Le “cattive medicine” rappresentano una grave minaccia per la salute perché, oltre ad essere inutili, possono uccidere o facilitare la diffusione di microbi resistenti alle cure

by Daniele Dionisio

Policies for Equitable Access to Health –PEAH  

 Nuove Norme UE Anticontraffazione Farmaceutica

 

Il 9 febbraio 2016 la Gazzetta Ufficiale dell’Unione Europea  (UE) ha pubblicato il Regolamento delegato in concreta attuazione della Direttiva 2011/62 sui Medicinali Falsificati (Falsified Medicine Directive).

Secondo l’ EMA (Agenzia Europea dei Medicinali), il nuovo sistema sarà in grado di impedire l’ingresso dei farmaci contraffatti nella filiera legale, renderà più trasparente ed affidabile l’acquisto on line dai siti certificati (legale in Europa dal 1° luglio 2015), e migliorerà il controllo sui farmaci scaduti, revocati, ritirati e rubati.

Il sistema si basa sull’apposizione di caratteristiche di sicurezza (un dispositivo anti-manomissione  e un identificativo univoco rappresentato da un codice a barre bidimensionale) sull’imballaggio dei medicinali per uso umano. Le parti interessate sono tenute all’apposizione delle caratteristiche predette non oltre il 9 febbraio 2019.

All’interno del codice a barre bidimensionale saranno registrati: il codice AIC (autorizzazione immissione in commercio) del farmaco, l’identificativo unico di ogni confezione, il numero di lotto, la  data di scadenza e, eventualmente, il codice di rimborso nazionale.

Rientreranno nel sistema tutti i medicinali etici (esclusi i farmaci omeopatici, le soluzioni, i solventi, alcuni test allergologici e pochi altri) e alcuni farmaci senza obbligo di ricetta.

Ogni Paese sarà tuttavia libero di estendere  l’apposizione ad altre classi terapeutiche.

Il sistema opererà a monte (industria) e all’atto della dispensazione, e i vari archivi si confronteranno con la piattaforma europea  che annullerà, all’atto della dispensazione, l’identificativo unico (in pratica impedendo che un medesimo farmaco possa essere venduto due volte).

L’EMA ha formulato un Piano di implementazione  per la normativa; nel contempo, la Direzione Generale Salute della Commissione UE ha reso disponibile un documento  di “Domande e risposte”.

Il ruolo dell’Italia 

Nella lotta alla contraffazione l’Italia è in linea con la Direttiva Europea 2011/62, di fatto recepita con il Decreto Legislativo n° 17/2014. Per certi versi l’Italia ha anzi normativamente giocato d’anticipo.

Infatti,  il DM 15 luglio 2004 già consentiva di monitorare, anche informaticamente, tutte le transazioni di farmaci nella filiera legale, attribuiva un codice identificativo a tutti i soggetti coinvolti nel ciclo di vita di un medicinale, e registrava le transazioni di tutte le confezioni trasmesse dagli attori della filiera in una banca dati centrale gestita dalla Direzione Generale del sistema informativo del Ministero del lavoro, della Salute e delle Politiche sociali.

Successivamente, in linea con i DL 219/2006, DL 248/2006, e DL 274/2007, tutti i soggetti coinvolti nel ciclo di vita di un medicinale divenivano noti in quanto oggetto di un provvedimento di autorizzazione o di notifica della loro attività.

Dal 2007 il sistema italiano anti contraffazione si implementava, inoltre, con la task-force IMPACT Italia costituita da Agenzia Italiana del Farmaco (AIFA), Ministero della Salute, Istituto Superiore di Sanità, Carabinieri NAS, Ministero dello Sviluppo Economico e Agenzia delle Dogane. Questa collaborazione ha sviluppato iniziative come la cooperazione internazionale, l’analisi di intelligence della vendita di farmaci attraverso internet,  il training e supporto agli investigatori, il monitoraggio delle reti illegali, la messa a punto di strumenti informatici da usare sul campo, l’informazione al pubblico, e la realizzazione di moduli online per la segnalazione di casi da parte degli utenti.

