At the cost of unprecedented suffering to a significant part of our populations, we now realize in many developed world countries, from a health point of view, we do not have adequate infrastructure and public resources for this era and this crisis. How can we address these challenges in the 21st century from a public health perspective? This is what many countries have had to accept and implement in a few weeks in the face of a pandemic that, as we write, promises to rage across the planet in recurring waves of contamination and mutations of the virus. Let us see how and why.
Health Systems and the Pandemic
First of all, we must reiterate, at the risk of creating dismay, that the position of many public health specialists is consistent on one point: the COVID-19 pandemic should have remained a no more viral and lethal epidemic than seasonal flu, with mild effects on the vast majority of the population, and very serious effects on only a small fraction of it. Instead – if we consider in particular the United States and some European countries – the dismantling, or lack, of public health systems turned this virus into an unprecedented catastrophe and a threat to all our economic systems.
What the experts say is that it would have been relatively easy to curb the pandemic by systematically screening infected people from the very beginning of the first cases; monitoring their movements; targeted quarantine; and mass distribution of masks to the entire population at risk of contamination to further slow down the spread. The privatization of public health systems worthy of the name into medical industries is a serious problem. This does not prevent “heroes” and “saints” from continuing their work in public health, as we have seen vividly in these days.
One outcome of the privatization of healthcare is governments failing to listen to warnings from the World Health Organization (WHO) about wildlife markets, such as the Huanan Market in Wuhan. It is not a question of giving ex post factum lessons to anyone, but of understanding our mistakes in order to act as intelligently as possible in the future.
Preventing events like a pandemic is not profitable in the short term. Hence no provisions were made for masks or tests to be carried out massively. We have reduced hospital capacity in the name of the ideology of dismantling public services, which is now showing itself for what it is: an ideology that kills. Having never adhered to this ideology, and strengthened by the experience of the SARS epidemic in 2002, countries such as South Korea and Taiwan have put in place an extremely effective prevention system: systematic screening and tracking, use of quarantine, and enabling the collaboration of a well-informed and educated population, getting them to wear masks. No confinement. The economic damage is negligible.
Instead of systematic screening, Western governments have adopted an ancient strategy, that of confinement, in the face of a small fraction of infected people, and an even smaller part of them that could have serious complications. But however small it may be, this fraction is even greater than the current care capacity of our hospitals.
Having no other strategy, it is clear that doing nothing would amount to condemning hundreds of thousands of citizens to death, as shown by the projections circulating within the epidemiological community, including those of Imperial College London. Although I consider some aspects of this document to be questionable, it has the merit of making it clear that inaction is simply criminal. It was this perspective that prompted Emmanuel Macron in France and Boris Johnson in the United Kingdom to abandon their initial strategy of “herd immunization” and “wake up” the Trump administration. But too late: these countries are now paying a heavy price for their delay in taking appropriate action.
The return of the welfare state
The partial isolation of Europe has revived the idea that capitalism is certainly a very fragile system, and so the welfare state is back in fashion. In fact, the flaw in our economic system now revealed by the pandemic is unfortunately simple: if an infected person is able to infect many more within a few days and if the disease has a significant mortality rate, as in the case of COVID-19, no economy can survive without a strong and adequate public health system.
Everyone, regardless of their socio-economic status from workers to our leaders and politicians will eventually contract the virus, sooner or later infecting their neighbors. It is impossible to maintain the fiction of individualism implicit in the neoliberal economy and in the policies of dismantling public service that have accompanied it for 40 years: the negatives brought on by the virus radically challenge the idea of a complex system modeled on the voluntarism of “atomized” entrepreneurs.
The health of everyone depends on the health of each individual. We are all connected in a relationship of interdependence. This pandemic is by no means the last “great plague” that will not return for another century. On the contrary, global warming promises the multiplication of tropical pandemics, as the World Bank and the Intergovernmental Panel on Climate Change (IPCC) have been saying for years. And there will be other coronaviruses.
