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Solidarity in a unified Europe
Martin McKeeLondon School of Hygiene and Tropical Medicine, London, UK
Correspondence: e-mail: martin.mckee{at}lshtm.ac.uk
The division of Europe that began in 1945 is now ended. The process that began with the decision by the Hungarian government to allow East Germans, free passage to the west led rapidly to the fall of the Berlin Wall and, two years later, the break up of the Soviet Union. The pace of change was remarkable and, in 2004 eight former eastern bloc countries, including three former Soviet republics, joined the European Union. In 2007 they were joined by two other former communist states, Romania and Bulgaria.1 The post-war division of Europe is now at an end. Or is it? It certainly can seem so, to the casual observer. But Europe is divided in many ways, and not just in geography. Benjamin Disraeli, a 19th century British Prime Minister, noted the presence, in England, of ‘Two nations between whom there is no intercourse and no sympathy; who are as ignorant of each other's habits, thoughts, and feelings, as if they were dwellers in different zones, or inhabitants of different planets ... The rich and the poor.’ 2
Disraeli was writing at a time when the inequalities in European societies were stark. The endless struggle against adversity waged by the poor, every day, of their often short lives is chronicled vividly, in their different ways, by Frederick Engels3 and Charles Dickens.4 The situation now is clearly very different. Europe's citizens emerged from the ruins of the Second World War determined to establish systems of social protection. The details differed but they all had a common goal, to protect one's neighbours and, if disaster struck, oneself, from penury and avoidable death.
This was a remarkable achievement, especially when compared with the United States. By the 1990s, every single European country had achieved universal health care coverage. Today, one in seven Americans is uninsured.5 So how did Europe achieve this?
To answer that question, it is necessary to ask who we are? However, to define who we are, we also have to define who we are not. Our shared experience in the Second World War provided a clear understanding of how, in times of crisis, no matter how wealthy and secure one had been, one could easily end up destitute. Europeans were defined by our shared citizenship. The situation in the United States was entirely different. There, the elephant in the room is race. Death rates from common conditions amenable to timely and effective care are far higher among African–Americans than those of European descent.6 Put simply, if an African–American is diagnosed with diabetes, the best advice a physician could give her is to emigrate to Europe where she will dramatically reduce her risk of dying prematurely.7 This may be the key to the difference. If you are a rich European it is always possible to become poor. If you are a white American you know you will never become black. But how is this relevant to Europe?
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Migration and solidarity |
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Migration is something that Europeans should understand very well. During the 19th century 40 million Europeans emigrated, mostly to North America but also to Australasia, South Africa, and Latin America. Many were what would now be called political refugees while others, to continue with current terminology, were economic migrants. When they reached their destination most were welcomed. The situation is now rather different. While Europeans are still migrating to other parts of the world, Europe has now assumed the historic role of the USA, Latin America, and Australia, as destinations for migrants from elsewhere.
Of course migration to Europe is not new. Ultimately all Europeans are descendents of Africans who migrated into Europe about 50 000 years ago and, more recently, there was large scale migration around the Mediterranean and from Asia in the years following the collapse of the Roman Empire. These waves of migration have long faded from memory, except among researchers in areas such as history, archaeology, and linguistics. Yet more recent migrations have not. Almost a thousand years ago the ancestors of the Roma left northern India for the territory of the Byzantine Empire. At first they were welcomed but, after some years attitudes hardened. Unlike those who had settled in Europe before, their physical features made them recognisable as not being us. As a consequence, they suffered profound discrimination, living on the margins of society.8 In many parts of Europe, Roma continue to be excluded from mainstream employment and are disproportionately represented among the poorest segments of society, suffering worse health than the majority population.9 A report by the European Centre for Roma Rights catalogues in horrifying detail the plight of Roma unable to obtain health care. 10 In some cases, a lack of valid identity documents is used to justify exclusion from coverage by health insurance systems. In others, even individuals with clear evidence of entitlement are turned away. The Decade of Roma Inclusion, now half way through, has led to many improvements but, for many Roma, full participation in a unified Europe is as far away as ever.
There are, however, many more ethnic minorities in Europe. One reason is Europe's ageing population. In many countries, the birth rate is now well below replacement level. Europe needs more young people, to fill the jobs that will be vacated by those who retire and, above all, to take the often low-paid and under-appreciated jobs of caring for this ageing population. There is no realistic prospect that current reproductive trends will change quickly. The only realistic solution is to encourage migration from other parts of the world.
