"Faccio del mio meglio per lasciare il mondo un po' migliore di come l'ho trovato" – "I am doing my best to leave the world a little better than I found it" – "Hago lo que de mi dependa para dejar el mundo un poco mejor"
I set up the nativity scene again this year with the same plaster figurines I used to set it up as a child. When I placed the Child ‘wrapped in swaddling clothes, lying in a manger’, I felt cold, the cold of Humanity overwhelmed by hatred and the violence of power and money. The cold of war, of all wars. The cold of Nature ravaged and plundered. The cold of suffering. Then I covered the Child with a blanket of solidarity with his land and his people, today however a symbol of solidarity with all suffering humanity. That Child born poor in Palestine yesterday as today, asks us for peace and justice.
Peace for humanity, Peace with Nature, Peace in our hearts.
As I have repeatedly emphasized, including in my most recent public speech at the event organised in Rome by the Independent Medical-Scientific Commission, the main reason for not trusting the WHO – in particular with regard to the indications for pandemic management – is the ‘capture’ of that organization by private actors and interests, through complex but well-designed mechanisms, according to a ‘multi stakeholder’ approach, which insists on the involvement of private actors in the governance of public health and, more generally, of global policies.
Under the impetus of Big Pharma and closely linked philanthrocapitalists, for years we have witnessed a growing trend in the WHO, towards a commodified and centralized approach to responding to epidemics, which seems to have lost sight of any emphasis on the determinants of health, primary care and community participation that characterized the golden years of that organization.
Since the 1980s, WHO’s regular budget (made up of compulsory contributions from member states) has been frozen; by now, the organization’s priorities and functioning are largely determined by the objectives to which public and private actors link their voluntary contributions. Even if these are still largely of governmental or intergovernmental origin, and thus made up of public funds, they nevertheless constitute one of the main, visible and quantifiable instruments of ‘capture’ of the WHO by a few private entities, first and foremost the Bill and Melinda Gates Foundation, second only to the United States of America in terms of WHO funding. The other instruments of ‘capture’ are less visible, but systemic: control of research, influence over human resources, control of the media, support for multi-stakeholder initiatives that marginalize the WHO, lobbying at all levels; not to mention less visible corrupt dynamics.
Now the WHO seems very anxious to ensure that the next World Health Assembly (27 May – 1 June) approves a new ‘pandemic treaty’ and a package of amendments to the existing International Health Regulations (IHR 2005), without the final version of the texts to be approved being available yet. This alone breaks the binding rules set out in the IHR 2005, which states in Article 55 that “The text of any proposed amendment shall be communicated to all States Parties by the Director-General at least four months before the Health Assembly at which it is proposed for consideration.“
Even to think of passing any international agreement without having submitted it to the States Parties in due time is at least heresy in the context of international proceedings. I remember how at practically every WHO meeting the delegates protested at the poor advance notice with which certain documents were circulated. And these were often technical documents of limited relevance when compared to the ones that are the subject of this analysis!
The amended text of the IHR only appeared on the web on 17 April (A/WGIHR/8 ), for the first time since 6 February 2023, after fourteen months of negotiations behind essentially closed doors. The latest draft of the pandemic treaty circulated on 22 April (A/INB/9/3 Rev.1). In both cases, it would appear that many of the critical points we had highlighted with the CMSI in October have been revised. Nevertheless, a careful analysis of the new versions of the documents still suggests the inappropriateness of their hasty approval; there is no reason why they should be approved at the next World Assembly, other than the quest for political visibility of a ‘historic event’ and the likely pressure of different interests.
Thus, the first reason to reject both instruments is precisely that pressure exerted on governments and public opinion for their hasty approval in the face of the persistent lack of consensus among the negotiators and the poor definition of several aspects, in effect postponed to future decisions once the treaty has been approved (‘the cat in a hurry makes the kitten blind’, goes an old Italian saying).
The pandemic Treaty
It may be worth recalling that the proposal for a pandemic treaty did not come from the WHO secretariat or its Director-General, but was first put forward by the President of the European Commission, Charles Michel, in 2020 and incorporated in the subsequent declaration of the leaders of the Group of 7 on 19 February 2021, and finally translated into the EU Council’s commitment to work on an international pandemic treaty within the framework of the WHO.