Without an efficient public health service to treat everyone there can be no enduring production system during a coronavirus epidemic. And this is likely to remain so for decades. The appeal launched on March 12 by the Mouvement des entreprises de France (Medef) – the French employers’ union – to “make the production system more competitive” betrays a profound misunderstanding about the pandemic.
How to get out of isolation?
If healthcare workers fall ill, there is a risk of the collapse of the hospital system, as seems to have happened in Italy in Bergamo, Brescia and, to a lesser extent, in Milan. It is therefore necessary for the state to manage distribution of anti- or retro-viral drugs, so that the burden on hospital systems everywhere on the verge of collapse can be relieved quickly. And, it is to be hoped that the citizens of all countries finally show a sense of responsibility.
In order for confinement to be rigorous, together with the well-known basic personal hygiene, everyone must understand the meaning and usefulness of confinement. Confinement effectively slows down the spread of the virus and – let us repeat – in the absence of a screening system, it remains the least negative strategy in the short term. However, if we stop there, the screening itself becomes pointless: if we leave confinement, let us say, in a month’s time, the virus will still be circulating and will cause the same deaths as it would have caused today in the absence of containment.
To wait, through isolation, for the population to immunize itself – more or less, the same strategy initially proposed by Boris Johnson, but “at home” – would require months of confinement. To understand this, it is sufficient to return to the essential parameter of a pandemic, R0, the “basic reproduction number,” i.e. the average number of secondary infections produced by each infected individual. As long as R0 is greater than 1, i.e. as long as an infected individual can infect more than one person, the number of infected people increases exponentially. If we leave containment without further delay before R0 falls below 1, we will have those hundreds of thousands of deaths that the pandemic threatened to cause from the beginning.
However, in order for collective immunization to bring R0 below 1, it is necessary to immunize about 50% of the population, which – given the average incubation time (5 days) – would probably require more than 5 months confinement given there are now more than one million infected. This is an unsustainable option in economic, social and psychological terms. It is the entire production system of our countries that would collapse, starting from our banking system, which is extremely fragile.
Not to mention the fact that, at the moment, the poorest among us – refugees, the homeless, etc. – die not because of the virus, but because they cannot survive unless society is active and looking after them. Not forgetting also that we have no guarantee that our food supply chain can withstand the shock of quarantine for such a long time: do we want to force middle/low income workers to put their lives at risk in order to continue, for example, to transport food for managers who remain quietly at home or on their farm in the countryside?
It is therefore necessary to organize a “first” release from containment, in a few weeks at the latest. Taking this risk collectively only makes sense, however, on one condition: to apply, this time, the strategy adopted in South Korea and Taiwan with the utmost rigor. The time we are gaining by locking ourselves up at home should serve to:
– Bring R0 (which was probably about 3 at the beginning of the infection) as close to 1 as possible;
– Encourage the conversion of certain sectors of the economy to mass produce the lung ventilators that intensive therapy needs to save lives;
– Assist local manufacturers to produce screening equipment and materials immediately, while the necessary systems are put in place within the next few weeks. At the moment there are two enzymes in particular, whose stocks are very insufficient, and therefore limit our ability to carry out screening;
– Increase production of personal protective equipment, essential to stop the spread of the virus when we leave our home.
If we end our collective confinement when our detection equipment is not ready or the masks are missing, we will again run the risk of a tragedy. Unfortunately, it is impossible to measure R0 today. Therefore, we must wait until we are organized for screening and plan an orderly exit from quarantine as quickly as possible.
What will happen then? Those who are “released” must undergo systematic screening and wear masks for several weeks. Otherwise, exit from confinement will have a worse outcome than at the beginning of the pandemic. Those who are still positive will then be quarantined, along with family and those around them. Others may go to work or continue isolating. Testing will have to continue throughout June/July/August to make sure that the virus has been eradicated by the northern hemisphere autumn.
