As more and more people are voluntarily or forcefully retreating to their homes and isolating themselves from public life and social contact due to the ongoing global health crisis, it might be a good time to reflect on the circumstance that, according to estimates by WHO and UNICEF, in 2018 globally every five seconds a child or young person under 15 died of preventable infectious diseases, such as measles, or of complications in childbirth – many of them a consequence of unsafe births, lacking personnel, equipment, hygiene, infrastructure, and poor maternal health. A few days ago, I met an acquaintance, whose school-aged children have not been vaccinated against measles, carrying a stack of toilet paper packages in preparation for what was bound to come, the German-wide COVID-19 lockdown. The encounter made me aware of the imbalance between our plausible and humane concern for the safety and well-being of ourselves and those close to us on the one hand and a lack of awareness of our own role in preserving public health beyond COVID-19 on the other.
The current global state of emergency caused by a pathogen should more than ever make us conscious of each and everyone’s responsibility for safeguarding the common good that is called public health. At the end of 2018, in Germany, 87.200 persons were living with an HIV-infection, with 2.400 new infections that occurred during that year. In 2018, the WHO regional office in Europe counted 82.600 measles cases in Europe, with immunization rates constantly dropping further below the required 95% percent of the entire population for complete eradication of the childhood disease. Sexually transmitted diseases in the US have risen dramatically between 2014 and 2018, with 94 newborn deaths in 2018 attributed to syphilis. These are just a few examples out of many for how the daily choices we make – for ourselves, our children, against safe sex – may pose a risk to the communities and societies we live in, endangering vulnerable populations.
Looking beyond the pandemic
Once they have gotten out of emergency mode – which is hopefully soon – my hope would be for governments, local authorities and media to capitalize on the maximum attention given to individual and societal health at present. They should seize that attention in order to remind and educate citizens of the broader health consequences that their individual health behavior can bear, beyond immediate health emergencies. Be it for reasons of not overburdening the ordinary citizen with disturbing news and ethical considerations, be it for reasons of strategic and narrow framing of COVID-19 as a problem of virology, strained or faltering health systems and the search for evidence-based, innovative solutions to the pandemic: the absence of connections between the current pandemic and habitual debates on civic responsibility for public health is disturbing. Writing from the vantage point of a Political Scientist specialized on issues of (global) health policy, I dare to say that politics has a role to play in explaining why, at present, non-medical and epidemiological explanations for how our societies’ respond to the coronavirus are virtually absent from the incessant public debate on COVID-19. This absence is, inter alia, due to the shockingly low priority that prevention and health education are given in national health systems and global health governance alike.
In Germany, we have just come out of an intense debate on organ donation, which has been decided in favor of self-determination and bodily integrity and against new regulations that would require making an active choice against organ donation rather than for it. Thousands of lives could be saved each year 1 if more German citizens were open to being organ donators. But all of a sudden, the formula of ‘saving lives’ is on everybody’s lips – for a great many people, because the only action required for contributing to that goal is shutting oneself up indoors and shutting society out. When it is about checking our immunization status and refreshing our vaccinations or about educating our kids to have safer sex in order to protect not only themselves but also others, though, things become more uncomfortable, and the ‘saving lives’ formula retreats to the background.
The hypocrisy of the ‘saving lives’ formula also lies in the fact that only in exceptional circumstances – such as now! – do we like to think about health politics as being not only about saving and prolonging lives and ensuring the best possible physical and mental health to people, but that it is fundamentally about saving some people’s lives and failing others. Just remember the public outrage when, in 2012, then German health minister Daniel Bahr suggested to curb down knee- and hip-replacements for older persons. It lies in the nature of health systems facing resource constraints that they will at some point have to weigh costs and benefits of specific health interventions – and the ongoing privatization and economization of even highly developed public health systems will reinforce that reasoning.
The reality of health politics
The choices of intensive care doctors in Italy, Spain, the UK and the US that we are able to watch from our living rooms right now are dramatic and of a terrible scale. Such choices and decisions – encapsulated in the word and concept ‘triage’- however, are being made every day, even during normal times, in intensive care, often within a couple of minutes, because even in normal times many hospitals experience a shortage of intensive care beds and a process of ‘rationalization’ of care. 2 The current tragedy that happens right in front of us, including not only the fatalities but also the systemic effects of the COVID-19 pandemic, makes us more than ever sensitive to the existential choices that are the norm rather than an exception, not only in medical practice but also in health policy-making. To argue, however, that health policy’s regular business is ‘saving lives’ is buying into a rhetoric that aims to shield public opinion from the cruel decisions that characterize this policy field. Health politics means negotiations over research and development for some drugs rather than others, negotiations over prices for medication and therapies that some insurances and patients will not be able to afford and, generally, a public good that depends to a large part on markets and the choices of profit-seeking industries, before all the pharmaceutical and biotechnology sectors.
Finally, the hypocrisy of the ‘saving lives’ metaphor extends also to global health. Raising awareness for the interdependency not only between ourselves and the “health of our nation” but also among national health systems in the current discussion on COVID-19 would allow for challenging the popular narrative of a national “walling-off”. It would mean to expose the link between our own health system and failing health systems elsewhere (e.g., Serbia) 3 in the context of a health workforce migration, openly and forcefully promoted by our government. Even though the national responses to this health emergency may be idiosyncratic across Western Europe, the German, Italian, and British health systems are united by their reliance on a health workforce trained abroad and recruited from countries struggling with upholding even a functioning health system. Germany and the UK, in particular, have benefitted immensely from the migration of doctors and nurses from Southern and Eastern Europe after the financial crisis in 2008/2009. 4 It is time to think about these global dynamics in terms of political choices and global inequalities that make many of us much less vulnerable to existential health threats than billions of others. In these inequalities, each and every one of us has a role to play or is at least a bystander. Every day, behind closed doors, far away from public scrutiny and often in parlance too cryptic and scientific for ordinary citizens to decipher, (global) health politics means making existential choices to ameliorate the health and well-being of some while sacrificing that of others. We should acknowledge this inherent dilemma of health politics in our reflections on the current crisis.
On 1 Januar 2020, Eurotransplant listed 9.004 persons in Germany waiting for an organ donation. See https://www.eurotransplant.org/patients/deutschland/, last access 26 March 2020 ↩
Joachim Boldt, „Intensivmedizin. Tabuthema Rationierung“, Deutsches Ärzteblatt 103: 8 (2006), pp. 462-465 ↩
Deutsche Plattform Global Gesundheit (DPGG), (2016), Brain Drain durch grenzüberschreitende Abwerbung von Gesundheitsfachkräften. Deutschlands Beitrag zu einem globalen Skandal (Berlin: DPGG ↩
World Health Organization (2014), Migration of Health Workers. WHO Code of Practice and the Global Economic Crisis (Geneva: WHO ↩