in others’ shoes in figuring out what makes a cures and other forms of metaphysical practices to seek life minimally good. Resolving disagreements about what healing. The underlying framework is that the individ- people need to live minimally well may require delibera- ual’s health is linked to other factors that derive from tion and discussion with others who are similarly rea- the relationality of being human. Although this vision sonable, caring and free. Whatever form the minimally in Africa is often clouded with religious or ritualistic good life takes, this account of solidarity sets the follow- connotations, from a philosophical viewpoint, it is not ing standard: When a person’s ability to live a minimally far removed from emerging concepts in global health good life is not secure, then she is entitled to the aid of that insist on socio-cultural determinants of health and others [26, 27] in helping her secure a minimally good notions like intersectionality [32]. life, provided that this help will not jeopardize their own From this perspective health is both an individual and ability to live a minimally good life [26, 27]. The notion a shared good. Thus, the pursuit of individual health of solidarity that we are putting forward here leads us to requires not only cultivating one’s physical well-being think that the human condition is such that solidarity is a but ensuring the wellness of the relations (human, necessary ingredient for a moral community. Humans, as environmental and other) that are part of this broader relational beings thrive morally when they strive to make notion of health. In the specific cases of epidemics and other persons thrive. pandemics, such vast disruptions of health are seen as a common threat that cannot be overcome without the collaboration of all. What is more, the solution does not African conceptions of health and ill‑health lie only in curbing the spread of the disease (effective To explore the relationship between health and the vaccines or therapeutics), but also seeking to establish notion of solidarity we are presenting, we need to exam- what behaviours may have contributed to the emer- ine the African conception of health and healthcare. A gence and spread of the disease. A way to character- common view in many African frameworks is that good ize this, as Jecker and Atuire [4] suggest, is to see an health is the outcome of a harmonious combination of event like the COVID-19 outbreak not as a pandemic, physical, non-physical, and social factors. Health, as but a syndemic, − “convergence of biosocial forces Omonzejele [30], puts it: that interact with one another to produce and exacer- is not just about the proper functioning of bodily bate clinical disease and prognosis”. Focusing the ‘syn’ organs. Good health for the African consists of men- (with, together) enables us to understand the emer- tal, physical, spiritual, and emotional stability of gence and spread of disease as the coming together of oneself, family members, and community; this inte- various factors. And this in turn informs a response grated view of health is based on the African unitary that requires the coming together of persons and tools. view of reality. Good health for the African is not a Fighting a syndemic or widespread disease ultimately subjective affair [30]. entails seeking greater harmony between persons col- lectively and ensuring more harmonious relationships Gbadegesin [31], drawing from the Nigerian Yoruba with the environment. The predominant conception of tradition, says: health in many African cultures, then, is in line with the The Yoruba, like most African culture groups, have WHO’s definition on which “Health is a state of com- a holistic conception of health and disease. To be plete physical, mental and social well-being and not well or healthy is to be in a position to do one’s daily merely the absence of disease or infirmity.” Some will tasks; it is to have a strong body and mind. (….) the object that people can fare poorly for reasons that have Yoruba word for health, alaafia, means more than nothing to do with health, arguing that, for instance, A tuire and Hassoun I nternational Journal for Equity in Health (2023) 22:52 Page 7 of 11 a broken heart may not qualify as a health problem for the allocation of resources in the widest sense of the or that some are lazy, poor, sad, wicked or otherwise word, ranging from the distribution of tax burdens to poorly off, while perfectly healthy. Yet, even those who healthcare to the right to vote, often enforced by state or reject this definition of health, should agree that people regional forms of power” (p. 45). This is because solidar- need the health-related components of welfare, what- ity “cannot be mandated and sanctioned in the way duties ever those are exactly, to fare well enough. So, one can of justice can”. adopt a pragmatic, functional, or normative conception The axiological model, which seems to be the most of health and still endorse our conclusions (though the common understanding within global health discourse, scope of what solidarity requires may change slightly in our opinion limits solidarity to an exercise of super- depending on one’s account, for example sympathy may erogation ([13], p. 79). Thus conceived, solidarity is not count as important). It only matters that health is contrasted with justice which