Health as a global common good
The pandemic is forcing us to understand that there is no truly viable capitalism without a strong system of public services and to completely rethink the way we produce and consume, because this pandemic will not be the last. Deforestation – as with the wildlife markets at Wuhan – exposes us to animals with unknown viruses. The thawing of the permafrost threatens to spread dangerous epidemics, such as the “Spanish influenza” of 1918/19 and anthrax. Intensive breeding also facilitates the spread of epidemics.
In the short term, we will have to nationalize unsustainable companies and, perhaps, some banks. But very soon we will have to learn the lessons of this painful time: reconvert production, regulate financial markets; rethink accounting standards to improve the resilience of our production systems; set carbon and health taxes; launch a major recovery plan for green industrialization and massive conversion to renewable energy.
The pandemic invites us to radically transform our social relations. Today capitalism knows “the price of everything and the value of nothing,” to quote an effective formula by Oscar Wilde. We must understand that the real sources of value are our human relations and those with the environment. To privatize them, we destroy them and ruin our societies, while putting human lives at risk. We are not isolated monads, connected only by an abstract price system, but beings of flesh interdependent on each other and with our environment. That is what we must learn again. The health of each individual concerns everyone. Even for the most privileged, the privatization of health systems is an irrational option: they cannot remain totally separate from others; disease will always reach them. Health is a global common good and must be managed as such.
The “common goods,” as the American economist Elinor Ostrom defined them in particular, open a third space between the market and the state, between the private and the public. They can guide us into a more resilient world, capable of withstanding shocks like the one caused by this pandemic.
Health, for example, must be treated as a matter of collective concern, with articulated and stratified modes of intervention. At the local level, for example, communities can organize themselves to react quickly, by isolating clusters of people infected with COVID-19. At the state level, a robust public hospital service is needed. At the international level, WHO recommendations to combat an epidemic situation must become binding. Few countries have followed the WHO recommendations before and during the crisis. We are more willing to listen to the “advice” of the International Monetary Fund (IMF) than that of the WHO. The current scenario proves us wrong.
Recently we have witnessed the emergence of several “common goods”: like those scientists who, outside of any public or private platform, have spontaneously coordinated through the OpenCOVID19 initiative to share information on best practice in virus screening.
But health is just one example: the environment, education, culture and biodiversity are also global common goods. We need to imagine institutions that allow us to value them, to recognize our interdependencies and make our societies resilient.
Some such organizations already exist. The Drugs for Neglected Disease Initiative (DNDI) is an excellent example. An organization created by some French doctors 15 years ago for the procurement of drugs for rare or forgotten diseases: a collaborative network of third parties, in which the private sector, the public sector and NGOs cooperate, which can do what neither the private pharmaceutical sector, nor states, nor civil society can do alone.
On an individual level, then, we discover the fear of scarcity of goods. Can this be a positive aspect in this crisis? It frees us from consumerist narcissism, from “I want everything and now.” It brings us back to the essential, to what really matters: the quality of human relationships, solidarity. It also reminds us how important nature is for our mental and physical health. Those who live locked up in 15 square meters in Paris or Milan know this very well. The rationing imposed on some products reminds us how resources are limited.
Welcome to a limited world! For years, billions spent on marketing have made us think of our planet as a giant supermarket, where everything is available to us indefinitely. Now we abruptly feel the sense of deprivation. It is very difficult for some, but it can be an opportunity to save money.
On the other hand, even a certain “collapsological” romanticism will quickly be mitigated by the concrete perception of what the brutal economic difficulties imply in the current situation: unemployment, bankruptcy, broken lives, death, daily suffering of those in whom the virus will leave traces for a lifetime.
In the wake of Pope Francis’ encyclical Laudato Si’, we want to hope that this pandemic is an opportunity to direct our lives and institutions toward a happy sobriety and respect for the finitude of our world. The moment is decisive: we can fear what Naomi Klein called the “The Shock Doctrine.” Some governments must not, on the pretext of supporting business, further weaken workers’ rights; or, to further strengthen police surveillance, permanently reduce personal freedoms.