Per effetto della normativa descritta è improbabile in Italia la vendita in farmacia di medicinali non in regola poiché il sistema consente l’ingresso nella filiera legale solo a farmaci “autentici” provvisti di bollino ottico, identificando nel contempo i responsabili di eventuali attività illecite.

Un problema cruciale

L’urgenza della normativa anticontraffazione è indiscutibile solo pensando al forte trend di crescita del fenomeno, oggi non più circoscritto ai Paesi in via di sviluppo bensì esteso anche a quelli industrializzati.

La contraffazione ingloba farmaci di marca e farmaci generici, medicinali salvavita e “life style saving”. Un medicinale contraffatto può contenere le stesse sostanze di quello originale o sostanze/dosaggi diversi, può non contenere alcun principio attivo o addirittura può essere composto da ingredienti contaminati e pericolosi. Le diverse tipologie sono tuttavia accomunate dalla scarsa qualità in quanto la produzione, pur se con ingredienti non tossici, esula dalle norme di buona fabbricazione e distribuzione accettate a livello mondiale.

Sebbene la contraffazione interessi moltissimi farmaci, generici e di marca (antidolorifici, antipiretici, sedativi, antibiotici, cardiologici, antitumorali, antidiabetici, anti-AIDS, antimalarici, etc.), essa non configura reato in diversi Paesi poveri; e se alcuni governi africani lamentano import di medicinali contraffatti, non per questo controllano la qualità offerta dalle proprie fabbriche. Anche quando i colpevoli siano catturati, le pene restano lievi.

Peggio, la globalizzazione agevola la distribuzione via internet di medicine fuori regola ad un’infinità di networks mondiali dove più della metà dei prodotti in vendita è contraffatta.

Le “cattive medicine” rappresentano una grave minaccia per la salute perché, oltre ad essere inutili, possono uccidere o facilitare la diffusione di microbi resistenti alle cure.

Se cicli di antibiotici sotto dosati possono risultare inefficaci o a rischio vita, centomila morti per malaria sono state annualmente registrate nella sola Africa per medicine di cattiva qualità.

L’industria della contraffazione vanta un fatturato di centinaia di miliardi di dollari, e immensi  guadagni si realizzano con piccoli investimenti. In tal senso, l’India è tra le sedi più a rischio perché offre di base costi manifatturieri  del 40% in meno che altrove.

La maggioranza dei farmaci contraffatti origina infatti in Asia, principalmente Cina e India e, se  l’Africa è sotto tiro, il mondo occidentale non è risparmiato.

Le statistiche dell’Unione Europea indicano un incremento pari al 384% di falsi medicinali sequestrati nel 2006 rispetto a quanto avvenuto nel 2005. E secondo stime ritenute attendibili, la percentuale di medicinali contraffatti sul mercato globale si attesterebbe intorno al 7 %, con punte significative del 50% in alcuni Paesi di Africa e Asia.

Il 70% dei contraffatti oggetto di sequestro proviene dalla Cina. Nel 2011, 50 carichi dell’antinfluenzale ‘Tamiflu’, privi di principio attivo e di sospetta provenienza cinese, furono intercettati alle dogane in USA. Più o meno nello stesso periodo, circa il 68% del mercato del farmaco in Nigeria risultava dominato da medicine cinesi contraffatte, mentre l’Ufficio Investigativo Criminale di Taiwan rendeva noto il sequestro di farmaci contraffatti cinesi per un valore di 9 milioni di dollari.

Ancora nel 2012 in Cina 200.000-300.000 decessi erano imputabili a farmaci contraffatti.

PER APPROFONDIRE

Measures to help protect patients from falsified medicines http://www.ema.europa.eu/ema/index.jsp?curl=pages/news_and_events/news/2016/02/news_detail_002467.jsp&mid=WC0b01ac058004d5c1

COMMISSION DELEGATED REGULATION (EU) 2016/161 http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=uriserv:OJ.L_.2016.032.01.0001.01.ENG

DIRECTIVE 2011/62/EU OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2011:174:0074:0087:EN:PDF

Implementation plan for the introduction of the safety features on the packaging of centrally authorised medicinal products for human use http://www.ema.europa.eu/docs/en_GB/document_library/Other/2016/02/WC500201413.pdf

