Health and European solidarity after the pandemic – by Xavier Prats Monné

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Introduction

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The Covid-19 pandemic has clearly exposed the Achilles heel of the European project: the gap between the European Union’s powers and competencies on the one hand, and, on the other, the issues that are closest to European citizens’ concerns – health, employment, social protection and education. At the same time, the pandemic has made an excellent case for the benefi ts of solidarity, at European as well as international level.


The proposals that the European Commission has presented in response to the health and social crisis are bolder and more ambitious than any previous initiatives. Yet there is still a long way to go to further transfer responsibilities in the social fi eld from the member states to the EU, and to make solidarity a strong feature of European social policies, as these, more than other policies, are inevitably linked to cultural values and political beliefs. In spite of this, a more solidary future for Europe is possible, if the EU can fi nd the political will to enforce a narrative for sustainable development that addresses inequalities and the well-being of EU citizens.


The social contract, a European idea


No scholarly article could make the case for strong European solidarity, or for better global multilateral governance, more eloquently than the coronavirus pandemic of 2019. Do we still need to demonstrate the merits of cross-border cooperation after watching the virus spread
across countries like wildfi re, or after witnessing the astounding success of international scientifi c cooperation in creating several vaccines in record time? Yet, at the same time, nothing like Covid-19 could expose so bluntly the Achilles heel of the European project.


While the EU has acquired powers that can transform people’s lives – trade, competition, macroeconomic stability – the issues that interest European citizens most are still those where the EU has the least direct competence: health, employment, social protection, education.
Healthcare is perhaps the most obvious example of this gap between people’s concerns and EU powers. Public health is an exclusively national competence, and with the exception of self-selected success stories, member states have been traditionally reluctant to share knowledge or engage in transparency and information-sharing about their national systems and policies. Up to a point this is inevitable. A common European demos is not strong enough to give EU institutions the legitimacy to make hard choices on (the distribution of) limited resources involving the lives of people. But the advantages of solidarity against health threats between countries united by a common border and common values should be obvious – and how
can you convince citizens that the EU matters for them, if it cannot keep them in good health? When the pandemic struck, even for health emergencies – where the importance of cooperation within the single market was obvious even without the Covid-19 pandemic – the one and only legal instrument at the disposal of the EU was a Decision of 2013 on serious crossborder threats to health.


That Decision, adopted in the aftermath of the H1N1 fl u outbreak, a good decade after the fi rst SARS coronavirus outbreak, established “the rules for epidemiological surveillance, surveillance of serious cross-border threats to health, early warning of and response to such threats, including with regard to planning preparation and reaction linked to these activities, in order to coordinate and complement national policies”. Those ‘rules’ failed the reality check of the Covid-19 pandemic. Predictably, an administrative decision agreed between health ministries in 2013 was not enough to ensure the transparent fl ow of information between member states, the coordination of restrictions to mobility and trade, or even less the distribution of protective equipment to fi ght the worst pandemic since the Spanish fl u of 1918. With this kind of inaction and solidarity gap, it is diffi cult to convince the average European citizen of the added value of the EU or the merits of a European social contract.


Yet the social contract is a very European idea: a heritage of Stoic philosophy and Roman Canon Law, rediscovered in the age of Enlightenment and, for the last three centuries, the main doctrine of political legitimacy. There are many views of what a ‘European social contract’ might entail, but the essence of the concept is simple: legitimacy rests on consent – and ever since the fi nancial crisis of 2007, European institutions have been at pains to explain why citizens should adhere to a project that ostensibly does so little for the issues they care about most.

Ask European citizens from Riga to Athens what they expect from (any) public authority and you know the answer you
are likely to receive: educate the young and keep adults in
work; raise the poor; preserve the social services, pensions
and health systems of our ageing societies.

A Grand Illusion: Essay on Europe – Tony Judt

Surveys over the years consistently show that Europeans are strongly attached to their national welfare regime. As the late Tony Judt put it 25 years ago in his extraordinarily prescient A Grand Illusion: Essay on Europe: European citizens have Ask European citizens from Riga to Athens what they expect from (any) public authority and you know the answer you are likely to receive: educate the young and keep adults in work; raise the poor; preserve the social services, pensions and health systems of our ageing societies consistently felt that protection from the forces of globalisation or natural disasters will come from national institutions rather than from European or multilateral organisations.

Since its inception, the European project has rested on the reductivist assumption that economic integration necessarily creates social and political affi nities. Time has shown that production and fi nance can become globally integrated, that European economies can become interdependent, more so today than at any other time in history – while other aspects of human existence do not necessarily follow suit, at least not at comparable speed. I can think of no better argument than Covid-19 to disprove this assumption.