is seen to be deontic, sanc- often an important component of, or precondition for, tionable and actionable at institutional levels. Solidarity faring well enough. may thus seem to be an optional activity that good and From our view, and others, the pursuit of health nec- praiseworthy persons and institutions engage in. In the essarily requires solidarity: a sympathetic and imagina- context of the COVID-19 pandemic, such a view perhaps tive enactment of collaborative measures to enhance our explains why high-income countries can practice solidar- given or acquired relatedness so that together we fare well ity by adhering and contributing to the ACT-Accelerator enough. Moreover, we should stand in solidarity with oth- and COVAX whilst at the same time practicing vaccine ers because we are related to them (and our flourishing nationalism. Standing in solidarity with low-and-middle- together depends on it) and to do so we must empathize income countries is perceived as an act of generosity, a with them appropriately (so we in fact flourish together). good thing to do, not sanctionable, and supererogatory. This view differs radically from ours because we see Alternative conceptions of solidarity in bioethics solidarity as morally foundational. Rather than a ‘putty’, To defend our conception of solidarity (and the frame- it is the basic building element, call it the cement, out of work based on it), however, it is important to explain how which the building blocks of a just society can be molded. it compares with and complements the main alternatives If solidarity is not sanctionable because it seems too ide- in the literature on global health and bioethics. Concep- alistic or too tall a call, we need to keep in mind that the tions of solidarity in global health and bioethics can be same can be said about the ideal of justice. Yet, through grouped into three models or approaches. centuries of effort, humanity has been able to elaborate tools (and sanctions) for building societies that try to The axiological model practice justice. In other words, we can, if we want to, This model sees solidarity as axiological; that is some- build tools to enhance solidarity, and also sanctions for thing linked to goodness, ideals, and virtues. Axiological failures to exhibit solidarity. We may need to think about models tend to focus more on moral agents and how they sanctions in a way that is different to those we currently ought to behave whereas deontic models pay more atten- apply for failures in living up to justice. tion to the actions. For Heyd [33] “the deontic sphere of morality is often taken as describing the minimal condi- tions of morality, the basic requirements of social moral- The instrumental approach ity that secure a just society, while the axiological sphere Gould [14] offers an “alternative reading of solidarity in aims at higher ideals which can only be commended and healthcare drawing on social movement and labor con- recommended but not strictly required. In its deontic texts” that highlights “a crucial dimension of contempo- nature, morality is closely associated with the legal, while rary healthcare provision, namely, structural injustice. the axiological is closer to the ideal or the ideological Systemic forms of injustice militate against adequate (sometimes referred to as “the ethical”).” healthcare for all, and suggest the need for solidaris- Prainsack and Buyx ([13], p. 79), follow this model tic action to struggle against and to remedy existing when they assert that, “while justice is a thoroughly entrenched inequalities” ([14], p. 2). In her view, solidar- deontic – and more so, a universal – principle, solidar- ity is an effective way to address and overcome the struc- ity is the ‘putty’ that fills some of the gaps that justice tural injustices that underlie issues of social concern like leaves open, for inter-individual, prosocial and super- health. Thus, whilst admitting that solidarity could be erogatory behaviour”. Thus, solidarity would seem to be required for its own sake, what is important for bioeth- a bottom up approach to achieving decent and just soci- ics is a view in which solidarity is aimed at promoting eties. However, at the institutional level, they hold that shared interests and overcoming domination and exploi- “justice is destined to guide the creation of mechanisms tation with the aim of achieving justice and equity. In her Atuire and Hassoun International Journal for Equity in Health (2023) 22:52 Page 8 of 11 view, even though this form of solidarity is usually found African conceptualization that we have outlined, is the among groups that share a similar situation of injustice insistence on justice. This is relevant because not all soli- (unity solidarity), such groups can also form a global daristic groups are always focused on justice and equity network of solidarity, “[coming together across borders for all. In fact, some mafia-type groups like the ndrang- to fight for social justice and] to help alleviate suffering” heta and the camorra in Southern Italy are infamously [14]. This form of networking solidarity is apt for captur- solidaristic among members. Yet, their goals and actions ing constructive relations across borders and towards can hardly be described as pursuing justice for all. Soli- distantly situated others. This view focuses on solidarity darity grounded