Like us, several authors have long insisted on its futility in the absence of a legal vacuum to justify it. In fact, there is the 2005 IHR, which is an equally binding instrument, the refinement of which could be justified if based on an impartial analysis of the evidence, point by point, of what has not worked so far (but the current process follows another logic and in any case the time is not ripe).
The Treaty would be an entirely new instrument, with complex implementation: with the establishment of new and costly governing bodies (Conference of the Parties, COP) and subsidiary bodies (Art. 21); an increase in bureaucracy, functions and costs of the WHO itself, which would function as a secretariat (Art. 24 ), with new financial mechanisms, all to be defined later (art. 20); a repeated call for the involvement of multiple stakeholders, which it is not difficult to identify mainly in industry, not least because of the Treaty text’s insistence on pandemic products and their development, production and distribution.
Dubbed as ‘scientific, health and pandemic literacy’ and access to ‘transparent, accurate, science- and evidence-based information’ to be reinforced by the Parties (Art. 18), there may still be a desire to censor any expression of dissent or evidence that challenges the official narrative.
But among the negotiators, these issues seem to be of no concern. Rather, the main controversies still revolve around the issue of equity in the distribution of costs and benefits between high-income and poorer countries. Particularly with regard to access to pathogens isolated in countries; access to pandemic products, such as vaccines produced from the genetic sequences of those pathogens; the equitable distribution not only of pandemic tests, treatments and vaccines, but also of the means to produce them, and hence the funding. But the treatment of some of those controversial issues – in particular the modalities for the functioning of a new WHO system for access to pathogens and the benefits derived from them (Pathogen Access and Benefit-Sharing System, PABS) – is postponed until after the approval of the treaty (to 2026) (Art. 12). Similarly, for the definition of the operational modalities of the One Health approach, it is postponed to the elaboration of an instrument that is linked to the requirements of the IHR and should become operational in 2026 (Art. 5).
In order to dispel the doubts, raised by several parties, that the Treaty was intended to take health sovereignty away from states and give it to the WHO, the negotiators took care to include the phrase in the text: “Nothing in the WHO Pandemic Agreement shall be interpreted as providing the WHO Secretariat, including the WHO Director-General, any authority to direct, order, alter or otherwise prescribe the national and/or domestic laws, as appropriate, or policies of any Party, or to mandate or otherwise impose any requirements that Parties take specific actions, such as ban or accept travellers, impose vaccination mandates or therapeutic or diagnostic measures or implement lockdowns“(art. 24).
In fact, instead of strengthening the WHO – which instead retains responsibility for IHR implementation – the Treaty would increase the fragmentation of pandemic preparedness and response in an already highly fragmented global health governance framework.
The amendments to the IHR 2005
But let us come to the reasons why the current proposed amendments to the 2005 CSRs should also be rejected. The first reason is still the unjustifiable haste to approve an instrument that is still under discussion, and the already mentioned intention to present it through a subterfuge in violation of the already mentioned rule of those same Regulations that requires its presentation four months in advance (Art. 55).
Even in this case, the passages that had caused most concern were removed or modified with the probable intention of making them more digestible to the most critical observers. For example, the amendment deleting the ‘non-binding‘ was removed to make the implementation of WHO recommendations mandatory (a contradiction in terms, moreover) (Art. 1). Similarly, the outrageous amendment that sought to delete the reference to ‘full respect for the dignity, human rights and fundamental freedoms of persons‘ from the principles, adding instead the reference to a shared duty of ‘equity and solidarity between States‘ (Art. 3), was deleted. It is worth remembering that for the Italian Republic, solidarity is an ‘unbreakable duty‘ (Art. 2 of the Constitution).
Among our comments on the old draft, we pointed out the danger of replacing ‘intergovernmental organizations‘ among the recipients of WHO information with a more generic ‘international organizations’, justifying our objection with the generic nature of the term that could include private organizations (global philanthropies, international NGOs, public-private organizations), which are neither signatories nor directly subject to the IHR. Unfortunately, the concern remains: ‘intergovernmental organizations‘ has been replaced with ‘international bodies‘, which equally lends itself to various interpretations, again with a view to the deleterious multistakeholderism that some would like to see as a new form of global governance.
