Posts Tagged ‘healthcare’

Learning from Mistakes in Pandemic Response

As of March 27, 2020, at 2:00 PM EST, there are over 5650,000 infection cases of COVID-19, the novel coronavirus discovered in December 2019, in the world. The number of global fatalities due to the virus has surpassed 26,000.

“Passengers spend St. Patrick’s Day waiting for their luggage at John F. Kennedy International Airport after returning from overseas before a number of airports shut down due to COVID-19 fears [WISE].

The majority of all COVID-19 cases, including those closed, have been concentrated in China, where the virus was first detected, with Italy and Iran trailing close behind. But, as symptoms often present similarly to the common flu, international travel and global trade have allowed the virus to leap between countries undetected—at least at the beginning of the outbreak.

The European Union (EU) is an example of the way that the free movement of goods and people today has enabled contagion; Director-General of the World Health Organization (WHO) Tedros Adhanom called Europe the new “epicenter of the pandemic” last week.

During global crises like COVID-19, there is a consensus that people in all countries must unite against a disease that doesn’t stop at borders. To combat COVID-19,  many states have cancelled or postponed large public events, shifted schools to online learning, and asked anyone feeling under-the-weather to self-quarantine if possible, depending on the severity of the outbreak.

This isn’t the first time that the world has had to respond to a pandemic; countries have grappled with Severe Acute Respiratory Syndrome (SARS), Middle Eastern Respiratory Syndrome (MERS), HIV/AIDS, Ebola, and others just in the past half-century. But, pandemics are not a modern phenomenon; even as far back as 430 BC, the Plague of Athens set fire to Libya, Egypt, and Ethiopia as it made its way to the Roman city-state on the back of the Peloponnesian War. It can be concluded, however, that as humanity grows more interconnected, modes of disease transmission also become more plentiful.

The question is: is there a trade-off between globalization and public health? Or, can we learn from past pandemics—and the world’s response to them—to craft a more conscious, prepared society?

Transmitting Disease

Historically, diseases have grown into pandemics through modes of human interaction. For example, the Black Death was carried from Crimea to North Africa, Italy, Spain, and France by Genoese trading ships in 1347 and 1348. Another outbreak of the bubonic plague, the Great Plague of London in 1665, spread through England via trading ports along the Thames River, and the 1855 Plague was spread from Yunnan province in China to Hong Kong and Guangzhou as the cities grew increasingly connected by mining. Sixty years later, in 1918, the Spanish Influenza was spread across North America by laborers using the Canadian rail system to reach Europe.

These are all examples of disease spread through benign means. Yet, there are also examples of pandemics being weaponized. Before it was spread to Europe, the Black Death was brought to Crimea by the army of Kipchak Khan Janibeg, which catapulted infected corpses into the town that is now Feodosiya on the Black Sea coast in an effort to cripple its population. As armies move, they can also pass infection unintentionally; like the armies that transmitted the Plague of Athens, the Huns were key in carrying the Antonine Plague in 165 AD.

Pandemics pose a clear danger to public health; but, they also hold an element of fear that make them a threat to the mental and economic wellbeing of society. This fear is, of course, due in part to potential fatality—but, what we especially fear is the unknown.

This is especially true with COVID-19. As COVID-19 is a novel, or new, coronavirus—viruses named just for the structure of their cells—information about its spread and possible prevention is still developing. With an unclear picture of the future, public health officials around the world are struggling to outline long-term needs and craft policy that will meet them without usurping resources too hastily.

Social Divides: Manifesting Fear

COVID-19 and the pandemics before it have taught us that fear often manifests in scapegoating. The tenth edition of the Journal of Public Health in Africa characterized leprosy, for example—which mushroomed from its minor existence into a European epidemic in the Middle Ages—as a “social killer” for the stigma it carried as opposed to “serial killers” like malaria.

Now, individuals and businesses of Asian origin all over the world are facing stigma associated with COVID-19, which originated in Wuhan, China. On March 9, two months into the hysteria, Twitter user @winyeemichelle asked followers to “pls consider making your weekly takeout a Chinese takeaway. My family’s businesses have all been impacted hugely by coronavirus panic.”

Similar Sinophobia, or hate of things Chinese, was witnessed during the SARS outbreak of 2002-2003, when a coronavirus originating in Guangdong, China, eventually infected 8,098 people worldwide as reported by WHO.

During the SARS pandemic, “The fact that China’s government initially suppressed information about the virus added to the climate of blame,” Rebecca Onion writes for Slate.

But, racist reactions have not been confined to viruses originating from China. “Our views about race have always colored our views about who is safe or who is contaminated,” Natalia Molina said in an interview with Sean Illing for Vox. “When we already have negative representations of certain groups…then it’s much more likely that we’ll see them as disease carriers or as health burdens.” Think of the stigma associated with Middle Easterners when MERS became an issue in 2012, with Africans during the Ebola outbreak of 2013-2016, and with Hispanics during the Zika craze of 2015-2016.

This ingrained racism manifests even in the way that a virus is named (i.e., “Middle Eastern Respiratory Syndrome”). COVID-19 is being called the “Wuhan Virus.” By marrying a virus with its origin, a label is slapped—intentionally or not—across people from that place identifying them as disease.