SAFETY FEATURES FOR MEDICINAL PRODUCTS FOR HUMAN USE: QUESTIONS AND ANSWERS http://ec.europa.eu/health/files/falsified_medicines/qa_safetyfeature.pdf

DECRETO LEGISLATIVO 19 febbraio 2014, n. 17 http://www.gazzettaufficiale.it/eli/id/2014/03/07/14G00027/sg%20

Lotta alla contraffazione farmaceutica http://www.agenziafarmaco.gov.it/it/content/lotta-alla-contraffazione-farmaceutica

IMPACT Italia http://www.impactitalia.gov.it/home.php

The Global Pandemic of Falsified Medicines: Laboratory and Field Innovations and Policy Perspectives. Am J Trop Med Hyg April 20, 2015 http://www.ajtmh.org/content/early/2015/04/16/ajtmh.15-0221.full.pdf+html

A Flawed “Bad Medicine” Campaign. Health Affairs Blog  October 18, 2011  http://healthaffairs.org/blog/2011/10/18/a-flawed-bad-medicine-campaign/

Farmaci contraffatti. Una minaccia globale  http://www.saluteinternazionale.info/2012/04/farmaci-contraffatti-una-minaccia-globale/

 

 

 

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This thematic review analyzes four key areas of public health and preventive medicine practice portrayed by the film 'Contagion': infectious disease transmission dynamics, the role of public health physicians, the interface between clinical practice and public health, and the role of social media in health promotion. The findings presented here promote an understanding of how the film represents these topics and illustrates the potential benefits to public health as a discipline arising from popular media depictions

Jin Hee Kim

Dalla Lana School of Public Health, University of Toronto

Michael Schwandt

College of Medicine, University of Saskatchewan

Lawrence C. Loh

Dalla Lana School of Public Health, University of Toronto, and Director of Programs at The 53rd Week Ltd

 Popular Media, Outbreaks, and Parallels with Key Themes in Contagion

 

INTRODUCTION

The film Contagion, which depicts fictional events surrounding the emergence of a novel virus and its rapid worldwide spread,[1] opened on September 9, 2011 to great fanfare, widespread advertising, and media frenzy. On opening weekend, a broad viewership in North America contributed $22.4 million in revenue to propel the movie to the number one spot at the box office.[2]

Numerous television interviews with moviegoers demonstrated that the movie had achieved some traction in guiding people through the work of public health in outbreak and emergency situations.[3] Other disciplines portrayed in film and television have resulted in altered public perception and expectations of real-life professionals working in those areas, such as the “CSI effect” on forensic scientists.[4],[5] A broad-reaching release such as Contagion similarly provided and opportunity for increased public knowledge and awareness of public health and preventive medicine practice, while also stereotyping and distorting nascent impressions of the discipline and its activities. It is thus worthwhile for public health physicians to reflect on this depiction of their specialty to identify potential changes in public perception.

This thematic review analyzes four key areas of public health and preventive medicine practice portrayed by Contagion: infectious disease transmission dynamics, the role of public health physicians, the interface between clinical practice and public health, and the role of social media in health promotion. The findings presented here promote an understanding of how the film represents these topics and illustrates the potential benefits to public health as a discipline arising from popular media depictions.

THEME 1: INFECTIOUS DISEASE DYNAMICS

“On day one, there were two people, and then four, and then 16…In three months, it’s a billion – that’s where we’re headed.”

– Jude Law (as health blogger Alan Krumwiede)

“Stop touching your face!”

– Kate Winslet (as CDC Epidemic Intelligence Service Officer Dr. Erin Mears)

While principles of infectious disease epidemiology by necessity underlie the story of any real or fictional epidemic, cinematic portrayals of outbreaks rarely mention the technical details.[6],[7] Characters in Contagion, however, make explicit reference to terms and concepts used in the public health practice of communicable disease control. These filmmaking decisions drive the plot and characterize the epidemic, while also providing information on infectious diseases and their control.