The amendments to Article 13, which provided for stricter conditions for the ceding of sovereignty by member states, have also been largely removed. However, what was a ‘should‘ is still amended into a ‘shall‘ and thus into the obligation of Member States to provide, at the request of the WHO, ‘support for response activities coordinated by the WHO‘ and this ‘to the maximum extent possible within the means and resources at their disposal‘ (para. 5, Art. 13). This aspect is taken up again a little later (para.7, Art.13) where it recalls the ‘duty‘ of States Parties, at the request of other States Parties or the WHO, to ‘cooperate with each other and support WHO-coordinated response activities‘ ‘to the maximum extent possible within the national laws and available resources.“
Much attenuated, but not disappeared (now in Annex 1) are the calls for strengthening at different levels (national, intermediate and local) the capacities of States Parties including to “counter misinformation and disinformation“.
Facilitating access to ‘health commodities’ (the Treaty speaks of ‘pandemic’ commodities, but IHRs were created to deal with all kinds of health emergencies – including, for example, those resulting from conflict or nuclear disasters – and so the term used is necessarily more inclusive) is included in several places in the draft amendments. Such access – which then means facilitating the development, purchase and distribution of products – should provide for mechanisms coordinated by the WHO (Art. 44). But we know, from the experience of the Covid 19 pandemic, how that role has been entirely secondary, with mechanisms (e.g. COVAX) directed by public-private organization such as the GAVI Alliance and the CEPI, which in turn are strongly influenced by the commercial sector and the known philanthrocapitalists.
Finally, with regard to financial support for health emergency preparedness and response activities, an articulated amendment indicates the duty of States Parties to mobilize resources also through ‘existing and future bilateral, sub-regional, regional and multilateral funding mechanisms‘; in particular ‘through coordination and/or funding mechanisms that may be established in future International Agreements related to pandemic prevention, preparedness and response‘ (Art. 44). This is in fact the link to the pandemic treaty, and to financial mechanisms whose definition has been postponed until after the treaty’s approval.
So why the rush? Better to stop and think. On the other hand, it is not the binding instruments already available – in particular the IHR 2005 – that have not worked in dealing with the Covid 19 pandemic. Rather, the rules that the IHR enshrine have not been respected and the unwritten rules of geopolitical and private interests at all levels of the global system have prevailed.
With Dominique Bénard, we can now proudly announce the publishing of our book of “Dialogues on Scouting”!
The idea of the book was born during a hike in the Chablais Alps, near where Dominique lives in the French Alps. We discussed the limited reference to the Scout Method in pedagogy books and the relative lack of knowledge of and interaction with other pedagogical methods in Scouting. Starting from that conversation and further reflections on the organizational setting of Scouting and how organizations can better serve their mission and the values on which they were established, we engaged in a written dialogue about our Scouting experience as well as its impact on our personal and professional development. We later decided to organize these reflections in a book.
More than a thousand of Italian health professionals have signed up to the moratorium promoted by the associations of the Sustainability and Health Network (RSS) – of which the association saluteglobale.it, to which I belong, is also a member – calling for a halt to anti-Covid vaccination for children. The RSS appeal follows similar appeals by 93 Israeli doctors and 40 researchers in the UK.
In an interview published on 26 May I explained to ilFattoQuotidiano.it why we should not proceed with the anti-Covid-19 vaccination of children. I recalled how in caring for the people of Nicaragua – where I was a volunteer in international cooperation – I was also involved in vaccination campaigns (see photo) and how later as a Unicef official I promoted childhood vaccinations with that organisation. So any suspicion that I am generically a ‘no-vaxer’ must be dispelled immediately.
The same applies for the Sustainability and Health Network. More than no-vax, we are interested in examining the main public health issues with scientific rigour: if anything, we are Info-vax on vaccines.
We call for an open and free scientific debate, which is currently repressed. We are faced with an attitude that is dogmatic and one-sided, with much science for various reasons (Narcissism? Convenience? Career?) appearing to be associated in different ways with politics (and perhaps not only with politics, given the multiple conflicts of interest that emerge if one examines the scientific publications regarding vaccine trials).
Instead, we should take the opportunity, as Edgar Morin tells us, “to understand that science does not have a repertoire of absolute truths” and that “controversies, far from being anomalies, are necessary for the progress of science”.
The RSS and the signatories of the Moratorium call for children not to be vaccinated for at least three reasons:
– children are at minimal risk of Covid, from 0 to 18 years of age the risk to the very young is negligible. Data from the Istituto Superiore di Sanità also show this.