In the meantime, how do you save the economy?
Let us try to envisage some possible economic policy choices in this situation:
1) Injecting liquidity into the real economy. Some German economists predict a 9% drop in GDP in Germany in 2020. The figure is reasonable and there are few reasons to expect that things might be different in France and even worse in Italy, the U.K., Switzerland and the Netherlands. This should induce Germany and the Netherlands – the proponents of the belief that greater budgetary austerity adjusts the economy, while basic macro-economics shows the opposite – to revise their dogmas if the escalation of victims in their respective countries is still not enough to open their eyes.
In the United States, Donald Trump and his Treasury Secretary Steven Mnuchin propose to Congress to distribute a check for $1,200 to each U.S. citizen. It is either “helicopter money” or, assuming central banks deal with this monetary problem, “a quantitative easing for people.” These are measures that, possibly, should have been taken already in 2009. We can also see this in the Trump administration’s plan of a universal minimum income for all. This is a proposal that has been made by many for a long time.
In Europe, suspending the rules of the Stability Pact, issuing “corona bonds” or activating loans from the European Stability Mechanism are all essential measures.
2) Create jobs. However, the initiatives just mentioned are insufficient. It is necessary to understand that the Western production system is, or will be, partially blocked. Unlike the stock market crash of 1929 and the sub-prime mortgage crisis of 2008, this new crisis is primarily affecting the real economy. In most companies, 30% of employees prevented from working would not correspond to 30% less production, but to zero production. If a company in a value chain stops producing, the whole chain is interrupted. We are finding that just-in-time supply chains (i.e. without stocks) make us extremely fragile. We are thinking of food production and its supply chain. Of course, some governments are prepared to send the police or the army to force workers to risk their lives so as not to interrupt supply chains. The workers at the bottom of the production and supply chain are the first exposed and the first sacrificed. A huge admission of impotence!
In most of the countries that are forced into containment, the production system is therefore partially blocked, or soon will be. Global value chains are slowing down and some will be cut. Work is involuntarily “on strike.” We are not only faced with a Keynesian shortage of demand – because those who have cash cannot spend it, since they have to stay at home – but also with a supply crisis. This pandemic introduces us, therefore, into a new and unprecedented type of crisis, in which the decline in demand and the decline in supply are combined. In this context, the injection of liquidity is both necessary and insufficient. To be satisfied with this would be to give crutches to someone who has just lost his legs!
Only the state, therefore, can create new jobs capable of absorbing the mass of employees who, when they finally leave home, will discover that they have lost their jobs. The idea of the state as employer of last resort is not new: it has been studied very seriously by the British economist Tony Atkinson. Of course, in order for that to make sense, we need to think seriously about the kind of industries that we want to help get out of the tunnel. This discussion will vary from country to country, in the light of the specific characteristics of their economic framework.
It is therefore legitimate and indispensable that developed nations, today as yesterday, use deficit expenditure to finance the effort to rebuild the production system that will be necessary at the end of this long birth; and they will have to do so in an acute and selective way, favoring this or that sector. Obviously, their public debt will increase. Let us remember that, during the Second World War, the public deficit of the United States reached 20% of GDP for several consecutive years. But the deficit would be much greater in the absence of huge spending by the state to save the economy.
We can also note that the structural adjustment plan imposed on Greece a few years ago was absolutely useless: the Athens government debt to GDP ratio reached the same levels as in 2010 in 2019. In other words, austerity kills – we can see it with our own eyes right now, in our resuscitation wards – but it does not solve any macroeconomic problem.
Rebuilding and saving democracy
At this point, a possible mistake would be to appreciate the effectiveness of authoritarianism as a solution. “What if our democracies are poorly prepared? Too slow? Blocked by individual freedoms?” This refrain resonated even before the pandemic. If we consider China, the situation is certainly improving, but the epidemic has not yet been defeated, not even in Wuhan. On the other hand, it is true that two hospitals were built in Beijing in a few days and that the Chinese government is not in the hands of the financial lobby, but, in order to reap the benefits of these two points in favor, should we perhaps give up democracy?