The basic reproductive number “R₀” is prominently referenced in the film’s dialogue, which correctly identifies it as the number of new infections transmitted by a single infected individual. Early in the MEV-1 epidemic, Dr. Mears (Kate Winslet) explains to local health officials that ascertaining the R₀ for the infection is critical to predicting its potential spread. Less overtly, Mears highlights the components of the R₀ for any infection: frequency of personal contacts within a population, probability of transmission during contacts, and the duration of the infectious period.

By describing these concepts, the film lays the groundwork for viewers to connect these themes to the mitigation measures later introduced, including: quarantine (lowering contact rate) and vaccine development (lowering the probability of transmission). While reviews drew parallels to other films addressing communicable disease control such as Blindness and Outbreak, which also employed quarantine and other measures as plot devices, Contagion was unique in that it further explored why these strategies work (or fail).

Contagion also focuses on the most universal and evidence-based approach to reducing transmission: hand hygiene. The emphasis of this control measure occurs alongside the perhaps more glamorous strategies of vaccine experimentation and novel cures. This is entirely realistic and educational; in the event of a novel respiratory outbreak, hand hygiene would be the chief infection control strategy messaged to the public. When Dr. Mears scolds her support staff in the film (“Stop touching your face!”) and various Centers for Disease Control (CDC) staff are seen fastidiously applying alcohol gels to their hands, they are communicating a valuable public health message to audiences, a message as memorable as the dramatic symptoms of MEV-1.

Popular media assessment of the potential impact of these realistic portrayal of disease transmission was mixed, with some outlets pointing out that existing hand hygiene messages are already largely ignored and that the message that “other loved ones” are actually potential disease carriers would not be well-received. [8] However, other outlets were more optimistic, highlighting the newfound awareness of celebrities from the movie, and suggesting that Contagion was “a 105-minute public service announcement with a simple message: Wash your hands. Often.” [9]

THEME 2: ROLE OF THE PUBLIC HEALTH PHYSICIANS

“I’d rather the news story be that we overreacted than have people dying

because we didn’t do enough.”

– Laurence Fishburne (as Dr. Ellis Cheever)

The film addresses the role of the public health physician early on, as Dr. Ellis Cheever (Laurence Fishburne) passes one of the service staff in the CDC parking lot. The staff member wonders if his son may have attention deficit disorder, and requests Dr. Cheever’s advice. Cheever responds “I’m not that kind of doctor,” and promises to refer the child on to a colleague.

As the outbreak investigation ramps up, two physician epidemiologists lead field investigations, demonstrating the role of public health physicians as experts in data analysis, risk communication, and knowledge transfer. One scene also captures the highly political nature of the job, with resistant local officials voicing economic concerns and referencing public outcry over the perceived pandemic influenza H1N1 overreaction.

Contagion also illustrates the critical balance between population health protection and personal privacy. Dr. Mears takes an exposure history from the husband of the index case, and during the interview, inadvertently divulges that the index case had an extramarital dalliance prior to her untimely death.

Media relations also figure prominently in the movie. One scene involves Dr. Cheever at a press conference, providing an overview of the outbreak and discussing control measures such as hand hygiene. He also responds to insinuations that the MEV-1 outbreak is “another H1N1 overreaction.” A later television interview has a different outcome; Dr. Cheever’s reluctance to provide the number of deaths results in a media catastrophe when the conspiracy theorist Alan Krumwiede (Jude Law) correctly accuses him of preferentially informing loved ones on the severity of the outbreak prior to the public announcement.

Contagion generally portrays the physicians as selfless and caring, but with human failings. In one dramatic field hospital scene, a dying Dr. Mears offers her jacket to a neighbouring patient suffering from rigors. In contrast, Dr. Cheever’s decision to divulge confidential information reveals his fallibility. When confronted, he states: “I did it because I have loved ones, and I would do it again in a heartbeat.” A later scene shows him immunizing his service staff’s son in lieu of taking the immunization himself.  Portraying such intensely personal conflicts allows the audience to find common ground with public health physicians, who often do not share a similar connection to individuals as those in traditional clinical practice.

THEME 3: INTERFACE BETWEEN CLINICAL PRACTICE AND PUBLIC HEALTH

Public health is often challenged to demonstrate its relevance to the people it serves. Some of the most common opportunities for public health to market its relevance arise through specific educational and clinical occurrences. Contagion provides no shortage of memorable scenes exploring such avenues.