– We also know that the vaccine protects from disease those who receive it, and reduces but does not prevent infection and the possibility of infecting others.
– Children are not a significant source of contagion for adults, the reverse is in fact true.
There are many unknowns about Covid vaccines. While vaccination of high-risk groups can be justified, mass vaccination, especially in children, cannot. The risk of contracting Covid19 in children is decidedly reduced, as the epidemic curves show us. Instead, there are unknown risks, in the long term or on a large scale, from inoculating the rapidly developing organism of a child with transgenic products (which, moreover, were introduced onto the market without having completed phase 3 trials). The precautionary principle is more important than ever in childhood.
Two handcrafted nativity scenes. One is made of cut out and coloured tin, from Mexico, the other is carved in wood, from Rwanda. Both crafted by children’s hands, with the flowers I picked today to adorn them. They remind us of the true spirit and message of the Holy Christmas of Christianity: simplicity, essentiality, solidarity expressing love for humanity – not generic, but concrete, daily, expressed in each person – respect for Mother Earth. The fundamental ingredients of our salvation. And they are universal, they do not belong only to the Christian Christmas, they are the values of rebirth in any culture.
The Agenda 2030 signed by the Heads of State and Government in 2015 set out 17 indivisible and universal Sustainable Development Goals (SDGs) and 169 targets. Among others the Agenda 2030 proposes to achieve “sustainable, inclusive and sustained growth” (SDG 8), in fact an oxymoron due to the “limits of growth” in a finite ecosystem.
The SDG 3, “Ensuring a healthy life and promoting well-being for all at all ages”, included among others the target “3.8: achieving universal health coverage”.
Besides representing a substantial regression from the original WHO’s Primary Health Care (PHC) strategy, which addressed among others the social and economic determinants of health, the UHC target and the SDG3 are deemed to be unattainable due to the constant increase in demand on the one side and inappropriate offer of health services on the other, both largely determined by factors outside the health sector and linked to the present hegemonic unsustainable growth-defined development model.
Focusing on the health care model and the generation of its human resources, we highlight how both remained mostly anchored to standardized and, today, globalized biomedical hospital-centric models, which are inadequate to meet populations’ health needs and expectations.
We then suggest the need for a paradigmatic shift in the health and social care organization (toward a human rights and social determinants approach, home- community-based care, integrated-holistic approaches, patients’ empowerment, etc.) and the health workers’ educational model (linking it to the specific characteristics of local contexts in terms of needs and resources, and to a new ethical framework). Both are pillars of the transformation of health systems toward a post-growth society.
With the association Saluteglobale.it we are following the epidemic of Covid-19 in Italy and have published articles and viewpoints on the issue. The title of this post refers to an article that we recently published on the Journal of Global Health.
Below a few highlights. The article is available to download here (open access).
During the COVID-19 pandemic, the Italian Na- tional Healthcare Service is proving the importance of providing Universal Health Coverage (UHC), and – at the same time – the consequences of years of definancing and privatization, fragmentation and lack of human resources.
UHC is essential to build a resilient and more equitable healthcare system, through improving health security, increasing access to essential health services and overcoming health care inequities. Moreover, granting the right to healthcare services, social security and financial benefits to the most fragile, as migrants, is a duty of a solidary society, as the Italian Constitution affirms. The COVID-19 pandemic urges a comprehensive and inclusive UHC for individual and societies around the world.
Essential quality health services must be provided to the entire population even more during exceptional events. The COVID-19 pandemic confirms the necessity of a comprehensive and inclu- sive UHC for individual and collective health security. Definancing, fragmenting and privatizing weaken National health systems and expose them to severe crisis in case of emergency. Governments should rather consider higher investments aimed at strengthening the community health services, epidemiological surveillance and emergency preparedness. This requires consistent management choices and a strong po- litical commitment with a vision of a more sustainable system and resilient society.
One of the most debated aspects in the fight against the current Covid-19 epidemics is the development of a vaccine.
Through the media the public is repeatedly led to think that only the vaccine will be the solution and only when a vaccine will be available there will be a solution.
A position that justifies a frenetic rush toward the development of a vaccine (with the risk of enormous public investments, but private returns).
