EAPM: Leviathan, or the rudder of public health

Welcome, health colleagues, welcome to the European Alliance for Personalised Medicine (EAPM) update. In this edition, we take a good, close look at public health provision in the EU, assessing the ramifications of the problems that the size of public health policy has manifested, as well as our usual look at the health news, writes EAPM Executive Director Dr. Denis Horgan.

The great Leviathan

Is public health provision in Europe not big enough, or is it just too big? Certainly its huge size has enabled it to do great things for European citizens for many years. Three generations of western Europeans have enjoyed an increasingly comprehensive range of services that have improved the length and quality of life for many, to the extent that such provision has come to be taken very much for granted. And even in the EU's newer member states and its candidate countries, expectations have risen in line with – and often ahead of – growing prosperity and access to more extensive services.

But the size that public health policy has attained, together with the consequent complexity, also makes it very difficult to manage, to modify, and above all to rethink. The health system in Europe is indeed a leviathan – and as with supertankers, there are no possibilities of a light touch on the rudder to make quick changes to its course.

The time is coming when some agile navigation may be necessary. There are risks in policy complacency when public health provision is confronted with the massive changes in its context, ranging from demography and scientific advance to new technological possibilities and economic constraints unparalleled since the rise of post-World War II public health thinking. The depiction of public health provision as the great leveller, the guarantor of a minimum of care for everyone, is a compelling argument for the retention of a standardized, one-size-fits-all approach. Negligent watch-keeping on the supertanker's bridge, clumsy hands on the tiller, or indeed reliance on an inadequate or unresponsive tiller, could endanger rather than enhance the general good that public health policy is deemed to protect.

Striking the right balance for the common good necessitates taking full account of competing and even conflicting dynamics. An unthinking acceptance that everything is right as it is at present can lead to blindness over emerging risks. Depending on nursery-rhyme reflexes that if ‘the bough breaks, The cradle will fall’ may cause undue attention to be given to just one bough, overlooking both the possibility that cracks may appear over time and the chance that other and younger boughs – or different and more modern technology - may offer equivalent or better support. Unquestioning attachment to the concept of a homogeneous health system could hinder exploitation of opportunities that may arise for local or spontaneous improvements.

The European Union, as the overarching framework for policy formation in most of Europe, brings an additional complexity to discussions about public health. It is a powerful potential channel for informed reflection, and at its best, the EU could serve as a compass, a lodestone in plotting the voyage. But the search for consensus as the EU's constant operating principle can also stifle original thinking, so that at its worst the EU can obscure the horizon with a self-generated fog, or have the effect of barnacles encrusting the hull below the waterline. Specifically in the health field, the strict limitations on EU competence act as a further confounding factor, with responsibility for public health uncomfortably half in and half out of the realm of coherent planning.

The EU attachment to equality – as most recently enshrined in its approach to social affairs and its bill of rights – is laudable as a philosophy, but can run into problems in such a diverse organization, where national conditions vary so widely across the bloc. This raises the question as to what is the appropriate role for the EU, and whether its espousal of a generalization so simplistic as the common good of EU citizens constitutes a route-map for the best service in public health. There is a risk in ready-made slogans, particularly in areas of great complexity, significance and sensitivity.

So the undeniably admirable concern for public health needs some nuance to translate the ideal into practice, both to avoid it being used too bluntly and to prevent it being overshadowed by other policies. A balance difficult enough at national level. In the European context, a more selective approach to policy design may be even more necessary to keep public health policy finely attuned to real public good.

It is not certain that the EU has practiced that selectivity optimally. It has exercised some choices, and some of those choices have worked out better than others. The ban on smoking in public places resulted more from the issue of protection of workers than directly from public health policy. The effect has been beneficial, but it is striking that an obviously valuable public health policy came about uniquely through the exercise of a completely different policy competence.

