The COVID-19 crisis is, without a doubt, the most important health challenge that European countries have suffered in the last century, although its effects are only now beginning to be quantified. The crisis is illustrating, sadly in the form of fatalities, that while globalisation entails benefits via free trade and mobility, it also carries health risks.
Although the consequences of the crisis are yet to be determined, it is already suspected that, even at best, it will lead to a paradigm shift in almost every area, and perhaps be the turning point desperately needed to address the challenges of globalisation once and for all.
In this column, I argue that a key political lesson of this crisis is that further collaboration is required in Europe to face such health challenges. Collaboration does not occur spontaneously, but rather requires stable institutions that allow problems of collective action to be solved. I suggest that a possible solution is the transfer of public health responsibilities to the EU when a health risk goes beyond the borders of a member state.
Most federal states have an authority or an agency with such a remit, such as the Centres for Disease Control and Prevention (CDC) in the US, a federal agency under the Department of Health and Human Services with responsibilities on global health and epidemic intelligence. In contrast, while there is a DG Health in the European Commission, the equivalent of the CDC does not exist for the EU. Responsibilities are decentralised to member states, which only began sharing information after the European Centre for Disease Prevention and Control (ECDC) was created in response to the SARS outbreak in order to coordinate a European response to future outbreaks. However, it has a limited data-sharing function and barely any authority. Other European agencies, such as the European Medicines Agency (EMEA), are focused on medicines but do not engage in public health decision making.
Higher exposure to COVID-19 given Europe’s ageing population
EU member states share common concerns about the readiness and capacity of their health systems to respond to pandemics. The ECDC (2020) reported on 25 March that 30% of diagnosed COVID-19 cases in the EU were being hospitalised and 4% had severe illness, which is slightly higher than the world average given to the large share of elderly in the population. Both the probability of death and the absolute number of deaths increase rapidly with age for those aged 60 years and over in every country. Among hospitalised cases, 12% have resulted in death, with higher case fatality rates among the elderly. In Italy, however, approximately 40% of patients have been hospitalised, with close to 7% admitted to intensive care units.
Another reason for a European authority lies in the similarities in the cross-country health system organisation in the continent. By influencing the spread of the virus, public health interventions (lockdowns, social distancing etc) can have significant spillovers on the way a health system works. If the transmission is slowed and the curve is flattened, stress on the health system in terms of hospital beds and the risk of intensive care units collapsing are reduced. As Figure 1 shows, there are large differences in critical care bed capacities across EU countries (from 29.2 beds per 1000,00 inhabitants in Germany to 4.1 beds in Portugal). Importantly, these differences are not correlated with the share of GDP invested in health care (Rhodes et al. 2012).
Figure 1 Critical care beds per 100,000 inhabitants
Heterogeneous responses to the same pandemic
The way in which each country has responded to the pandemic does not reflect the objective needs of that country (number of fatalities, share of older people or people infected, etc.), but rather the differences in the character of its national elites and, almost without exception, the country’s self-interest.
While Germany has managed to keep death rates low with intense testing – and testing seems key (Baldwin 2020) – other European countries have reacted much more slowly. Austria and Poland revealed some nationalistic instincts in their responses by closing their borders. And while Finland locked out the region of Helsinki (where most cases emerged at the beginning of the spread), in Spain no region was locked and instead the regional health systems were centralised under the declaration of a state of alert, despite the knowhow being at the regional level. France followed Spain’s steps. Hungary offers another example of the politicisation of the crises – the pandemic has been used as an excuse to control the country to a degree which has been denounced by the European Parliament.1 In contrast, in Italy, the regions were the first to establish quarantines and to urge locals to stay home, and the results in Veneto region have been exceptional (unlike other regions with the same or more resources). In the UK, Wales and Scotland acted first by announcing policy measures such as the closure of schools, which were then followed by similar measures in England.
The modest role of the European Union
Article 3 of the Treaty of the European Community establishes that the European Community will contribute to a "high level of health protection", and public health is explicitly mentioned as an EU responsibility in the Maastricht Treaty. More recently, a 2013 European Council decision opened the possibility for the EU to act in the face of “serious cross-border threats”. The COVID-19 crisis undoubtedly represents a threat that exceeds the territorial limits of the states. However, the EU has reacted with considerable delay – it was only in the second week of March that travel to the EU was suspended for 30 days, and earlier in March the EU threatened France and Germany with infringement proceedings for limiting the export of masks.
There is no doubt that the COVID-19 crisis is an example of a situation where the EU should be more proactive. It is at times of crisis that member states are tempted to follow their self-interest and face problems of collective action. They prioritise their own interests, even when it undermines solidarity with other EU countries. The most obvious example is the exports limits on medical protection equipment (such as face masks) imposed by France and Germany, despite severe shortages in some countries.
That said, we have seen some examples of cross-border collaboration, such as the help offered by the German state of Baden-Wuerttemberg to patients in the French region of Alsace. And on 28 march, a handful of patients in Lombardy were transferred to Cologne and the European Commission interceded to send masks to Italy from Austria, France and Germany. However, these examples of collaboration have been the exception rather than the norm, and an argument can be made that such help was aimed at minimise the potential externalities from an increase in cases in a neighbouring state.
A European authority to respond to 'cross-border health risks'
One way to overcome problems of collective action would be to create a public health authority at the European level, with powers beyond the limited coordination activities carried out by the European Centre for Disease Prevention and Control. Pandemics such as COVID-19 affect EU countries in a different way from the rest of the world (given the unique institutional design of health systems defined by universal coverage and healthcare mobility), and a public health authority could ensure cooperation when each member state is tempted to follow its own self-interest. If all European countries had implemented the same response to the current crisis as Germany, Europe would probably have prevented some deaths.
Given that the management of pandemics does not respect borders, and pandemics are a ‘global public bad’, they require form of collective action to face the challenges. Such action would not occur spontaneously unless some institutional design is put in place to enforce cross-country collaboration across EU countries. This collaboration could potentially involve EEA countries, the UK and other neighbouring countries to the EU. If such institution building were to take place soon, it could arrive in time to face the needs of a potential second phase of the pandemic later in 2020 and into 2021, and it could support, with other agencies, the rapid diffusion of a vaccine and related treatments as they become available.
The European public health authority should be as independent as the ECB is with regards to price stability, with a clear mission and remit for global health. The authority would confer additional value on EU membership in a time of rising populism, and would add to the technical guidance offered by WHO to ensure that European countries build their capacity to respond to pandemics and other public health challenges.
Baldwin, R (2020) “COVID-19 testing for testing times: Fostering economic recovery and preparing for the second wave”, VoxEU.org, 26 March.
EDCD (2020), “Rapid risk assessment: Coronavirus disease 2019 (COVID-19) pandemic: increased transmission in the EU/EEA and the UK – seventh update”.
Rhodes, A, P Ferdinande, H Flaatten, B Guidet, P G Metnitz and R P Moreno (2012), “The variability of critical care bed numbers in Europe”, Intensive Care Medicine 38(10): 1647-1653.