However, there are at least two aspects that are not taken seriously into consideration:
1. Information about the intimate immunologic response to Sars-Cov-2 virus (the etiologic agent of Covid-19) is still very limited and does not offer yet a clear and safe path to is development
2. To develop a safe and effective vaccine may take years (not months), poses significant technical and ethical challenges and success is by no means granted. Researchers are working on a vaccine against HIV-Aids since about 40 years and a vaccine is still not available.
3.The virus is only the very last ring of the chain, there are many upward determinants to be considered (social, economic, environmental, cultural, political)in the fight against the disease (not just the virus) and for health. A response that cannot be, but systemic.
Thus the question is: “Why so much, almost exclusive emphasis on a vaccine?”
In 2016 in the context of the international conference on “Epidemics and societies, past present and future” (which took place in Geneva) I presented a paper on the subject “The political economics of epidemics” (published 2017). Below, I reproduce a few paragraphs of that work which may contribute to answer the question.
Significant new global resources are being proposed and mobilised for emergency responses. Assessment tools and reporting systems are being discussed in the WHO, with some proposals for new global mechanisms, global financing facilities and independent assessment by global actors. However “global health security” appears to be reduced to emergency responses and infectious disease control, without considering necessary measures to be taken at local and national level within countries, and cross border, to strengthen health systems’ capacity to provide universal access to care, starting with primary health care and health promotion at community level.
For example after the Ebola epidemic the most notable improvements were in surveillance and laboratory capacities. There has been investment in surveillance and laboratory capacities in Africa through an Integrated Disease Surveillance Response, and international support for African and sub-regional communicable disease control centres for detection and early warning of infectious disease risks. However, scarce if any progress was seen, for example, in capacities to deal with chemical and food safety risks, suggesting that while the region may be better prepared to deal with infectious disease epidemics, this may not be the case for other public health risks, including NCDs, whose anticipated unaffordable costs will threaten individual and collective health security.
In addition, the global health security
approach gives no attention to the promotion of public health through public
policies beyond the immediate competence of the health sector, to control or at
least to reduce the impact of the determinants that we have described above.
In this context, the international response to
epidemics is also biased by the need to “avoid unnecessary interference with international traffic and trade”.
The epidemic of Bovine spongiform encephalopathy (BSE) in British cattle that started in 1986, reached its peak in 1992. When the first cases of human BSE appeared in 1987 the attempt by a government veterinarian to publish a paper describing one of the first cases of BSE, in the south west of England, was suppressed, with the argument “of possible effects on exports and the political implications”.
Too often epidemics also elicit international public interest and mobilization only when they spread beyond the limits of the poorest countries. The global response to the recent Ebola epidemic (2013-2016) has been reportedly slow. It was not until August that the WHO declared the 2014 Ebola outbreak a Public Health Emergency of International Concern; this was five months after the first cases were reported to the WHO, 1,779 people already had become infected, 961 had died, the outbreak had spread to Nigeria, and two American aid workers infected in Liberia had been evacuated to the United States. It was only at this time that the outbreak could no longer be seen as a humanitarian crisis affecting a few poor countries in Africa, but instead began to be viewed as an international security threat to developed countries. In September an emergency meeting of the U.N. Security Council was held and the U.N.’s first-ever emergency health mission, the United Nations Mission for Ebola Emergency Response (UNMEER) was established, as “the unprecedented extent of the Ebola outbreak in Africa constitutes a threat to international peace and security”. Even colonial legacies became obvious in the organization of Ebola response, with military assistance being delivered along old colonial lines.
The emphasis on the technological response is another common aspect of global response to epidemics, that distracts from the underlying causes of the outbreak, and from much needed strengthening of health systems, facilitating access to services and public health interventions. The current system of drug and vaccine development follows the market and favours chronic diseases that primarily affect people in the developed world, rather than neglected and infectious diseases likely to cause epidemics. However, in presence of ‘transnational’ epidemics emphasis is put on search for a vaccine or a drug, often perceived as a ‘magic bullet’. It was not until the ‘transnational’ Ebola epidemic that investments were mobilized in search of a ‘last-minute’ vaccine, and eminent personalities such as Bill Gates, Jeremy Farrar of the Wellcome Trust, and Seth Berkley of GAVI The Vaccine Alliance called for funding additional research into drugs, vaccines, and diagnostic tests, as well as creating a system for accelerating the approval of these interventions during a crisis.
