Securing health in Europe: setting priorities, sharing responsibility

Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.21 | No.3 | 2015 5 SECURING HEALTH IN EUROPE: SETTING PRIORITIES, SHARING RESPONSIBILITY By: Martin McKee and Bernd Rechel Summary: The idea of Europe has been severely tested in the past year. The crisis facing the Greek economy has challenged the political basis of the single currency. The migrant crisis, with its major consequences for southern Europe, has placed the Schengen Agreement under strain. These experiences highlight the need for Europe’s political leaders to reflect on the resilience of our shared values, our commitment to solidarity, and our ability to secure health for all in Europe. Keywords: Europe, Solidarity, Shared Responsibility, Economic Crisis, Health Impacts Martin McKee is Professor of European Health Policy at The London School of Hygiene and Tropical Medicine, Research Director at the European Observatory on Health Systems and Policies, United Kingdom and President, of the European Public Health Association; Bernd Rechel is Researcher at the European Observatory on Health Systems and Policies and Honorary Senior Lecturer at The London School of Hygiene and Tropical Medicine, United Kingdom. Email: Martin. McKee@lshtm.ac.uk Bringing Europe and its citizens together The people of Europe are linked in many different ways. Some of those links involve what might be termed “hardware”, going deep in the earth, such as the tunnel under the English Channel linking France and the United Kingdom or those under the Alps, joining Austria, France, Italy, and Switzerland, or into the air, such as the bridges that cross Europe’s mighty rivers, the Rhine and the Danube. A few combine both, such as the elaborate structure that now links Copenhagen with Malmo. Others involve “software”, such as the computerised systems that guide planes across European airspace or allow Europe’s citizens to communicate effortlessly across borders using their mobile phones. In these myriad ways, engineers have fostered the idea of Europe as an integrated whole, and not merely the sum of individual countries, thus echoing the theme of the 2014 European Health Forum Gastein, on the vision of Europe. Those engineers who create these links are judged on many different criteria, whether it be their ability to drive shafts deep into the highest mountains or under the sea and meet in the middle, the aesthetic beauty of a bridge or the volume of traffic it can support, or the ease with which the computer programme can be used by those lacking complex technical skills. However, one of the most important of these criteria is resilience, another theme of an earlier European Health Forum, this time in 2013, and a topic now attracting growing interest from health researchers and policy makers. 1 How well do the structures or systems cope when exposed to a severe shock? If they fail, there can be profound implications for health, whether it be the collapse of a bridge, a mid-air collision, or the inability of the mobile phone system to cope with the increased call volume in an emergency. Health professionals will wish to know that there are mechanisms in place to reduce, as far as can reasonably be achieved, the risk of failure. Engineers put enormous effort into ensuring that their creations can withstand almost anything imaginable. Take perhaps the most iconic of all Europe’s bridges, that in the divided city of Mostar, a city whose very name is derived from the C O M M EN TA RY Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.21 | No.3 | 2015 6 presence of the “stari most”, as the old bridge is known in many of the languages spoken in the territory that was once Yugoslavia. Even though he lacked modern materials, and using techniques still not fully understood, the 16th century Ottoman architect Mimar Hayruddin was able to create a structure of beauty and strength, only succumbing finally to sustained shelling by 20th century tanks. Fortunately, the bridge has now been reconstructed, taking its place once again as an iconic structure. 2 More recently, the engineers who created the Great Belt, linking different parts of Denmark with Sweden have created a structure that combines aesthetic appeal with resilience, both to the effects of Baltic tidal movements and even, on the 3rd March 2005, to a collision by a merchant ship which interrupted traffic for less than five hours. Testing times for the vision Strong, secure bridges are thus a means of bringing the people of Europe together. However, they represent much more than assemblies of metal and concrete. They exemplify vision. The vision that people and places can be joined together, both geographically and cognitively. This second meaning was not lost on those charged with creating another system linking the people of Europe, the single currency. For them it was natural that bridges from across Europe should adorn euro notes of all denominations. The euro is, just like a bridge or a piece of software, a means to an end and, specifically, a means to bring the people of Europe, or at least those living and working in the Eurozone, together. By most of the conventional criteria, the euro has been a success, eliminating both the uncertainty and cost of currency transactions by those trading across borders, and facilitating trade that brought many benefits, especially to the traditional manufacturing areas of Northern Europe. The rising prosperity has provided the means to invest in health-promoting policies. Yet, as is now clear, the architects of the euro never subjected it to the stress tests that they would have applied if they had been designing the bridges that feature in their designs. When the first severe shock came, the system was shaken to its roots. The causes of the global financial crisis are now well understood. 