Jennifer Prah Ruger, the director of the Health Equity and Policy Lab at the University of Pennsylvania, studies national and international public-health policies through a moral lens, examining the ways in which world leaders can insure more just health outcomes for their fellow-citizens, as well as for citizens of other nations—and how those two things necessarily intersect. Prah Ruger’s work is influenced by her former teacher Amartya Sen, whose “capabilities approach” to economics—developed with the philosopher Martha Nussbaum—envisions a broad definition of human flourishing, one that transcends indicators like G.D.P.

Prah Ruger’s most recent book, “Global Health Justice and Governance,” published in 2018, examines international crisis responses to past epidemics, such as the Ebola outbreak of 2014. “Public health and health care systems capacity and governance vary considerably across the globe,” Prah Ruger writes. “Like rapidly spreading contagions and global inequalities, this arbitrary patchwork of health systems is morally troubling.” That work is especially relevant today, with the coronavirus pandemic straining health systems around the world, from China to Italy and the United States. In the U.S.—a country that is infamous for the unequal outcomes of its health system—hospitals find themselves overwhelmed with patients and short on medical equipment.

I recently spoke with Prah Ruger by phone. During our conversation, which has been edited for length and clarity, we discussed how different types of health systems have responded to the current crisis, the area where the U.S. shines in keeping its population safe and healthy, and whether health care should be understood as a universal human right.

What have you been thinking about for the last couple of weeks, as this thing has spread, and how does the coronavirus fit into what you study and write about?

The first thing I’ve been thinking about is the underlying principles of justice and equity that we’ve been working on in our approach and in our lab. In the recent book that we just published, the underlying philosophy of human flourishing and the attempt to create the global and domestic conditions for people to have the ability to flourish is very relevant for the current situation. Flourishing is about enabling people to do and be what they want to do and be, and health is an instrumental and an essential part of that. So global public health that protects people’s ability to flourish is an essential part of a just society—a global society and a domestic society.

And so what I’ve been looking for and trying to understand better, as you look globally but also domestically and in our own country, is how are we going about effectuating that or not. So I’ve been advancing a particular approach to that called provincial globalism, in which we look at the intersection or the commonalities between provincial or state or nation or local-based norms and values about equity in public health, and global foci on health and equity. Are those intersecting? Do we have a sense that, globally, we’re really trying to work together, coöperate on the common good to insure people all over the world are able to be healthy, and protecting them and working collaboratively in coöperating? Or are we advancing the status quo in terms of a rational-actor model of global health governance, which has different nations and different countries and different interests advancing their own interests, rather than working together toward the common good of equity and health.

You’re talking about flourishing, and one of the things related to that is something called the “health capability paradigm.” What is that, and how does it fit into the broader idea of a “capabilities approach” to economics?

Well, the health-capability paradigm is a theoretical framework for justice and health, and that is at the domestic level. So, if you think about it in terms of an alternative to a free market, the free market is focussed on allocating goods and services in the economy at the domestic level based on people’s preferences, or their desires for things. So, whether we’re buying computers or phones or chairs or picture frames or whatever it is, we’re advancing our interests in terms of our preferences for those goods and services through the free market. And we’re regulating the market, to a certain extent, to protect consumers.

Alternatives to the free market are looking at a role for other institutions in promoting different goods that we have reason to value in society. The health-capability paradigm puts forward a framework that what we have reason to value—and what we have an interest in, societally and collectively—is people’s ability to flourish and their ability to be healthy. So are the conditions in place? Are there public-health systems and structures that are in place that enable that? Is there a health-care system in place that enables that? Do we have the social conditions, and do people have enough income, and is that income distributed in an equitable way so that people have this opportunity? Are people educated, and do they have jobs?

All of these conditions are necessary for people to be able to be healthy. And what are the principles of justice that apply to the health sector and health-care sector? And so we advanced an approach that looks at advancing a public-goods or common-goods approach to the health sector and health policy, as opposed to a private-goods or private-sector, market-based approach to health and health policy.

We have seen a lot of countries already ravaged by this pandemic. Some have health care that is at least relatively equitable—at least compared to most countries on earth—such as Italy, and others, like the United States, do not. Are there things that you’re noticing from this pandemic about why it’s so important to build as much equity into the system as possible?

Yes, I am noticing some real differences. What we have here is we have a set of natural experiments unfolding before us, right? You have a very good display of different kinds of approaches to public health domestically. And it’s within the context of a global public-health system, or lack of a system. So, for example, we have the contrast between what we would call two typologies. The first is a more centralized public-health policy that has more of a focus on equity and health, and looking across the population, as opposed to a more decentralized public-health policy.

There are real differences between the two, generally speaking. Centralized public-health policy is more planned. It’s more deliberate. It’s more intentional. There are several steps along the way. Centralized governance and authority tends to be federally located in terms of decisional latitude and authoritative standards with national guidelines and triggers. The decentralized public-health policy tends to be very ad hoc, more patchwork, unscripted. It tends to be spontaneous and reactive, and there tends to be a lot of voluntary actors in the mix. And we’re seeing in general a difference in, for example, the United States approach, which tends to be very decentralized, and countries like Taiwan or Singapore, which tend to be more centralized. Other differences are that under a centralized public-health policy you tend to have more uniform standards and uniformity in policies and practices.