on the African notion of faring well as an effective tool in the fight against societal injustices. together as humans implicitly requires equity and justice Thus, ideally, in the absence of such structural injustices, for all. Highlighting the relationship between justice and solidarity might not be needed at all. solidarity makes this even more explicit, thus preempting Gould’s view is a reactionary approach to injustice. the risk of limiting solidarity to only those we can easily For Gould, solidarity has a restorative power to push empathize with, which would be a form of tribalism. for justice in the face of societal and structural injus- tice. This view differs from ours because, even though it Why solidarity requires creative resolve in protecting acknowledges solidarity as a value in itself, it focuses on the vulnerable and investing in basic health systems the instrumentality of solidarity in achieving justice. Our As we explain below, solidarity on our account, assumes view is that, if solidarity were practiced in the first place, that human lives everywhere have the same value and the injustices that Gould seeks to combat through soli- that a public health emergency like COVID-19 is a threat darity would not exist. Rather than a reaction to injustice, to the lives and livelihoods of all humans. We subscribe solidarity as we see it, is foundational and necessary for to the often-repeated phrase that, in the context of the building societies in which we contribute to each other’s pandemic, no one is truly safe until we are all safe. This flourishing. Injustice, especially structural, is ultimately a phrase that has been repeated by various leaders sup- breach of solidarity. Thus, rather than appeal to solidarity ports protecting vulnerable people everywhere and not as a tool for fighting injustice, we see the implementation just those in rich countries, and this requires helping of solidarity as a means to preventing injustice. everyone access the existing resources they need to pre- pare for and respond to terrible diseases like COVID-19, Relational approaches but also addressing the issue of often artificially induced Finally, Dawson and Jenning [34] and Tosam et  al. [35] medical resource scarcity. offer relational accounts of solidarity that are in many In our solidaristic framework, resources should be dis- ways similar to ours. Tosam et  al. draw from African tributed in line with needs, not economic power, because ubuntu philosophical views of personhood to account global health is a global public good. So absent evidence for a solidaristic approach to global public health [35]. that a different distribution will better help everyone For them an “African approach to solidarity stems from live at least minimally well, allocation should be based the African conception of a person as an interdepend- on proportions of vulnerable populations. Globally, per- ent being [35]. As interdependent persons with a com- sons most at risk of dying or suffering severe disability if mon destiny, individual persons and communities have infected should receive priority attention. However, the the responsibility to share with and protect one another” relevant resources do not just include vaccines but pre- ([35], p. 246). It is not only African accounts that see soli- ventative equipment (PPE etc), diagnostics, therapeutics darity as a foundational dimension of human relational- (monoclonal antibodies, etc) and other essential health ity. Dawson and Jenning [34], using a semantic approach, protecting technologies. arrive at a conception of solidarity that is foundational Moreover, an important part of solidarity is to over- and relational. For them, solidarity “arises from the come the fundamental problems of scarcity. That is, nature of humans as biological and social creatures. It is helping the vulnerable often requires what one of us a constitutive concept, not a voluntarist one.” ([34], p. 76). has termed creative resolve: a fundamental commitment This, in their view, ought to lead us to a view of solidar- to overcoming apparent tragedy [28]. To have creative ity as a “deep and enmeshed concept, a value that sup- resolve, we must not only question evidence against the ports and structures the way we in fact do and ought to possibility of helping the vulnerable but come up with see other kinds of moral considerations” ([34], p. 73-74). creative ways of doing so and act to help them insofar as Thus, solidarity for them is not a value to be contrasted possible and otherwise permissible. It is not enough to with other or “added to any list of values”. consider all the options on the table, we must put new An important aspect that these views on solidarity ones on that table. highlight, which we see as enriching and perfecting the A tuire and Hassoun International Journal for Equity in Health (2023) 22:52 Page 9 of 11 Consider a few examples from the history of public the indirect as well as direct effects of the pandemic to health of how people have successfully responded to fail- save lives and help the most vulnerable amongst us. ures of solidarity to restore relationships with creative We should also address some of the fundamental bar- resolve. By the late 1990’s, most people in rich countries riers constraining access to essential medicines and were living long and productive lives with HIV/AIDS other