3 The global financial corporations engaged in reckless lending and, when interest rates rose, they made massive losses. The prevailing doctrine of privatisation of profit but socialisation of risk required that governments bail them out, which they did, contributing several trillion euro. The one exception, Iceland, which refused to bail out its banks, instead prosecuting some of the bankers whose actions precipitated the crisis, faced action under anti-terrorist legislation from countries normally regarded as its allies. Partly to make up the shortfall, European governments imposed, or in some cases were forced to impose, severe austerity. There is a widespread consensus among leading academic economists that this made things worse, with recovery delayed much longer than in earlier severe recessions. 4 5 Yet, ultimately, most of the worst affected countries did come through, albeit with many casualties along the way, including several thousand additional suicides. 6 The one country that has not so far achieved any recovery is Greece. As we write this commentary in mid July 2015, no-one can tell how events will unfold. What is clear is that the Greek people are suffering grievously, with rising suicides, 7 outbreaks of infectious disease, and shortages of essential medicines. 8 It is also recognised by independent observers, and now also by the International Monetary Fund, that Greek debt is unsustainable and it will either have to be written off, as happened with German debt in the 1950s and Polish debt in the 1990s, or the country will default. Whatever happens, its creditors will lose. They are not alone. Many Greek people have lost, their livelihoods, their homes, and in too many cases their health or even their lives. Yet perhaps the greatest loss has been a belief in the idea of Europe, a people with many nationalities, many and no religious faiths, and speaking many languages, all joined together in solidarity. Individually and collectively, Europe’s governments have simply failed to step up to the mark and find a solution. It is too easy to forget that the architects of the European Union, such as Schuman and Adenauer, were driven by an earlier failure. The challenges of staying together The Greek referendum in July 2015 was quite explicitly not about Europe or the euro, despite being portrayed this way by some politicians. However, there is another referendum coming up that is explicitly about Europe and, specifically, whether the United Kingdom wishes to remain a member of the European Union. It is already apparent that a narrative, pitting unelected European officials against the democratic will of the Greek people, will be exploited gleefully by those supporting exit from the European Union, with consequences that seem no easier to predict than was the case with the Greek referendum. There seems little doubt that the people of Scotland, Wales and Northern Ireland do recognise the many benefits of being part of the European Union, but many in England may not, which some fear may lead to the break-up of the United Kingdom, raising questions about the resilience of both Europe and some of its Member States. Yet Euroscepticism is not confined to England and, while it is important not to exaggerate their support, political parties with an explicit anti-European agenda have attracted increasing adherents in many countries, including Finland, France, Denmark and Hungary. 9 One by one, the political and economic bridges are being placed under stress, with concerns that some may even collapse. Evidence of a political willingness to share responsibility seems to be receding rapidly. The need for united action It is, however, important to recognise that Europe’s bridges are not solely internal. The European Neighbourhood Policy creates another set of bridges, linking countries to the East and South. These bridges have also been coming under strain, in this case from rapidly increasing numbers of migrants, many fleeing conflict in countries such as Mali, Syria, Iraq and Afghanistan. These events provide many examples of Europeans securing health and sharing responsibility. They include Antonis Deligiorgis, an Eurohealth OBSERVER Eurohealth incorporating Euro Observer — Vol.21 | No.3 | 2015 7 off-duty Greek soldier pictured widely in the media pulling a young Eritrean woman from the sea of Rhodes, 10 and the Italian and Maltese sailors and coastguards risking their lives to rescue young children drowning as their overcrowded boats capsize. Yet, as with the financial crisis, it has also exposed Europe’s lack of resilience, with some countries struggling to absorb migrants and others unwilling to share responsibility. 