Similarly, as soon as the Zika epidemic hit the top news, much emphasis was put on the need to develop a vaccine, rather than on the relation of the disease and its vector with poor urban peripheries and the urgent need to intervene with sanitation and waste control, and to provide adequate global investments for that purpose.
. . .
Conclusions
The determinants of old and new epidemics,
including the increase of non-communicable diseases in an epidemic fashion, are
deeply rooted in the way societies are structured. With the acceleration of globalization
and the hegemony of the neoliberal development model, not only infectious
diseases spread faster without borders, but also new pandemics linked to unhealthy
lifestyles and environmental degradation have become part of humanity’s common
planetary destiny.
Clearly, the global fight against XXIst century
epidemics cannot be narrowed to one of emergency responses to infectious
disease. Instead, it also needs to extend to NCDs and identify, and act on their
social, economical, political and environmental determinants.
Medical rescue processes and public health
interventions in response to epidemics are last resort measures. Technical fixes to health problems tend to
leave the social and economic determinants of health, and the relationships
that underpin them, untouched.
Resources are indeed needed to deal with
emergencies and their economic and social impacts, nevertheless a health sector
response to preventing and controlling epidemics needs to be based on long term
health systems strengthening. This starts locally, within countries and
particularly with the comprehensive primary health care, universally accessible
services, social protection, and public health approaches capable to identify, prevent
and manage risk before it grows into an epidemic.
However, many determinants of epidemics and in general of global health security, lie outside the health sector and the traditional domain of health authorities, and are heavily related – as global health in general – with processes of production and consumption, with societal structure and social, economic and political processes, interests and influences, prompting the need for a global governance that would make equitable health the priority in all sectors (e.g. agriculture, commerce, industry, education, environment) in which public policies are developed and negotiated. Prevention of epidemics must thus bring epidemiological knowledge to bear on political processes that are collective and involve challenges to economic and social institutions that will certainly meet political opposition, and will thus require appropriate strategies and alliances to be faced.
To modify the structural drivers of epidemics will require a combined global, national and local action redirecting the hegemonic growth-based development model which is not sustainable, socially inequitable, and globally unhealthy. Such a paradigm shift necessarily needs a substantial reorientation of policies at national level in addition to citizens’ engagement at community level. Local and national action in turn, cannot leave out the complexity of the globalized world and the need to control transnational forces influencing our everyday life and finally our health, through institutions and policies able to do so. . . .
With Saluteglobale.it association for social promotion, in particular the right to health, we explored in depth the issue of masks, concluding on the need for an urgent further revision of the WHO guidelines, as well as to direct research on appropriate technologies for a widespread production of personal protective equipment, bearing in mind also the conditions of the most disadvantaged populations.
The use of surgical masks and other Personal Protective Equipment (PPE) is now at the centre of the debate and controversy on pandemic control measures COVID-19. In Italy, also on this issue the Regions and the national coordination continue to go in scattered order, with conflicting ordinances and decrees. The repeated image of representatives of the institutions wearing a mask, often even improperly (e.g. leaving the nose uncovered), while stressing that its use must be reserved for symptomatic people is certainly an additional element in creating great confusion. The World Health Organization (WHO) guidelines of 6 April 2020 continue to advise against the use of surgical masks in asymptomatic people, as there would not be sufficient evidence of their complete effectiveness, a position followed so far by our national health authorities, but which several Italian regions, as well as a growing number of countries in Europe, have not taken into consideration at all. Such as the Czech Republic, which was the first to make their use obligatory for everyone, and as was done in South Korea and China, countries where the use of masks has long been part of the custom and whose generalized use is considered among the elements of success in the containment of the epidemic. In particular, since the first edition (29 January 2020), the WHO guidelines have been imperative in advising against the use of fabric masks, because they could even propitiate contagion through reduced effectiveness due to incorrect use or generating a false sense of security. However, on Friday, April 3, Mike Ryan, WHO’s emergency manager, admitted that homemade masks could also help reduce the spread of the virus; in fact, he was contradicted on April 6 by the Organization’s new guidelines and felt that he could not make a recommendation in the absence of conclusive evidence either for or against their use in the community. Rather, the WHO continues to stress the potential risk arising from the generalised use of masks which could create a false sense of security, lead to neglect of hand hygiene and physical distancing