SPRINGTIME

It is Springtime. The days are getting longer, the weather is getting warmer, mimosa flowers cover the stems, little birds sing their love songs, and politicians sign declarations.

March 25 was a splendid Spring day in Rome and the Leaders of 27 Member States and of EU institutions - convened to celebrate the 60th anniversary of the Treaty of Rome – enjoyed their staying in the eternal city. Even street demonstrations were infected with joy. Instead of livid anti-European protesters, streets were invaded by a jubilant crowd of pan-European supporters.  Could you ever imagine a better scenario to sign a declaration? “The European Union may be a Franco-German construction, - wrote The Economist - but when the project needs a dose of grandiosity it invariably turns to Italy”.

The 2017 Rome Declaration was  eagerly awaited  by most  political commentators, being the first solemn declaration, involving all EU Member States and institutions,  after the Brexit, and after Angela Merkel's statement concerning the two-speed Europe.  The Declaration was prepared by a White Paper on the Future of Europe, and accompanied by a series of parallel initiatives, including a booklet on EU’s past achievements, a dedicated website, various audiovisual products,  60 video testimonials from people across Europe, a GIF competition, and some other activities (even including a European origami).

The Declaration starts by recalling European values and emphasizing the 60 years of peace guaranteed to countries whose main activity was for centuries battling one other (admittedly, not the best argument to advertise “European values”).  Together with peace, the EU has also guaranteed – continues the Declaration –economic growth, democracy, civil and social rights for all. The EU now is “facing unprecedented challenges, both global and domestic”, and the second part of the Declaration is dedicated to a vision of the future. The 27 Leaders commit themselves to work towards, 1) A safe and secure Europe, which includes prevention of crime and terrorism, control on migration flows; 2) A prosperous and sustainable Europe,  which includes growth and jobs, technology innovation, economic convergence, clean and safe environment;  3) A social Europe, which includes  equality between women and men, equal opportunities for all, fight against  unemployment, discrimination, social exclusion and poverty, preservation and promotion of the cultural heritage; and 4) A stronger Europe on the global scene, which includes promoting stability and prosperity everywhere, supporting  European defense industry, collaborating with the NATO, promoting multi-lateralism and a positive global climate policy (too bad, Mr. Trump). Brief, nothing’s missing, but health. “Health” is not mentioned in the Rome Declaration and it has not been included - even implicitly – in the 27 Leaders’ agenda.  This omission is confirmed by other documents produced by the EU for the 60th of the Treaty of Rome. For instance, the booklet on EU’s past achievements – the sole document in which there is a vague reference to health issues – considers them under the wider topic of citizens’ wellbeing, never mentioning health explicitly.  Yet in his first speech on the State of Union, in 2015, Jean-Claude Juncker listed  public health among EU priorities, but that reference completely disappeared in his 2016 speech. Why?

The key for understanding this omission  is in the  White Paper on the Future of Europe,  which describes five possible future scenarios for the EU. The fourth scenario, called “Doing Less, More Efficiently” (the scenario the EU is now going towards, unless the trend is inverted) describes a future in which “the EU27 stops acting or does less in domains where it is perceived as having more limited added value”.  “Public health” is the first domain to be mentioned among non-strategic policy areas to be delegated to national authorities.

Yet, this is not a future scenario, unfortunately it is the present situation. In Europe, there are  as many vaccination policies as Member States and almost no Member State has the same vaccination scheme of another Member State. Even the same words mean different things, in some EU countries the label “mandatory” does not entail any penalty for non-compliance, in other Member States this label implies administrative sanctions (e.g., fines, prohibition to attend school, etc.), in others it could even imply criminal penalties. “Moreover, the enforcement varies in practice. It is possible that in some cases penalties are only theoretical and never applied”. No surprise, then, if a world-wide survey carried out in 2016 shows that Europe has the lowest confidence in vaccine safety. The contradictory message conveyed by EU Member State policies is not certainly made for reassuring their citizens.

National policies to prevent and contain outbreaks were tenable when most Europeans did not cross, or crossed very rarely, their national borders. Today Europeans make over 1.25 billion journeys within the Schengen area every year, 6.5 million of them are currently working in another EU Member State, and more than 9 million students have been participating in the Erasmus Programme. Epidemiologically speaking, there are no longer “national communities” in Europe, but there is a unique community of people, who share germs and infections, and whose health statuses are unavoidably linked.

“Our Union is undivided and indivisible”, solemnly claims the Rome Declaration, adding “we will act together, at different paces and intensity where necessary”. This sounds reasonable in many policy areas, except in public health. A two-speed Europe is perhaps a realistic solution to address economic and political problems;  it is, however, a complete nonsense, when speaking of contagious diseases.

