No illusion. Covid19 is closer to us than we imagine. And getting closer day by day. Globally, in big cities and small centres alike, people are sliding into a sort of dystopian fiction as if empty streets, latex gloves, face masks and self-isolation were the new normal. Last Sunday, India with its population of over 1.3 billion citizens, had a first try at a total shutdown from 7am to 9pm, in a country where 1.8 million are homeless and 73 million don’t have a decent home.
The media of the entire planet is gripped by coronavirus. Never before has a virus stopped the entire world’s gears. Deep concern has spread throughout, and finally we start to see governments engineering some mass planning for worst-case scenarios. As it should be, the repercussions move from the global health sphere into business and politics.
The Coronavirus shockwave will end, at some point. Meanwhile, it is forcing a Copernican re-thinking of the interconnected global economy we have had in place for over three decades. Covid19 is not the first wake-up call to the world of the twenty-first century. The first seismic shock came with the terrorist attack of 9/11, followed by the global financial crisis which boiled over in 2008, with the collapse of Lehman Brothers. Yet again, this invisible and silent virus – a minuscule RNA packet enveloped in a protein capsule – has shaped up to be an enormous stress test for globalization, shaking up all our certainties and individual lives.
We are re-discovering just how vulnerable nations and people are. Just how fragile the globalized economy is, with its productive arrangement. In his latest book on inequalities, Walter Scheidel reminded us that epidemics have always been one of the most transformative events in human history[i]. Nothing new under the sun. Except that we don’t seem to learn the key lessons that the past, including the recent past, offers us.
Since the start of the millennium we’ve had repeated species jumps of the coronavirus variety. The first occurred in China with SARS in 2002-2003, then in 2012 with MERS in Saudi Arabia and Jordan. Other species jumps occurred with swine flu (H1N1) in 2009, bird flu in 2013 and 2017 (H7N9), and other pathogens like Zika and Ebola (still active in Africa). For decades, experts from the science community have warned about the need to prepare for another pandemic like the 1918 Spanish flu (“the Great Influenza”), which killed over 50 million people worldwide, but their premonitions have gone unheeded. Now that we are in it, SARS-CoV2 looks pretty much like the pathogen that scientists had been waiting for. It kills healthy adults as well as elderly people. Covid19’s global 3.4% fatality rate, according to the figure of the World Health Organization (WHO), is much higher than the 2% of the Spanish pandemic. It is true that we lack reliable evidence on how many people have been infected. Figures are calculated by divining the number of officially confirmed cases, but there are many more mild or simply undetected cases that go uncounted, and that would bring the mortality rate significantly down.
What we do know for certain, though, is that the virus has an exponential transmission rate: one affected person may pass it on to 2-3 people, 10 people if the vector is a doctor or a nurse. The efficiency of the contagion applies equally to symptomless and pre-symptomatic individuals, or people with few symptoms[ii]. This means that Covid19 is much harder to contain than SARS, which had a slower transmission pace, and only through symptomatic persons. Covid19 has caused 10 times more cases than SARS already, in a quarter of the time.
The virus has an exponential transmission rate: one affected person may pass it on to 2-3 people, 10 people if the vector is a doctor or a nurse.
When the emergency ebb withdraws, we shall no longer recognize the landscape. Yet, in the reflections that accompany the coronavirus spread we may verify several political hypotheses, which take us from globalization to its direct effects at home. Let’s sample a few.
The sad geopolitics of the crisis
Let’s start with the uncomfortable truth. While geared to prepare for war, the world is amazingly unprepared to fight viruses. NATO, for example, has a rapid reaction force (NRF) which regularly performs months’ long exercise programmes in order to integrate and standardize all operational aspects – logistics, food and fuel provision, operational language, radio waves, etc. – across national contingents. Nothing, nothing like that exists in the domain of health emergency and pandemic containment. The last serious simulation of a pandemic catastrophe in the US, the Dark Winter Exercise, took place in 2001. European countries are no better placed. Europe does not even have a common health policy. In addition, WHO emergency preparedness structures aimed to promote a global alert and immediate response system are, unlike NATO’s, short of funding and poorly staffed.
WHO emergency preparedness structures aimed to promote a global alert and immediate response system are, unlike NATO’s, short of funding and poorly staffed.
After several geopolitical slaloms and visible resistance, the World Health Organization (WHO) declared the Covid19 pandemic on March 11, finally. Pandemic means sustained and continuous transmission of the disease, simultaneously in more than three different geographical regions. This threshold had long been met: according to public health experts, weeks before the announcement the trajectory of the disease had gained a foothold across the globe and multiplied quickly even in countries with relatively strong health systems. The highly due signal came in the end to rebuke and shake governments, mostly in the industrialized West, for their “alarming level of inaction”, in the words of the WHO Director General, Tedros Adhanom Ghebreyesus.