The limits of European solidarity


If inclusion and solidarity are not the EU’s strongest suit, it is not for lack of words. For half a century, the European institutions have been remarkably productive on the declamatory aspects of EU solidarity. Particularly since the Maastricht Treaty of 1992, there has been much repetition of a ‘Social Europe’ or ‘European Social Model’ that combines economic growth, high living standards and universal social protection. The Charter of Fundamental Rights of the EU, proclaimed in December 2000, states that “Everyone has the right of access to preventive health care and the right to benefi t from medical treatment under the conditions established by national laws and practices.

A high level of human health protection shall be ensured in the definition and implementation of all the Union’s policies and activities” (Article 35). This emphasis on welfare and inclusion is what sets the EU apart from other less ambitious multilateral organisations and regional economic integration projects, and it is what supposedly binds Europeans together in contrast to the ‘American way of life’ or the objectivism of Ayn Rand. But solidarity and a shared sense of identity are diffi cult to translate from paper into practice. Social Europe has never been a homogeneous set of objectives or instruments. Some elements were born in 1957 with the original EC Treaty, and evolved through qualifi ed majority voting, the European Single Act, free movement, health and safety, and the European Social Fund.

Other policies acquired a Treaty basis in the 1990s. The cumulative result is a panoply of legal, fi nancial and policy instruments that are not entirely coherent, but certainly not negligible either. As the EU begins to address the social, political and economic impact of the Covid-19 pandemic, the debate on European solidarity remains handicapped by confusion and contradictory views about the role the European Union should play in employment, social protection, public health and health threats, education and skills development and, more broadly, in the reduction of inequalities.

For a long time, European institutions as well as national leaders have entertained the unhealthy habit of overpromising and underdelivering on the social dimension of the EU


For a long time, European institutions as well as national leaders have entertained the unhealthy habit of overpromising and underdelivering on the social dimension of the EU. And in more recent years, populist governments and nationalist parties across Europe have rekindled a divisive narrative of identity politics that would shock earlier generations of Europhiles. Then came Covid-19.

The harsh lessons of a pandemic


The pandemic has revealed the shortcomings and limited resilience of EU welfare regimes, be it with regard to healthcare systems, social protection or education. In human resources and human capital, strategy planning, infrastructure or technology, very few countries, systems or institutions were prepared. Covid-19 has reminded us of an obvious but often forgotten fact: strong, resilient health systems are not a cost for society, but an investment. Hundreds of years of wildfi res have taught us that emergency preparedness is not a waste of time or money: every single urban centre in Europe has a permanent fire department and a reserve of fire engines.


Now we will remember – hopefully – that we also need better preparedness against pathogens, which spread like wildfi re across our borders and societies. And we will remember that the social determinants of health – in other words, not just healthcare coverage but also the factors that make people more vulnerable such as poverty, joblessness and exclusion — deserve far greater policy priority, at European level as well as nationally. Several factors, such as the age and density of the population, imply different policies and country performances. But we can already draw a few common lessons on what the EU and its member states need to do as a matter of urgency. None of these lessons is new (1 Colombo, F. (2020), ‘Resilience of Health Systems to the COVID-19 Pandemic in Europe: Learning from the first wave’, OECD.).


First, invest in the recruitment and training of the health workforce (to address skills needs, ageing and structural shortages), and in the capacity of health systems (the number of ICU units relative to the population, for example, is six times higher in some countries than in others). Second, increase the response capacities (testing, tracking, isolating) and the efficient use of data. Most Member States implemented similar containment measures, but with dramatically varying speeds and effectiveness; many of them have been unable to use simple health data for effective decision-making and surveillance. Most governments’ ministries had no mechanism for, or practice of, coordinating between them.

The lack of communication between regional and national authorities, or between public health and social policy has been extremely damaging. Third, strengthen primary healthcare and prevention, as a key instrument of public health resilience and to maintain the continuity of care. The pandemic should be an incentive for Member States to address an old problem that takes new relevance today: the insufficient levels of (absolute and relative) investment in health promotion and disease prevention. This is only 3 per cent of total health spending on average.

Lastly, deepen EU and international cooperation, in a wide range of areas with clear European added value: to tackle the cross-border nature of health threats, to obtain more effective synergies in research cooperation as well as in public procurement for medicines including vaccines and medical devices, to improve the mobility of healthcare professionals, to make medicine supply chains more resilient. In the years before Covid. The EU has always seen itself as a paladin of multilateralism and global governance. In recent years, the rise of populist ideologies has made this ideal seem unrealistic, quaint even. In 2021, Europe may well feel vindicated, even if the task remains daunting.

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