As one of the top ten greatest public health achievements, identified by the CDCvaccines represent a significant point of linkage between individual patients and public health. The movie follows the chain of vaccine development from bench research to administration to individual patients, demonstrating to viewers the role of public health in research and policy. Similarly, popular scepticism and the anti-vaccine movement are other clinical considerations with significant connections to public health practice that are heavily explored by the movie.

Another interface between public health and clinical practice is the role of government agencies in disasters and emergencies. Patients do not often consider who administers a health care system until it begins to fail. Contagion cinematically reinforces this link through scenes involving overcrowded waiting rooms and field hospitals, mass graves, and immunization centres.

Communicable diseases – both the common and the rare – represent another intersection of public health priorities and individual patient care. The film strengthens this point with references to a wide spectrum of diseases which require public health action. The fear of an unknown disease weighs heavily throughout the film, thrusting public health officials into action, but some scenes focus on the medical care of MEV-1 patients and reference societal perceptions about the common cold.  As much as public health needs to be informed by medical care of the ill, the control of communicable diseases provide tangible opportunities for the field to connect with the minds of individual patients.

Public health generally fares poorly at promoting its work. Contagion reminds us to be aware of the linkages between certain everyday clinical interventions and public health. At the same time, scenes from the movie depicting these linkages will also draw public attention to the public health basis of these activities. Overall effects on audience perception remain to be seen, and public health physicians should consider how to take advantage of potential changes in the population’s interest and understanding.

THEME 4: SOCIAL MEDIA AND PUBLIC HEALTH

“If I could throw your computer into jail I would.”

– Enrico Colantoni (as U.S. government agent Dennis French)

Another theme front and centre in Contagion is social media as a platform for magnifying and hastening the spread of sensational messages.  Rejected by mainstream print media, blogger Krumwiede amasses an online following to whom he promotes an alternative treatment (Forsythia) while spreading dire warnings about the vaccine.  The viewer inevitably links his activities with a riot in a community pharmacy over Forsythia rationing. In another example of online information spread, Facebook is identified as having propagated Dr. Cheever’s breach of confidence, resulting in widespread revelation and legal consequences.

Contagion illustrates the internet’s ubiquity and the rise of social media, while linking these phenomena to the personal contexts in which they exist – Krumwiede is depicted as exploiting his newfound influence to acquire investor interest in his activities, while news arising from Cheever’s breach spreads out of control online. Both examples demonstrate the power of social media to reach the masses and potentiate action or behaviour change; both also show the unpredictable and uncontrollable nature of such communications.

While the movie depicted the reliance of public health officials on traditional media outlets, a rapidly changing event of such magnitude is precisely the kind that requires the instantaneous information transfer that social media facilitates.  Many public health organizations function on outdated information technology systems, with social media websites frequently excluded from communications plans and even blocked to employee access.[10] In many ways, it reflects a denial that such technologies are increasingly integral to today’s society, with this shift in mass communications reflecting possible changes in the populations they serve.

As social media and information technology continues to evolve, public health institutions will need to find ways to engage their communities through these new modalities and remain attentive to emerging research on online behaviours.  In Contagion, a government official’s retort to Krumwiede, “If I could throw your computer into jail I would,” is especially telling – attempts to control the technology rather than trying to understand the technology’s users are probably misguided and likely to fail.

CONCLUSIONS

Overall, Contagion explores key public health concepts, achievements and messages in the midst of a novel outbreak, and portrays dilemmas faced by public health physicians who straddle the worlds of population and clinical medicine. Contagion promotes an understanding of modern public health practice in a world of dense connectivity and rapid advances in telecommunications. More than tools for modern living, these developments are changing the way we interact in our social environments.

Many of the themes identified in Contagion have been observed in recent outbreaks of notable scale, including the 2015 Ebola outbreak in West Africa and the 2016 Zika virus outbreak in Latin America, current as of this publication. During Ebola in particular, themes around social media information and misinformation was demonstrated by YouTube videos that ranged from comedy to detailing conspiracy theories; health behaviour messaging and the role of public health physicians was observed in press releases and communications (e.g. to encourage changes to burial practices in West Africa); and linkages between front line services and public health were made real in preparations and responses to suspect Ebola cases both in West Africa and in high income settings.