practices, entail unnecessary costs and take masks away from frontline operators, especially when stocks are short. The WHO wash its hands and leaves it to the national authorities to decide what to suggest regarding the use of non-approved masks and to carry out further research in this respect. Let us try to analyse more in depth. Especially in emergencies, public health decisions cannot be based solely on insufficient evidence of optimal efficacy when there is no equally firm evidence of a potential risk. Instead, it is essential to adopt a systemic vision that also takes account of social, cultural, economic and even ethical determinants, as well as common sense. Indeed, the systematic review of the scientific literature does not identify studies that indicate a real danger in the widespread use of surgical masks in the general population (“in the community”) there is instead an almost general consensus on the role of surgical masks in reducing at least partially (depending on the material or combination of materials they are made of) the exposure of healthy people to respiratory infections and, to a greater extent, in counteracting the ability of infected people to spread the infection. On the other hand, there is now broad consensus that the coronavirus can also be transmitted by asymptomatic people. It is therefore clear that the use of a protective barrier, although not optimal, for both symptomatic and asymptomatic people should be universal. Unless its proper use is promoted and distracted from other protective and control measures. The problem of supply remains. The pandemic has called into question the functioning of the global market. Paradoxically, when China – the world’s leading producer – at the height of the epidemic called for international support, many of the masks sold in Italy were “made in Wuhan”. At the same time, other producer countries were blocking their exports to meet the foreseeable increase in national demand. Meanwhile, in Italy, in contravention of the recommendations of the Ministry of Health, an army of panicked consumers ran to buy all types of masks and respirators, leaving retailers and, above all, health care facilities and workers without any PPE. Since this mobilisation cannot be stopped – it must be understood that people are primarily motivated by their right desire for personal protection – then it should be managed. Ideally, masks should meet recognised safety and quality standards, but the current pandemic is by no means an ideal situation. Almost everywhere, in Italy and abroad, demand is greater than production capacity, including the conversion of domestic industry. Only in Italy, where the availability of disposable masks to the entire population should be ensured, the supply should be at least one hundred million masks per day, without considering the environmental impact of their subsequent disposal. This is why alternative solutions must be sought at all costs, rather than hiding behind the lack of effectiveness so as not to promote the universal use of individual protection. Widespread production at community level and homemade masks also appear to be a good solution to allow high quality and maximum protection of approved material to be reserved for health care personnel and that should be guaranteed by the health authorities. This line has recently been taken over, with a significant change of direction, even by the CDC in Atlanta, the United States of America’s centre for the control of infectious diseases, and by its counterpart, the European Centre for Disease Control and Prevention (ECDC). Nonetheless, in the absence of adequate industrial and/or import capacity, widespread production at Community and/or domestic level in the poorest countries could be the only possible option. More advanced and sustainable solutions also come from new technologies, such as low-cost 3D printers that are becoming increasingly affordable worldwide, allowing the production at community level of perfectly fitting respirators made of compostable plastic, but where the question of the material to be used for the filter element remains open, also to be investigated with a view to accessibility and sustainability. It is therefore up to the institutions, first and foremost the WHO, to identify and promote the best possible solutions (materials, models, etc.) and promote further in-depth studies based on criteria of effectiveness, safety, availability, affordability and sustainability, or rather appropriate technology even in disadvantaged social and economic contexts. Prioritizing reusable models to avoid contributing to the generation of millions of tons of special waste. However, it is essential, in this they all agree, to accompany the promotion of the universal use of masks with rigorous instructions and intense education campaigns on the correct methods of production, use, disposal and maintenance, always insisting on the fundamental need to combine the use of PPE, with frequent hand washing, the sanitation of objects and common areas, social distancing and other measures to prevent and control infection. Finally, the widespread use of masks, local production and the cooperative approach could also be a further form of emancipation of the population and a way to rediscover the value of the contribution we can all make to win the battle together, as in Dumas’ Risorgimento (resurgence) epic “masks for all and all for the masks”.
In February 2018 I announced the publication of a paper on “The Political Economy of Epidemics” included in the book edited by Prof. Bernardino Fantini “Epidémies et sociétés, passé, présent et futur”. With the current COVID-19 pandemic the argument of that paper (as many other chapters of the book) may offer renewed food for thought. This is why I am happy to share the full text here.