Superficially, this may seem quite easy. Bodies washed up on the beach of southern Spain and scenes of families clutching to rafts in the sea around Malta and the Canary Islands testify to the many people who want to come to Europe. The problem they face is that Europe is seeking migrants with skills.
So what are the consequences of large scale migration for our shared social values? Europeans take pride in their shared values. Yet perhaps this framework of values is more fragile than is realized. The consensus around the European social model, based on the principle of solidarity, delivering universal health care and social protection, is not seen in the United States, a difference that seems to be due, at least in part, from an unwillingness to support those who are viewed as ‘them’, rather than ‘us’. If Europe is to recruit the workers it needs, the most likely sources are Africa, South Asia, and the Middle East. Disraeli talked about two nations in England, but now we have many more. In London's schools, children already speak over 300 languages at home. European societies will inevitably become more diverse, in terms of ethnicity, language, and religion. So far, success in integrating migrants within welfare states has been, at best, mixed.11 Europe still has to resolve the debate about whether the goal should be cultural homogeneity, exemplified by policy in France, or multi-culturalism, as in the UK. Both have advantages and disadvantages but a shared vision on this most fundamental policy goal is long overdue.
The challenges are especially great with religion. The Muslim population of Europe is growing, and will continue to. There is a danger that a combination of forces, some arising from within the majority community who see radical Islam as the enemy within, and some arising within the Muslim community, who see modern, secular society as a threat to their traditional values, will lead to another division of Europe.12 In this case it will not be one divided by a physical wall, as in Berlin, but rather by a cultural barrier that is just as impassable. If this happens, will future generations begin to reassess the European social model, especially when faced with the inevitable financial consequences of ageing populations and technological progress, and decide that perhaps those at the top of the pile are less willing to share it with those at the bottom than they once were, especially when they are visibly different?
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Ageing and solidarity |
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TopMigration and solidarityAgeing and solidarityConclusionAcknowledgementsReferences |
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Ageing is the second way that we risk being divided. So far, Europe has maintained a commitment to inter-generational solidarity. We benefit from the efforts of our parents when we are children and are unable to look after ourselves and we, in turn, contribute to their wellbeing when they are too old to look after themselves. This is a good deal for everyone concerned. Yet terms such as the ‘burden of an ageing population’ are used increasingly frequently by those who forget that one day they will be that aging population.
There can be little doubt that this longstanding social compact has come under unprecedented strain, for many reasons. Most obviously, people are living much longer following retirement. Only a few decades ago, most people could expect to enjoy only a few years of retirement but now they can reasonably expect to live twenty years or more. Changing family structures and patterns of employment also play a role. Children are likely to live far away, making it impossible to provide traditional levels of support. However, the greatest challenge is cost. Once people have left the workforce they are dependent on pensions. For some, these are provided by returns on investments made over a lifetime but others are based on a pay as you go model, where each generation pays for the previous one, in the knowledge that the following generation will pay for them. This works as long as the old age dependency ratio (the number of people above retirement age compared with those of working age) stays the same. The problem is that, this is increasing everywhere, although not to the same extent. Coupled with this, many countries are implementing policies that are, in effect, borrowing from the next generation. This is typified by some models of public-private partnership being used to finance infrastructure, such as the Private Finance Initiative in England.13 Instead of finding the money up front, governments enter into long term, inflexible arrangements with private providers that let them have the facility now but pay for it, and at a very much higher overall price, far in the future. Coupled with pay as you go pensions, it is clear that our children will be paying a great deal more for us than we paid for our parents.
There are, however, things that can be done. Projections by the OECD show how even a small increase in retirement age will substantially limit the increase in the old age dependency ratio.14 Clearly, this also depends on ensuring that older people are sufficiently healthy to stay in work. The compression of morbidity predicted over two decades ago by Fries 15 is occurring.16 In part this reflects a reduction in exposure to certain risk factors, most obviously smoking. However, another important factor is the ability of modern health care to enable people to stay alive with multiple chronic disorders.17 Yet there is still a long way to go. Emerging evidence identifies the critical importance of sustained engagement with life and self-confidence in promoting healthy aging. This has implications for everyone. Those who will soon be retiring must believe in themselves and stay engaged. Those who have many years to go must ensure that older people have the opportunities to do so. At the same time, it is essential to counter policies that involve spending now in the knowledge that someone else will pay tomorrow.