During novel outbreaks, public health physicians would thus do well to recall Contagion, and use elements of the movie’s themes together with evidence-based strategies to consider potential responses, inform public health efforts, and engage the public.

REFERENCES

[1]. Soderbergh, S. (Director). (2011). Contagion [Motion picture]. United States: Warner Bros. Pictures.

[2]. Barnes, B. (2011, September 11). Contagion’ Is No. 1 at Weekend Box Office. The New York Times, Arts Beat. http://artsbeat.blogs.nytimes.com/2011/09/11/contagion-is-no-1-at-weekend-box-office (accessed on October 11, 2011).

[3]. CNS News.com. Uh-oh: Scientists say film ‘Contagion’ is for real. http://www.cnsnews.com/news/article/uh-oh-scientists-say-film-contagion-real (accessed on March 1, 2016).

[4]. Scott R, Skellern C. DNA evidence in jury trials: the “CSI effect”. J Law Med. 2010 Dec;18(2):239-62. Retraction in: J Law Med. 2011 Mar;18(3):preceding page 421.

[5]. Holmgren JA, Fordham J. The CSI effect and the Canadian and the Australian Jury. J Forensic Sci. 2011 Jan;56 Suppl 1:S63-71.

[6]. Petersen, W. (Director). (1995). Outbreak [Motion picture]. United States: Warner Bros. Pictures.

[7]. Meirelles, F. (Director). (2008). Blindness [Motion picture]. United States: Rhombus Media.

[8]. The Guardian (2011) “Contagion won’t spread disease prevention” Retrieved July 21, 2014, from http://www.theguardian.com/film/filmblog/2011/oct/24/contagion-spread-disease-prevention

[9]. Access Hollywood (2011). “Steven Soderbergh Acknowledges Washing Hands More After Making ‘Contagion’.” Retrieved July 21, 2014, from http://www.accesshollywood.com/steven-soderbergh-acknowledges-washing-hands-more-since-making-contagion_article_53009

[10]. Acceptable Use Policy. Policy No: 1002. Version 2.1. February 6, 2009. Information and Technology Division, IT Strategic Planning & Architecture. City of Toronto.

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Values such as respect for human rights, human dignity and equality are at the heart of European Union (EU) mission. Yet, even a patchy survey shows that the healthcare system built to assist illegal immigrants does not couple with these concepts since each country gets its own system. Owing to the lack of a shared agenda, across the board improvement perspectives still lie beyond the EU grasp

by Pietro Dionisio

Degree in Political Science, International Relations

Cesare Alfieri School, University of Florence, Italy

Illegal Migrant Status and the Littleness of the European Health System

 

Illegal immigration is hot topic today. Indeed, the future of  Shengen Agreement is in the politicians’ hands now that a flow of exhausted immigrants requiring health assistance crosses the EU borders every day. Is the European healthcare system able to cope with such an unprecedented emergency?

Illegal migrants are at most risk of health problems since, as a result of their financial fragility and illegal status, their rights and privileges are far below those enjoyed by the regular citizens. Under these circumstances, they are denied access to countries’ health assistance system because they are not entitled to the rights granted by national laws. Social benefits for them are usually limited to basic medical assistance in emergency situations, whereas poverty and hardship prevent them from accessing private healthcare.

The current dynamics of external migration to EU incorporate many health risks including epidemic diseases, difficulties related to pregnancy, vulnerability to HIV and AIDS, as well as children’s illnesses and psychological problems.

Some countries in the EU including France, Belgium, Italy and Spain have put systems in place to cope with these issues.

For instance, the Italian government has set up a scheme whereby foreign citizens who are illegally present in Italy are given an “STP” (Temporarily Present Foreigner) six month-valid, though renewable, identification code entailing some benefits. Illegal migrants who cannot afford to fork full ticket expenses out of pocket will only pay a fraction. Otherwise, by signing a “declaration of indigence”, which is valid for six months, they can be exempted from the entire amount duty. The “declaration” entitles them to services such as first level health, emergency and pregnancy services, as well as services for exempted diseases and aging or disabling conditions.