Whether because the pandemic can rattle markets and lead to more drastic travel and trade restrictions, or out of a dubious sense of political opportunism, a number of world leaders until very recently have either kept hiding or underrating the spreading capacity of Covid19. In any case, they have delayed and still are delaying any serious containment measure.
A number of world leaders… have delayed and still are delaying any serious containment measure.
The WHO Director General’s preoccupation with the lack of cooperation among member states, voiced in late January at the eve of the WHO Executive Board, has only been confirmed, two months into the global spread of SARS-CoV2. In violation of the obligations provided by the WHO International Health Regulations (adopted in 2005, on the wake of SARS, to improve global capacity to prevent and control diseases), inter-governmental cooperation has been supplanted by a viral health sovranism in dealing with the disease. That’s what we have seen happen in Europe, currently the cradle of the most violent SARS-CoV2 outbreak worldwide. Only until a few days ago, pretending that not much was happening, most European countries were indulging in inertia at home on how to face the disease. Buying time, somewhat in a state of denial.
But time and trust are essential to good epidemic management. When Italy, the epicenter of the pandemic in Europe and the first democratic laboratory for Covid19 management, asked for urgent medical supplies under a special European crisis mechanism, no EU country responded. Germany, on the contrary, issued a decree to block exports of medical masks and other protective gears to Italian healthcare and France, for its part, confiscated all medical supplies. Another slap in the face came from the European Central Bank (ECB) president Christine Lagarde, whose declaration implied that it was no longer ECB’s job to preserve Italy in the euro. The result was the collapse of the Italian stock market, the loss of € 68 billion of savings in one day, and the renewed kindling of the financial spread, alongside the viral. The impending question is whether Europe’s post-war institutional setup, grounded on principles of solidarity and cooperation, still exists. Or if it will survive the Covid19 pandemic.
Will … Europe’s post-war institutional setup, grounded on principles of solidarity and cooperation… survive the Covid19 pandemic.
Covid19 is a groundbreaking test for European unity, a few weeks post-Brexit. After the initial dormancy, measures never before seen in peacetime Europe are now forcing dramatic changes on daily life. More than 250 million people are in total or partial lockdown in the EU as Belgium and Germany are deciding to follow Italy, Spain and France in closing schools and urging, or asking, people not to leave their homes. Only between March 17 - 18, over two months after the Chinese declared their emergency outbreak in Wuhan (January 7), did Europe start to grasp the dimension of the challenge. It took the ECB heated internal debates before adopting a stimulus of € 750 billion bond buybacks for the Eurozone to combat the economic and financial spillover unleashed by coronavirus. It has faced harsh criticism for its inactivity, but finally the European Commission found its footing and announced the suspension of the Stability Pact last week, much advocated for by the Italian government as coronavirus stretched the country’s defences.
“We’ll take the right steps, at the right time”, and “we can turn the tide of this disease in 12 weeks”, says Prime Minister Boris Johnson upon apparently reviewing his initial – and quite controversial – strategy in virus management. Mass testing, social distancing and schools to be closed (not all of them, though): even the most hesitant government is ramping up measures. But the SARS-CoV2 pandemic “could not have occurred at a worse time for the UK and its citizens”, writes Prof. Martin Mckee of the London School of Hygiene and Tropical Medicines, referring to the Brexit negotiations. Instead of doing everything possible to preserve the areas of relevant collaboration with the EU, such as health, “the UK has decided to isolate itself from European systems that have been built up over the past decade, many as a result of problems exposed by the 2009 swine flu pandemic“.
The country is now outside of the European Medicines Agency (EMA) rapid authorization mechanism for pandemic vaccines and medicines, which means that the UK will have to wait longer for these health tools then the EU member states. To worsen the picture, the UK has also withdrawn from the EU’s emergency bulk purchase mechanism for vaccines and medicines. This lever allows EU governments to enhance their market power and speed up access to vaccines and medicines during an emergency situation.
Ultimately, as humans we are a limitless pastureland for the virus but we are, above all, a very disordered, unprepared, and yet arrogant herd. The result is considerable governance failure so far, while the WHO Director General invokes “Do not let the fire burn”. More of this is to be seen if we open a broader view beyond the borders of Europe. What will happen, now that SARS-CoV2 creeps steadily into the Middle East and most African countries? The geopolitical implications may not come secondary to matters of health and safety.
