EU tests the temperature for an active health role

Date: 30/04/1998

Member states are fiercely protective of their national sovereignty in setting public health policy, reports Rory Watson. But illnesses and disease do not stop at EU borders

IF DEATH and taxes are the only two certainties in life, it is not surprising that the EU has an interest in both. The Union's impact on taxation is already apparent. What is less visible is the degree to which its involvement in public health issues has grown. It has always been there.

As far back as 40 years ago, the EU's role in promoting the health and safety of workers was explicitly guaranteed. But it was only with the arrival of the Maastricht Treaty five years ago that the Union was given an opportunity to develop a public health strategy for the first time.

As today's (30 April) meeting of health ministers demonstrates, it is now a clearly defined area of Union involvement. On the ministerial agenda are programmes to tackle rare diseases and pollution-related illnesses, to reduce tobacco consumption, screen the suitability of blood and plasma donors, and cooperate with the US in handling communicable diseases.

While there is no suggestion that the EU will try to usurp member states' role as the providers of health care, there is a growing awareness that the Union does have a part to play. That contribution will be underlined by the televised broadcast of the ministers' first debate on the European Commission's latest attempt to explore public health priorities for the 21st century.

The initiative has been launched by Social Affairs Commissioner Pádraig Flynn, who is keen to prepare the ground for the next public health action plan, to begin in 2000 when several of the eight existing programmes come to an end.

Although his discussion paper was only formally tabled earlier this month, Flynn has been taking the temperature since the beginning of the year to gauge support for a change in approach and a greater emphasis on cooperation between national authorities in meeting these challenges.

“I have been trying to promote a debate at the European level on these huge challenges. Quite simply, they are too big and too complex to be addressed by each member state in isolation,” he told participants at the World Economic Forum in Davos earlier this year. “Moreover, many of the challenges such as demography and cost pressures are common to all and clearly are better addressed in unison. Slowly, I think we are succeeding in promoting the debate.”

The Commissioner has also bounced his ideas off the European Parliament's health intergroup, senior national officials and the German Land of North-Rhine Westphalia, which has traditionally taken a keen interest in EU input on public health policy.

The challenges referred to by Flynn are increasingly evident. In many ways, the health of EU citizens has never been better when measured in terms of life expectancy and the virtual disappearance of the killers of previous centuries: smallpox, cholera and measles.

But just as nature abhors a vacuum, so fresh dangers have appeared. New diseases include avian flu, Ebola haemorrhagic fever and a variant of Creutzfeldt-Jakob Disease. Alongside these, there is the continued presence of AIDS and the resurgence of some old infectious diseases, whose impact increases as populations become more mobile.

Six hundred thousand people still die prematurely every year in the Union, while the lengthening of life expectancy means that, by 2000, some eight million people in the EU will suffer from Alzheimer's disease.

Union enlargement will bring several new dimensions to the public health debate. While EU governments spend, on average, 1,500 ecu per citizen per year on health provision, the figure in central and eastern Europe, despite the greater need, is just 300 ecu.

The enlargement negotiations will also raise such issues as the mutual recognition of diplomas for doctors, nurses and other health professionals, the right of patients to seek treatment in another country, the problem of transmissible diseases and the export of pharmaceuticals from one country to another.

While not totally turning his back on the eight existing public health programmes - which have concentrated on combating cancer, drugs and AIDS, promoting health awareness and monitoring statistics with a minuscule budget of some 45 million ecu a year - Flynn has suggested some new priorities.

These would focus on three main themes: improving public health information, reacting rapidly to health threats and preventing diseases.

One factor which should stimulate the wider debate is the recent BSE crisis, which brought home to people the knock-on health effects throughout the Union of practices in one country.

It was also instrumental in ensuring that the new Amsterdam Treaty gives the Parliament shared legislative power with governments over veterinary and phytosanitary legislation - the only area of public health policy where the Union has the right to pass binding laws.

The altered climate is also reflected in the fact that, as part of the current reorganisation of the Commission, there are now suggestions that the many policies with a public health dimension which are scattered among different departments should be grouped within one directorate-general.

However, despite the Commission's attempts to widen the debate, some health professionals believe the parameters are still too narrow.

“Health is a much wider issue. Most citizens' concerns are not affected by public health policy. We have to look very seriously at the health implications of EU enlargement, the reform of the Common Agricultural Policy, pollution and the impact of transport, for instance,” argues Andrew Hayes, president of the non-governmental European Public Health Alliance. “We need a new philosophy, as health is the touchstone of the sort of Europe we want to see in the 21st century.”

The Commission's attempts to spark off a fundamental reappraisal of the EU's public health policy are being matched in the Parliament. The coincidence is not surprising. Both institutions were very much on the same wavelength when the blueprints were first being drawn up to take advantage of the new opportunities offered by the Maastricht Treaty in the early Nineties.

“The Parliament's environment committee is organising a public hearing in October and we intend to take up the debate which we started post-Maastricht,” says the committee's chairman, UK Socialist Ken Collins. “We are going to review the progress made so far and try to identify our priorities. We should not simply be reacting to events, but should assess where health fits into the panoply of European policy.”

Collins is convinced that a combination of pressures will gradually create an irresistible demand for greater Europe-wide activity on public health. After almost 20 years in the thick of the environmental debate, during which EU participation has moved from the wings to centre stage, he sees obvious parallels.

“Health policy is at the stage environment policy was at in the late Seventies or early Eighties. There is an increasing need to coordinate health policies and this is genuinely popular with citizens, who would like to see public health having a certain evenness across the Union,” he says.

The problems facing the applicant countries in central and eastern Europe, as they struggle to contain diseases such as malaria, tuberculosis and syphilis and provide the standard of medical treatment which people expect when they travel to other member states, are breaking down national health barriers.

For Collins, as for almost every other EU practitioner in the health field, the dividing line between Union involvement and national responsibility is clear.

“The demarcation is that we do not deal in the delivery of health care. That is a matter for member states. But the trans-border aspects of public health are crucial,” he explains.

The debate which Flynn and Collins, in their separate ways, are now promoting, on the EU's contribution to improving public health in the early years of the next century, will inevitably throw more light on how that dividing line is applied.