“Aide Médicale de l’État” is the scheme provided by France: one year validity and renewable, it allows undocumented migrants to access health care free of charge.

In the face of this, other countries that do not provide the same health care protection, such as Sweden or Denmark, presently are among the main final destinations of immigrants.

In Sweden, the entitlement of undocumented migrants to health care is highly restricted. However, since July 2013, undocumented adults have the right to subsidized care for conditions requiring urgent medical attention, whereas undocumented children are given the same rights as Swedish residents: a step forward since illegal migrants were previously entitled to unsubsidized emergency care only, except for former asylum seeking children, who had the same rights as Swedish residents.

In Denmark the situation is even worse. In fact, asylum seekers and foreign nationals without legal residence are not covered by the national health insurance system. Only children benefit from the health care service on equal footing with regular residents. Actually, while the “Danish Immigration Service” is tasked with caring for illegal migrants, it only covers pain relief treatments or interventions that cannot be postponed.

The reported country cases above shed some light on the main EU problem, namely the lack of any relevant shared agenda and common operational strategy. Article 35 of the Charter of Fundamental Rights of the European Union leaves the establishment of rules for access to health care to national legislators by stating that “everyone has the right of access to preventive health care and the right to benefit 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”.

What’s more, at country level marked  differences exist in the way regions and municipalities implement existing national legislation with the effect that irregular migrants are not granted equal enjoyment from health care services throughout the country.

In this regard, the local authorities of Stockholm city in Sweden and of Bremen, Cologne, and Frankfurt cities in Germany have chosen a more friendly health policy towards irregular migrants as compared to the rest of either countries. For example, the municipal administrations of Bremen, Cologne and Frankfurt have set up dispensaries for medical consultations to illegal immigrants and basic services as outpatient centers providing free medical examinations without restrictions. The patients are only charged the service cost in proportion to their income if they have one. In case of serious illness, the medical officers may opt for the patient admission to specialist hospitals involved in the project, and/or check whether it would be the case for an asylum grant on health reasons. The structures in question are also collaborating with local NGOs that seek to offer complementary services to health care assistance.

Overall, the fragmented system highlighted here is inconsistent with the main values flaunted by the EU institutions. Expressions such as respect for human dignity and human rights, including the rights of persons belonging to minorities, or equality and human dignity, represent the core values supporting the EU legitimacy. Unfortunately, these concepts risk to lose their integrity when they collide with political and financial interests and a narrow-minded mindset.

All the European member states must find a common solution to the illegal migration issue. Meanwhile, the EU leadership should firmly bear in mind that if Europe lacks the structural strength to host overflowing masses of people, the respect for human rights and equality should never be forgotten.

 

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Conditionalities attached to loans from the World Bank and IMF were among the key negative influences  on health and its social determinants between 1980 and 2000 in many of the more than 75 low- and middle-income countries in which they were applied. Best available evidence suggests that this 'neoliberal epidemics' era is not over. In the future, neoliberalism is likely to reflect the erosion of territorial divisions between core and periphery, or the global North and the global South, in the world economy

by Ted Schrecker, professor of Global Health Policy

and Clare Bambra, professor of Public Health Geography

Durham University, England

‘Neoliberal Epidemics’ in Global Context

 

An aid-funded Canadian team that sought to rebuild Tanzania’s health system on a pittance wrote in 2004 that: ‘The era of structural adjustment may be over, but the effects of earlier damage continue to cast a long shadow’.   The length of that shadow became apparent a decade later, when the Ebola outbreak in Africa in 2014 dramatised the fragile state of national health systems – attributed by commentators writing in The Lancet and Foreign Policy to the damage done by long periods of expenditure restraint mandated by the International Monetary Fund.  (The IMF, predictably, contested these claims.)  The specifics of the Ebola response aside, conditionalities attached to loans from the World Bank and IMF were among the key influences on health and its social determinants between 1980 and 2000 in many of the more than 75 low- and middle-income countries in which they were applied, and the best available evidence is that the era was not over at least circa 2007.