GLOBALIZATION, PANDEMICS AND POPULISM

Reflecting on a series of political events - including the electoral victory of Donald Trump, and the Brexit vote – commentators have argued that the current political turmoil is part of a worldwide backlash to globalization, the rebellion of “globalization’s losers”.  There is indeed a vast mass of people who feel that their life conditions are deteriorating notwithstanding, of even because of, globalization. They mostly belong to the extended middle-class that benefited from the economic boom that followed the end of World War and granted one of the longest period of economic prosperity ever experienced by industrialized societies. Now, these people see their economic conditions and social status progressively degrading, without any actual possibility to invert the trend. Their agency is nullified, vis-à-vis epochal processes such as globalization, digitalization and automation, which totally escape from their control.  They feel (not completely wrong) that the wealth of the West is going to be redistributed at global scale chiefly at their expenses. This social group is only the peak of the iceberg, because many other categories  perceive themselves as globalization losers, although they are not in absolute terms. In other words, losers of globalization are not only those who have been marginalized, but are also those who feel that they haven't profited as much as others from globalization. These people, who feel that that they got just the crumbs of the cake, are still more full of anger and resentment, because they believe they have been misled and used as “cannon fodder”  by politicians, intellectuals, journalists, who advocate globalization.   

Even public health issues, notably those related to infectious diseases, are affected by the backlash to globalization. Not only many militants of populist movements are involved in anti-vaccine movements (for instance,  President Trump appointed Robert Kennedy Jr, a prominent vaccine conspiracy theorist, to chair a commission on "vaccination safety and scientific integrity"), but it is the very cultural climate, which surrounds populist movements, to be the same that  has fed, in the recent past, suspect, skepticism, mistrust, towards global health initiatives and vaccination.  

Economic and health globalization are indeed the two sides of a same coin. Germs travel together people, animals and goods; the increasing global mobility corresponds, epidemiologically speaking, to the confluence of all germs in one world pool. In the while, advances in sequencing technologies and in bioinformatics are making possible to explore interaction between germs, people, animals, and the environment at global scale, and mapping the global microbiome (the genome of the Earth's microbial community) and its role in the biosphere and in human and animal health.  This is providing concrete foundation for the concept of One Health, which was once a purely theoretical notion, and is today a concrete research strategy. Finally, Internet based epidemiological surveillance and outbreak intelligence play more and more a pivotal role in early detection and monitoring of infectious diseases; this has led, inter alia, to blurring of the distinction between civil and military (including bioterrorism) applications of epidemiological research,  as witnessed by the new concept of biodefence field.

Three conceptual political tools emerged to deal with these profound modifications of the epidemiological context, 1) the notion of global public goods for health; 2) the concept of global health governance; and 3) the model of global public–private partnership.  These three conceptual tools are today under attack.

The idea of global public goods for health is contested by people who argue that an increased global integration is not the right answer to infectious diseases. It is obvious – they argue -  that infectious diseases do not know national borders, but it is false – they add – that outbreaks can be addressed only at global scale. Instead of relying on buzzword such as "health as a global good",  one should consider  that epidemic risks are increased by global interconnectivity, which is altering "the geographic distribution of pathogens and their hosts, causing the emergence, transmission, and spread of human and animal infectious disease". To these people, less globalization would be the right answer to pandemic risks. Migrants are often accused to bring with them germs and infections, and research shows that the public perception of risks of outbreaks is strictly associated to social acceptance of migrants among resident population.

Still the notion of global health governance is harshly criticized.  Even admitting that protection against epidemics is a global good, shared by the global human community, this would not imply – criticists argue – that such a good needs to be governed at global scale. To be sure, some kind of international collaboration is necessary, but this is a truism. Apart from that, each nation is perfectly fit to deal with infectious outbreaks occurring within and across its national borders, as it was in the past, with the advantage that national approaches can pay more attention to the national context, its economic, social and cultural specific features. The notion of global health governance would then be – according to the populist perspective - just the gimmick used by global elites to infiltrate and weaken national governments. 

Finally, also the global public–private partnership model is strongly rejected. In the view of populist movement, this formula would hide a business alliance between major industrial players, world bureaucratic and technocratic elites, and global financial capital.  They would be responsible for creating and diffusing new germs, such as HIV, Ebola, ZIKA  (conspiracy theory supporters are quite common in populist movements); for experimenting dangerous medications and vaccines on indigenous populations;   for exploiting natural resources of low income countries and biopiracy; for altering and threatening natural environment and agriculture through genetic manipulation (populist groups are often also involved in anti-GMO movements).

Bill  Gates  and Mark Zuckerberg have recently taken position in this debate.  In their praise of globalization, and explicit polemics against anti-global populism, they both play the card of infectious outbreaks. The risks of new, deadly, pandemics would provide,  in their views, one of the strongest arguments in favor of globalization.  It is difficult to predict whether Gates and Zuckerberg’ support to globalization could be effective or risk to produce opposite results. Although they advocate more globalization, they speak eventually the same language of populists. By reading carefully Gates and Zuckerberg's texts it is evident that their ideal (at least, the ideal that they both advocate)  is a communitarian ideal, as it is the ideal of most populist movements. While populists dream of national communities, Gates and Zuckerberg dream of a global online community,  yet  both parties  share the same vision of an integrated, organic, community as an answer to contemporary challenges. Should one eventually opt for the Facebook global  gemeinschaft, to avoid falling back again into a national gemeinschaft?

I am not able to answer this question, it is difficult, however, to escape the impression that infectious outbreaks are only instrumentally evoked by both parties.