In the same way that increased migration will test how strongly Europe is committed to ethnic solidarity, if we do not act now it will test our children's reserves of intergenerational solidarity.
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Conclusion |
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TopMigration and solidarityAgeing and solidarityConclusionAcknowledgementsReferences |
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I have tried to convey the view that the unification of Europe takes much more than tearing down a wall in Berlin. Europe has benefited enormously from its social model. Yet this model is coming under unprecedented attack from a loose coalition of those who, on ideological grounds, object to the very concept of solidarity and those who see an opportunity to profit from more fragmented systems. When reading about the seemingly endless reports from think tanks, such as the Stockholm network,18 describing the failings of Europe's welfare states and predicting their imminent demise, it is essential to ask ‘who benefits?’ from the messages being conveyed. There have long been siren voices calling for change, arguing that the future cost of health care is unaffordable because of what they describe as the burden of an aging population. It would be surprising if, in due course, they will argue equally stridently that we cannot afford to pay for health care of migrants. Indeed, this is only a small step from some of the messages already being promulgated by even mainstream politicians in some countries. Step by step, the model we have adopted, based on transfers from rich to poor, from young to old, and from healthy to ill, can so easily be eroded. Is this what we in Europe really want? I do not think so but, if I am right, we should speak now before it is too late.
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Acknowledgements |
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TopMigration and solidarityAgeing and solidarityConclusionAcknowledgementsReferences |
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This article is based on a plenary speech given at the 2007 EUPHA conference in Helsinki, Finland. I am grateful to Johan Mackenbach for encouraging me to prepare this article and for his guidance during its preparation.
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References |
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1 McKee M, Balabanova D, Steriu A. A new year, a new era: Romania and Bulgaria join the European Union. Eur J Public Health (2007) 17:119–20.
2 Disraeli B. Sybil. In: Or the Two Nations (1980) Harmandsworth: Penguin.
3 Engels F. The Condition of the Working Class in England (1999) Harmandsworth: Penguin.
4 Dickens C. Hard Times (1994) Harmandsworth: Penguin.
5 Starr Sered S, Fernandopulle R. Uninsured in America: Life and Death in the Land of Opportunity (2005) Berkeley, CA: University of California Press.
6 Kunitz SJ, Pesis-Katz I. Mortality of white Americans, African Americans, and Canadians: the causes and consequences for health of welfare state institutions and policies. Milbank Q. (2005) 83:5–39.[CrossRef][Web of Science][Medline]
7 McKee M, Nolte E. Beyond Euro-trashing. Foreign Policy (2007) Sept/Oct: 10–13.
8 Hajioff S, McKee M. The health of the Roma people: a review of the published literature. J Epidemiol Community Health (2000) 54:864–9.
9 Kósa Z, Széles G, Kardos L, et al. Health of the inhabitants of Roma settlements in Hungary – a comparative health survey. Am J Public Health (2007) 97:853–9.
10 European Roma Rights Centre. Ambulance Not on the Way (2006) Budapest: ERRC.
11 Baldwin-Edwards M. Immigrants and the Welfare State in Europe. International Migration (2004) 18:318–35.
12 Masci D. An uncertain road: Muslims and the future of Europe (2005) Washington DC: Pew Research Center.
13 McKee M, Edwards N, Atun R. Public-Private Partnerships for hospitals. Bull WHO (2006) 84:890–6.[Web of Science][Medline]
14 Oliveira Martins J, Gonand F, Antolin P, et al. (2005) The impact of ageing on demand, factor markets and growth: Economics working papers No.420: Paris: OECD.
15 Fries JF. Measuring and monitoring success in compressing morbidity. Ann Intern Med (2003) 139:455–9.
16 Parker MG, Thorslund M. Health trends in the elderly population: getting better and getting worse. Gerontologist (2007) 47:150–8.
17 Nolte E, McKee M. Does health care save lives? Avoidable mortality revisited (2004) London: Nuffield Trust.
18 Stockholm network. (accessed 19 October 2007). Available at http://www.stockholm-network.org/home.php.
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