Diversity of approach

The sheer diversity of approach confirms that there is no underlying logic or overarching perspective for making EU policy decisions on public health. Policy is often the result of random factors, a consequence sometimes of caprice more than of coherence. There is, for instance, a manifest reluctance by some in the healthcare community to make use of emerging technologies, to harvest the fruits of scientific research in new health applications that can treat the patients or the broader public. Just take the example of patients contributing to earlier diagnosis of melanoma by using their own smartphones, making the condition easier to treat – and then just look at how widely that is endorsed and supported across the member states.

As the stakes rise in ensuring sustainable health systems, the time is coming when a more sophisticated rationale will be needed to guide public health policy effectively – a more soundly based social contract to move forward, above all at EU level. Retaining public health as a sovereign member-state competence demonstrably has had adverse unintended consequences, and continues to do so. Most obviously, it has handed each member state an effective veto on any EU-wide joint approaches, because any country can simply invoke the sovereignty clause to bring any common action to a juddering halt.

COVID-19

Since the beginning of the pandemic, the EU has been working with member states to reinforce national healthcare systems and limit the spread of the virus. It has been coordinating action at EU level based on the best available science and giving recommendations to EU countries on public health measures. The EU's response in the field of public health includes increasing capacity for production of a safe and effective vaccine and through the EU vaccine strategy ensuring the provision of medical supplies and personal protective equipment.

There are the seeds of injustice in standing in the way of progress in something so fundamental to each person's rights as health care, and there are the seeds of something approaching an undemocratic élitism in brandishing 'public health' as a pretext for opposing change. And when the current uneasy status of health policy in the EU leaves action within it vulnerable to veto, then the rights are compromised of many who might wish to embrace change – such as those sharing a genetic characteristic or a rare disease.

The rudder that once acted to steer public health is no longer adequate to the job, and new thinking is needed to take advantage of opportunities that did not before exist.

Outgoing German Chancellor Angela Merkel said on 21 April that the European Union needs more power to coordinate the bloc’s response to health crises like the coronavirus pandemic, and did not rule out a treaty change to secure them. Her comments to an online meeting on the Future of Europe of fellow European conservatives raised eyebrows in Brussels, where the start of a large-scale public debate on the future of the EU has revived talk of reopening the bloc’s governing structure.

In other news…

Draft report on pharma strategy will be presented in ENVI committee in late May

MEP Dolors Montserrat will present a draft of the own-initiative report on the Commission’s pharmaceutical strategy to the the European Parliament’s health committee at the end of May, she said today (29 April).

“This requires an ambitious, clear and up-to-date regulatory framework as well as dedicated resource for science and health research,” said Montserrat, speaking at an event organized by the Portuguese EU Presidency and the European Commission. 

Health commissioner offers sweeping ambitions for pharma reform

No patient in Europe should have to go without medicines that he or she needs due to money or other obstacles, said Health Commissioner Stella Kyriakides today (29 April). 

Speaking at an event organized by the European Commission and the Portuguese EU presidency, Kyriakides pledged that EU’s pharmaceutical strategy will tackle the core issues that make medicines unavailable to those who need them. 

Kyriakides’ willingness to tear up the current rules may make drugmakers nervous, since they rely on perks like market exclusivity to protect their bottom line. The 2022 reform will take into account “the relationship with intellectual property rights to address aspects that impede the competitive functioning of markets,” she noted. “The failures of markets should not be the failures of our health systems.”

Parliament approves COVID-19 certificate position

The European Parliament adopted its position on the digital green certificates Brussels wants to use to reboot travel by proving holders got a jab, a test, or have antibodies following a coronavirus infection with a broad majority. In Wednesday’s (28 April) plenary vote, 540 lawmakers voted in favor of the position; 119 opposed and 31 abstained. Parliament’s position on certificates for third-country nationals got the backing of 540 MEPs, while 80 opposed and 70 abstained.

And that is everything from EAPM for now – have a safe, enjoyable weekend, stay well, see you next week.

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