11 Nowhere was this more obvious than in the sea off Libya. While many European, and other, governments, joined enthusiastically in the military action to overthrow President Gadhafi, they were less willing to join together to tackle the consequences of the political vacuum that resulted, which allowed people smuggling to become established on an industrial scale. The Italian Navy, in the front line, committed substantial resources to Operation Mare Nostrum, rescuing thousands from a possible watery grave. Yet it soon became clear that the task was on a scale far beyond the resources of a single country. The European Union eventually came to its aid, with Operation Triton, but deploying many fewer ships and aircraft. As Amnesty International noted, this is “a face-saving not a life-saving operation”. 12 Developments in the Mediterranean have, in turn, placed a major strain on another of the main elements of the European vision, the Schengen Agreement. A week before the European Union initiated celebrations of twenty years of passport-free travel, France temporarily reintroduced border controls to prevent migrants who had arrived in Italy from travelling north, causing the Italian Prime Minister to threaten to issue them with temporary Schengen visas. As a European Union official is reported as noting: “it’s not looking good”. 13 Securing health and sharing responsibility These two examples, the financial crisis and mass migration, provide examples of how Europe has been called upon to secure health, set priorities, and share responsibilities but questions are being raised about whether it has failed. Worryingly, there are many other challenges on the horizon. Some are only possibilities, such as pandemic illnesses, with little evidence that the lessons of failures in the Ebola epidemic have yet been learned. 14 Some are certainties, like the consequences of falling birth rates, and thus future labour supply, and rising numbers of old people, many with multiple complex illnesses. 15 Others are not inevitable, but are extremely likely unless concerted action is taken soon, including the severe health effects of climate change and the growth of antimicrobial resistance. 16 Previously, at the European Health Forum Gastein, Europe’s leading thinkers, policy-makers and practitioners have sought to instil a vision of Europe based on solidarity, shared values, and the need for resilience, both in health systems and beyond. Recent events suggest strongly that these messages have not been taken up sufficiently in the corridors of power, whether at national or European levels, despite the clearly stated commitments of governments to “Health in all policies”. 17 The 2015 Forum offers an opportunity for the European health community to issue a powerful wake-up call to Europe’s leaders, reminding them of their responsibilities to “secure health in Europe, set priorities, and share responsibility”. References 1 Glonti K, Gordeev VS, Goryakin Y, et al. A systematic review on health resilience to economic crises. PloS One 2015;10(4):e0123117. 2 Petrovic J. The old bridge of Mostar and increasing respect for cultural property in armed conflict. Leiden/ Boston: Martinus Nijhoff Publishers, 2013. 3 McKee M, Karanikolos M, Belcher P, et al. Austerity: a failed experiment on the people of Europe. Clinical Medicine 2012;12(4):346 – 50. 4 Krugman PR. End this depression now! 1st ed. New York: W.W. Norton & Co., 2012. 5 Stiglitz J. Austerity – Europe’s man-made disaster. Social Europe Journal 2012;8. 6 Reeves A, McKee M, Stuckler D. Economic suicides in the Great Recession in Europe and North America. British Journal of Psychiatry 2014;205(3):246 – 7. 7 Rachiotis G, Stuckler D, McKee M, et al. What has happened to suicides during the Greek economic crisis? Findings from an ecological study of suicides and their determinants (2003 – 2012). BMJ open 2015;5(3):e007295. 8 Kentikelenis A, Karanikolos M, Reeves A, et al. Greece’s health crisis: from austerity to denialism. The Lancet 2014;383(9918):748 – 53. 9 FitzGibbon J. Euroscepticism and the 2014 European Parliamentary Elections. L’Europe en Formation 2015;373(3):29 – 44. 10 Smith H. Migrant boat crisis: the story of the Greek hero on the beach. The Guardian 2015. Available at: http://www.theguardian.com/ world/2015/apr/25/ migrant-boat-crisis-the-sergeant-who-did-his-duty- towards-people-struggling-for-their-lives 11 Razum O, Bozorgmehr K. Disgrace at EU’s external borders. International Journal of Public Health 2015;60(5):515 – 6. 12 Amnesty International. Europe’s response: “Face- saving not a life-saving operation”, 2015. Available at: https://www.amnesty.org/en/latest/news/2015/04/ face-saving-not-a-lifesaving-operation/ 13 Traynor I. Italy threatens to give Schengen visas to migrants as EU ministers meet. The Guardian 2015. Available at: http://www.theguardian.com/ world/2015/jun/15/ italy-threatens-to-give-schengen-visas-to-migrants- as-eu-dispute-deepens 14 World Health Organization. Report of the Ebola Interim Assessment Panel. Geneva: WHO, 2015. 15 Rechel B, Grundy E, Robine JM, et al. Ageing in the European Union. The Lancet 2013;381(9874):1312 – 22. 16 Davies SC, Grant J, Catchpole M. The drugs don’t work: a global threat. Penguin, 2013. 17 Ståhl T, Wismar M, Ollila E, et al. Health in all policies: Prospects and potentials. Helsinki: Finnish Ministry of Social Affairs and Health, 2006.