Once containment has occurred in a controlled manner, another dangerous trap would be to simply restore yesterday’s economic model and content ourselves with marginally improving our healthcare system to cope with the next pandemic. It is urgent to understand that the COVID-19 pandemic is not only not a so-called “black swan” – it was perfectly predictable, although it was not foreseen at all by the omniscient financial markets – but it is not even an “exogenous shock.” It is one of the inevitable consequences of the anthropocentric consensus abroad in the world at present. The destruction of the environment that our extractionist economy has exerted for over a century has a common root with this pandemic: we have become the dominant species on earth, and therefore we are able to break the food chains of all other animals, but we are also the best vehicle for pathogens.
In terms of biological evolution, it is much more effective for a virus to infect humans than the Arctic reindeer, already endangered by global warming. And this will be increasingly so, because the ecological crisis will decimate other living species. Above all, the destruction of biodiversity that we have been engaged in for some time will encourage the spread of viruses. Today, many people are aware of this: the ecological crisis guarantees us recurring pandemics. To content ourselves with having masks and enzymes for the foreseeable future would be tantamount to treating only the symptom. The evil is much deeper, and it is its root that must be treated. The economic reconstruction that we will have to carry out after coming out of the tunnel will be the unexpected opportunity to carry out the transformations that, even yesterday, seemed inconceivable to those who continue to look at the future through the rear-view mirror of financial globalization. We need green re-industrialization, accompanied by the re-localization of all our human activities.
But, for the time being, and in order to speed up the end of the health crisis, it is necessary to do what is possible, and therefore to continue our efforts to shield and protect the population.
. Cfr P. Baker – E. Sullivan, “U.S. Virus Plan Anticipates 18-Month Pandemic and Widespread Shortages” in New York Times, March 17, 2020.
. Cfr J.-D. Michel, “COVID-19: fin de partie?!” (https://bit.ly/3996Evs), March 18, 2020; T. Pueyo, “Coronavirus: The Hammer and the Dance. What the Next 18 Months Can Look Like, if Leaders Buy Us Time” (https://bit.ly/3bjAA9K), March 19, 2020.
. As early as 1347 Pierre de Damouzy, doctor to Margaret of France, Countess of Flanders, recommended confinement to the inhabitants of Rheims to escape the Black Plague. See Y. Renouard, “La Peste noire de 1348-1350” in Revue de Paris, March 1950, 109.
. Cfr N. M. Ferguson – D. Laydon et Al., “Impact of non-pharmaceutical interventions (NPIs) to reduce COVID-19 mortality and healthcare demand” (https://doi.org/10.25561/77482), London, Imperial College, March 16, 2020.
. It is well known that the first temptation of the Johnson government was to launch the UK into a collective immunisation experiment. The French government was also tempted by this “solution,” albeit in a less explicit way. On this subject, see T. Vey, “La France mise sur l’immunité de groupe pour arrêter le coronavirus” in Sciences, March 13, 2020.
. This is reverse transcriptase (AMV or MMLV) and Taq (or Pfu) which amplifies the chemical reaction, allowing the presence of COVID-19 to be identified. These are the two enzymes that several laboratories are trying to produce continuously.
. “Low-cost & Open-Source COVID19 Detection kits”, cfr https://app.jogl.io/project/118 and also the hashtag on Twitter: #OpenCOVID19
. Collapsology is a multidisciplinary discourse interested in the collapse of our civilization. It starts from the idea that human actions have a lasting and negative impact on the planet. It is based on scientific data, but also on intuition, so sometimes it is accused of not being a real science, but rather a movement.
. Cfr J. Duquesne, “Coronavirus: ‘La disparition du monde sauvage facilite les épidémies’”, interview with Serge Morand, researcher at Cnrs-Cirad, in Marianne, March 17, 2020.