As humans we are a limitless pastureland for the virus but we are, above all, a very disordered, unprepared, and yet arrogant herd.
Tension between health and the economy
One of the reasons why the right to health is subject to so many violations lies in the fact that health cannot live in isolation. The right to health drags along several other social and economic rights, in a constant friction with economic rules and financial profits. Disease spreads imply losses. That’s what makes health and the economy so intertwined. The 2019 report of the World Bank Global Preparedness Monitoring Board pointed out the “very real threat of a rapidly moving, highly lethal pandemic of a respiratory pathogen” which could wipe out nearly 5% of the world’s economy. With a specific reference to the coronavirus outbreak, the OECD has warned that it could halve global economic growth this year to 1.5%, the slowest rate since 2009. It has cut its 2020 growth forecast for China to a 30-year low of 4.9%, down from 5.7% in November. The virus is causing already massive economic disruption, the more so because of the virtual shutdown of the ‘factory of the world’, which has decreased the supply of products and spare parts from China, disrupting production the world over. Low and middle income countries, especially those dependent on commodity exports and global supply chains, are particularly vulnerable in this economic havoc.
In Italy, far too many instances have confronted us with the dilemma between health and the economy (and employment) across the country. To this same tension must be attributed the flagrant missteps in the early management of SARS-CoV2, particularly at the regional level. No need to lecture: things are complex, and policy decisions are not easy. Yet, right from the start, the highly productive valleys of Lombardy got engaged in arm wrestling between the need to recognize and curb the contagion with rigorous public health measures and the local entrepreneurs’ pressure to avoid the contraction in economic activity stemming from the health lockdown. Local authorities hesitated as the contagion kept creeping, and central government likewise fluctuated at the end of February. After initial containment measures, contradictory messages aiming to reassure the North’s economic exuberance (“Milano non si ferma”, Milan does not stop), ended up legitimizing baseless patterns of behaviour that favoured the virus spread.
We have identified two different strategic approaches in tackling Covid19 so far: 1. The strong combat of virus spread through social distancing measures, including extraordinary provisions of forced isolation of communities (the Chinese, Korean and Italian model); 2. the flimsier approach to the contagion, with exclusive focus placed on treating affected people (the English, German, Dutch and partly French model). Of course, the containment option entails relevant economic costs but, as Roberto Buffagni highlights, it is rooted in the legacy of ancient cultural and political values that apparently keep inspiring the decision-making style in those countries, if only by instinct.
On the other hand the laissez faire strategy, still partially enforced, has its roots in a pragmatic and realistic analysis. In the case of Covid19, the more at risk population is largely made up of elderly people, or people with other forms of disease. Their loss does not pose a real threat to the functionality of the economic system. Rather the reverse. In fact, it operates with somewhat re-generational leverage, insofar as it alleviates the pension system costs alongside the costs of several other social welfare structures in the country. The resulting dynamic therefore triggers off an economically expansive process “due to the legacies that, as in the great past epidemics, will enhance the liquidity and assets capacity of new generations who have a higher inclination to investments and consumption than their elders”. By so doing, a government increases its economic and political operability, when compared to countries that choose the costly lockdown route.
The more at risk population is largely made up of elderly people, or people with other forms of disease. Their loss does not pose a real threat to the functionality of the economic system. Rather the reverse.
Italians know this only too well. The viral outbreak will lead to massive economic deaths, a toll linked also to the exasperating epidemic of precarious labour conditions rife even in highly successful economic sectors like tourism. Covid19 has brought to the surface the many hidden pathologies lingering in the economic fabric of the country, untreated for too long. If the virus marks a watershed in our history, and in the history of Europe as a whole, we need to depart from Covid19 to project the urgent political and economic regeneration we have long wanted to see. It’s time to work for a systemic reframing, in the post-virus era, to prompt positive changes in line with our constitutional rights.
Health as a common good, and the role of the public function
We needed the SARS-CoV2 shock wave to convince Italian public opinion about the value of a national health system (Servizio Sanitario Nazionale, 1978) to secure individual protection from adverse life events. After two world wars, national health systems were gradually introduced into Europe as the most effective institutional mechanisms for sealing societies’ democratic pacts. In Italy, the universal public health system has been instrumental in the social and economic development of the country and still today accounts for its high population life expectancy.[i] The renewed awareness of the key role played by a universal free public health setup, present in the hardest hit countries now – Spain has put all private hospitals under state control indefinitely – should spread like the virus and become a strong global demand. It takes a rights-based vision, beyond the financial resources, and I consider it the political point-of-no-return of the current viral crisis. In fact, the coronavirtue we must hold onto if we are serious about sustainable development for all.