technologies - including pharmaceutical compa- due to antiretroviral drugs. At the same time, millions of nies incentives for research and development. Solidarity people in poor countries were still dying in droves from requires implementing measures to address artificially lack of access. South Africa’s Treatment Action Cam- created legal scarcity. For instance, countries should paign refused to accept pharmaceutical companies’ claim revisit patenting and licensing laws so that everyone can that it was impossible to lower prices from US$12,000/ access new medical technologies at a reasonable cost and per patient per year. They educated patients to demand in a timely manner [45–47]. New proposals include tying access to treatment and engaged in legal battles that rewards for new innovations, through COVAX or similar eventually forced prices down to approximately US$350/ mechanisms, to the health impacts of resulting technolo- per patient per year [28, 36]. gies [28, 45]. Countries should then require open access Or consider how Agnes Binagwaho helped increase life to the patents and other intellectual property constrain- expectancy in Rwanda from 27 years to 65 years [37]. She ing access to promote low cost generic production. worked with the Rwandan Ministry of Health to reduce Some charge that we should not reduce intellectual the incidence of non-communicable diseases as well as property barriers to accessing new innovations because HIV/AIDS. She refused to accept the going wisdom that the problem is really manufacturing capacity [48, 49], but fighting cancer was not cost-effective in poor countries we should both rethink incentives for research and devel- like Rwanda. Instead, she decided to create a human pap- opment and increase manufacturing capacity in poor illomavirus infection (HPV) vaccination campaign for countries. More generally, we should put basic health sys- girls to prevent cervical cancer [37]. During her time as tems in place for all [50]. Many poor countries lack the leader of Rwanda’s Nationals AIDS Control Commission, resources, equipment, cold chains, transportation and she similarly expanded efforts to fight HIV/AIDS and health infrastructure, and workers to help everyone access reduced AIDS-related deaths 44% [38]. essential medicines in a timely manner [51]. Even reliable Finally, consider how Partners in Health refused to accept electricity, clean water, and adequate roads are problems the World Health Organization’s assertion that it was too in many locations and putting this basic health system in expensive and difficult to treat drug resistant tuberculosis place will not only allow us to address COVID but many in poor countries. Partners in Health created a system of other terrible pandemics that are also ravaging the earth community health workers in Lima Peru to provide care for [52]. Solidarity requires protecting the most vulnerable (as people with multidrug-resistant tuberculosis [39]. Demon- well as the rest of us) by making these investments now. strating that good treatment outcomes were possible, they helped expand care around the world [28]. These stories should inspire solidarity in our global fight Conclusion against COVID-19. Currently the largest component of Our definition of solidarity derived from the African the global response effort is through the WHO-led Access frameworks is, broadly, this: a sympathetic and imagi- to COVID-19 Tools Accelerator or ACT-A.The ACT-A native enactment of collaborative gestures and measures invests in diagnostics, therapeutics and vaccines and sup- to enhance our intrinsic or acquired relatedness so that ports basic health systems and access [40]. But, even together we fare well enough. Embracing it in our efforts its best funded initiative to support vaccination efforts to combat COVID-19 requires exercising our imagina- - COVAX - has struggled to secure the requisite funding tion to help people everywhere out of concern for the to help vaccinate 20% of the global population [41, 42]. relationships we stand in to others around the world. Solidarity requires much more. We must do whatever we Doing so requires addressing artificially created (as well can to vaccinate the global population without sacrificing as natural) scarcity and reconsidering how we incentivise other things that are more important. We must also invest new research and development as well as putting basic significantly in the other aspects of our global response. health systems in place to help all. We must also invest Moreover, solidarity requires preparing for, and significantly in basic health systems and other aspects responding to, many other pandemic and epidemic dis- of wise pandemic preparedness and response. Only by eases beyond COVID-19 [43, 44]. COVID-19 has inter- standing in solidarity with others can we together realize rupted service delivery for many other terrible diseases our human potential. from malaria and tuberculosis to a host of neglected tropical diseases around the world. So, we must address Atuire and Hassoun International Journal for Equity in Health (2023) 22:52 Page 10 of 11 Acknowledgements 8. Shubin V, Traikova M. There is no threat from the eastern bloc. In: The This work arose from a Brocher Foundation Workshop 2020: “African Perspec- road to democracy in South Africa. 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