Structural adjustment programmes involved a relatively standard neoliberal package of privatisation, deregulation, reduced subsidies for consumer goods including food, economic restructuring that prioritised export sectors, and what would now be called austerity – demanded in exchange for loans that enabled countries to reschedule their external debts.  At least as early as 1987, a major UNICEF study warned of the destructive human consequences.  Similar consequences are now being experienced in Greece in the context of analogous demands by the ‘troika’ of the IMF, the European Commission and the European Central Bank.  As in the 1980s and the 1990s, primary beneficiaries are commercial banks that hold the country’s debts.  (The ‘debt crisis’ that ushered in the era of structural adjustment became part of the US foreign policy agenda in the early 1980s mainly because of threats to several of the country’s major banks.)

In a book published last year, we used the term ‘neoliberal epidemics’ to describe the spread of overweight and obesity, austerity (expenditure cutbacks), inequality and insecurity in the United States and the United Kingdom – the large, high-income countries that have travelled farthest down the road of neoliberal or ‘market fundamentalist’ policies.  These are epidemics in the sense that they exist on such a scale and have spread so quickly across time and space that if they involved pathogens they would be seen as of epidemic proportions; indeed, references to the epidemic of overweight and obesity are now commonplace.  They are neoliberal in that they are direct consequences of neoliberal economic and social policies.

The example of structural adjustment programmes and their contemporary European analogues shows that in global context, the concept of neoliberal epidemics is even more relevant.  In another example, references to the epidemic of overweight and obesity, now convincingly linked to the neoliberal transformation of food systems and the increasing unaffordability of healthy diets, have become commonplace in the high-income world.  The connection is evident, as well, in many low- and middle-income countries where rapid transitions to a diet that is conducive to obesity have been connected with trade liberalisation and the growth of foreign investors, to the point where one article described a pattern of ‘exporting obesity’ from the United States to Mexico, notably in the form of (subsidised) high-fructose corn syrup for use in fizzy drinks.  Predictably, the prevalence of obesity in the two countries is now comparable.  Neoliberalism is also implicated in the spread of precarious and insecure work, which is increasingly recognised as a social determinant of (ill) health.  One author, Guy Standing, has argued that it has generated a new global class – the precariat – as ‘flexible’ labour market regimes become the price of attracting and retaining foreign investment.  In an especially striking illustration of the consequences, in 2012 The New York Times revealed that not long before a disastrous fire at a Bangladeshi garment factory, Walmart had resisted an initiative to improve fire safety in such factories.

In the future, neoliberal epidemics are likely to reflect the erosion of territorial divisions between core and periphery, or the global North and the global South, in the world economy.  William Robinson, a leader in the emerging field of critical globalisation studies, pointed this out more than a decade ago when he argued the need to move from a ‘territorial’ to a ‘social cartography’  in understanding development.  More recently, social theorist Nancy Fraser has made a similar point, noting not only the spread of austerity programmes to Europe but also phenomena like ‘the terrible impoverishment of the old industrial cities, of the global north, which are starting to look more and more like the periphery’, and the fact that ‘the conditions of working class people in the global north are converging with the conditions of the global south’.  On one estimate, 1.4 million UK workers are on zero-hours contracts, which do not guarantee them even a single hour of work in a given week.  Trends like this help to explain the widening of health inequalities in the UK, such that in the small municipality of Stockton-on-Tees where one of us (TS) lives and works, the 17-year gap in male life expectancy between the most and least deprived neighbourhoods is comparable to the difference in national average male life expectancy between the UK and Senegal.

This analysis is not a counsel of despair, but it does suggest that the success of efforts to fight neoliberal epidemics and reduce health inequalities will depend on blurring boundaries: between the global and local frames of reference, and between public health practice and the politics of health.  This last blurring means a return to the wisdom of Rudolf Virchow, to the effect that ‘medicine is a social science, and politics is nothing else but medicine on a large scale’.  As Martin McKee and colleagues wrote in a 2012 commentary on the failure of austerity policies, ‘Virchow’s words are as relevant today as they ever were’.  Understanding how to translate that insight into political action will require the development of a comparative political science of health inequalities – a critically important project that remains in its infancy.