Renewed awareness of the key role played by a universal free public health setup, present in the hardest hit countries now… should spread like the virus and become a strong global demand.
In the name of neoliberal ideologies, the development and strengthening of health systems in the global South has been stubbornly opposed for decades, with a huge toll for billions of people. Years of spending cuts due to fiscal austerity policies have undermined public health provisioning in developed economies, so that health systems have been dismantled and broken into pieces in Europe, too. As for Italy, debt reduction and spending reviews have shrunk investments – health expenditure increased by 14.8% from 2001 to 2008, by a meagre 0.6% from 2009 to 2017.
In the face of an aging society, the health budget was trimmed by 25 billion Euros between 2010 and 2012[i], local health units were dismantled (from 642 in the ‘80s to 101 in 2017), and 175 hospitals closed down. Repeated rounds of devolution and privatization have wrecked the Italian health system to the advantage of private insurance schemes. The compelling title of the 2018 Censis-Rbm report – Resentment Healthcare, Resentment for Healthcare: Scenes from an Unequal Country – illustrates the disquieting portrait of an out of control “out-of-pocket-society”. Private disbursement for health services increased by 9.6% from 2013 to 2017, forcing over 7 million people into debt, or into selling their properties (2.8 million people) to access their right to healthcare. A perfect crime against common sense. Confronted with SARS-CoV2, Italy has today less than half the number of intensive care beds than Germany, or France.
Building on Covid19’s lessons: policies for the future
The devastation is under our eyes. Italy’s death toll has overtaken China, and is increasing by the day. The immediate reduction of the virus spread is no doubt the most urgent priority now to avoid the collapse of the health system, with all its implications.
At the same time, we need to start planning now for the necessary policy change across the social and economic spectrum. Health-wise, the adequate financial and human resources will have to be injected into the universal health system. We need to undo the damage caused to public services in the past and we need to revise the balance of power and the rules of engagement for the private sector, including in the area of scientific and medical research. There is no reason why health should be allowed to assert itself as a profit-extracting mechanism.
A new governance for health will have to be set in place in Italy. National Health Service means national, i.e. centralized, and not splintered into a variety of regional strategies more or less ancillary to the temptations of the private sector. Health devolution, introduced in 2001, has not functioned. Overall, it has resulted in significant health inequalities – on a small scale, Italy mirrors the health divide existing between the North and the South of the world. It has produced different and diverging approaches, multiplying inefficiencies and opportunities for corruption (in line with the global empirical evidence), and ultimately increased costs.
On a small scale, Italy mirrors the health divide existing between the North and the South of the world.
As the early stages of the virus outbreak have clearly demonstrated, health devolution responds very poorly to the complexities surrounding the production of health. That is why we need to reverse and definitely remove national policies introducing the principles of differentiated autonomy, especially in the northern economic powerhouses (Lombardy and Veneto). Italy is thriving in emergency conditions, for a series of structural reasons. We have the second oldest population in the world after Japan – possibly, the main cause of Covid19 higher mortality rate in Italy. The country is the hardest hit by climate change in Europe, both for its geographical position and orographic conformation. Above all, Italy bears already a number of serious health crises that need adequate policies. Antimicrobial resistance (AMR) is one good example. We are the EU country hosting the highest number of bacteria resistant to antibiotics; their population has decoupled in ten years. According to the European Centre for Disease Control (ECDC) and the Istituto Superiore di Sanità (ISS), Italy alone accounts for one third of all the AMR-related deaths in Europe. Only a few days ago, virologist Ilaria Capua hinted at the possibility of relating AMR to higher SARS-CoV2 mortality trends in the country.
Post Covid19 will be like post-war, with its unpalatable numbers of victims, its rubble, and the need for reconstruction. But new conditions are emerging, a new awareness is spreading, urging us policymakers to redesign a stronger and better country. A stronger and better Europe. In its tragic manifestation, silent and intrusive Covid19 is paradoxically our best chance.
Notes and references.
[i] Walter Scheidel, The Great Leveler: Violence and the History of Inequality from the Stone Age to the Twenty-FirstCentury, 2017, Princeton University Press.
[ii] Hoehl S, Rabenau H, Berger A, et al. Evidence of SARS-CoV-2 infection in returning travelers from Wuhan, China. N Engl J Med. DOI: 10.1056/NEJMc2001899.
[iii] Bloomberg (2014): Most Efficient Health care Around the World Report. In this regard, see also here.
[iv] Carraro, F. and Quezel M., (2018), Salute SpA: La Sanità Svenduta alle Assicurazioni, Chiarelettere, Milano.