Of course, some see “The Wuhan Virus” as a fitting—at the very least, factual—name for a disease that did, in fact, originate in Wuhan. Deputy Editor of USAToday David Mastio wrote for the publication that “Finding excuses to hurl the racism charge over such minor issues as how to refer to a new disease cheapens the currency of a serious allegation.”

Likewise, U.S. president Donald Trump regularly refers to COVID-19 as the “Chinese Virus.” When asked on Thursday to comment on the use of the phrase “Kung Flu” by an unnamed member of his administration—and whether it puts Asian-American community at risk—he said, “I think [the Asian-American community] probably would agree with it 100 percent.  It comes from China. There’s nothing not to agree on.”

The Economic Impact of Social Distancing 

To limit the spread of COVID-19 as much as possible, many restaurants have switched to takeout or delivery-only. Schools and universities, from Northeastern University in Boston to Egypt’s American University in Cairo, have transferred their classes online and evacuated their dormitories. Many restaurants and cafes operate under curfews, and some other workplaces are requesting that employees work from home (though, to be clear, working from home has been a white-collar privilege that largely excludes service workers).

These measures are part of the broad “social distancing” measures that are being followed worldwide. In hard-hit countries like Italy, social distancing is federally enforced; NPR’s March 10 episode of its “Up First” podcast describes conditions inside Italy’s “red zone”, or national lockdown. In what contributor Sylvia Poggioli describes as “the most draconian measure ever taken in a Western country, at least in peacetime”, police cars patrol empty streets, entreating residents over a loudspeaker to stay inside. France and Spain have since taken similar measures.

In countries like Egypt, all airports have closed, and air carriers elsewhere have chosen to limit their flights. The Friday prayer, a staple of religiosity in Muslim countries, has been halted by edict from Saudi Arabian Islamic scholars.

Similarly, shipping and manufacturing have been limited; Honda, Ford, General Motors, Fiat-Chrysler, and Toyota have announced their intent to suspend all production in North America. Public gatherings like parades and sporting events have been cancelled, decreasing money flows domestically and internationally. Stocks have fallen and tourism has been depressed.

The United Nations (UN) Center for Trade and Development has estimated that these trigger points could cost the global economy between $1-2 trillion in 2020. But, economic impact is not distributed evenly; mirroring existing socio-economic disparities, low-income countries and individuals are usually hit the hardest.

The Center for Strategic and International Studies warns that, “At the sectoral level, tourism and travel-related industries will be among the hardest hit.” This has implications for tourism-dependent economies, chief of which are developing Caribbean states like the Dominican Republic and the Bahamas. Additionally, materials prepared by Chicago-based law firm Baker Mckenzie point out the reliance of African countries on Chinese demand for raw materials, which has been severely reduced.

That’s not to say that wealthy countries don’t feel the economic effects of COVID-19; in the United States, trading on the New York Stock Exchange, Nasdaq and TSX on March 10 was all halted as “circuit breakers” cut in to mitigate a selling frenzy. On that day, the Dow Jones fell 10 points, its worst performance since the 1987 market crash.

Within countries, inequity also persists. Consumers have devastated the aisles of supermarkets in “panic buys”: large bulk purchases of enough foodstuffs to last them a potential 14-day quarantine. Don Goldmann, Chief Medical and Scientific Officer at the Institute for Healthcare Improvement, describes the madness in Boston: “I can tell you I went shopping today, to Trader Joe’s, and the place was mobbed. All I wanted was frozen peas, and there was no frozen pea to be had in any store I went to.”

These aisle clearouts disadvantage those who don’t have the financial reservoirs to buy hundreds of dollars worth of groceries at a time; when people who shop day-to-day are met with vacant shelves, that may either eliminate the possibility of dinner or force consumers towards fast-food restaurants, where the possibility of contracting disease is higher. Similarly, without the guarantee of paid sick leave, low-income individuals are more likely to go to work when experiencing symptoms of COVID-19 at risk of infecting others.

Moreover, refugee and homeless populations are left exposed to the elements with little ability to self-quarantine. The UN High Commissioner for Refugees (UNHCR) and the International Organization for Migration have suspended refugee resettlement services. Although the UNHCR has implored individual states to enable resettlement to the extent they are able, widespread border closures make intake unlikely.

Similar social distancing measures were seen in the United States during the 1918 Influenza epidemic, but not after Ebola, SARS, or MERS. Gina Kolata reports for the New York Times that public gathering places in Philadelphia as well as schools and theaters in Albuquerque were all closed in 1918.

Political Crossroads

This outbreak of COVID-19 comes in the midst of primary voting for the 2020 U.S. presidential election, attempts to form a coalition government in Israel, and attempts by Russian president Vladamir Putin to extend his time in office.

Iran held its parliamentary elections on February 21—and saw only 43 percent voter turnout, the lowest since the Iranian Revolution in 1979. “Some people might have not gone to the polls because they were worried that they were going to catch the coronavirus,” scholar Holly Dagres explained in a podcast for the Cairo Review.

In countries undergoing election cycles, COVID-19 has many worrying about the integrity of results when many people are afraid to—and in some cases, have been advised not to—leave their homes.

Even in the United States, the Connecticut, Maryland, Kentucky, Ohio, Louisiana, and Georgia state primaries have been postponed. Some states have tried to maintain voting normalcy while taking precautions; for its primary on March 2, Massachusetts directed voting staff to disinfect polling booths with more frequency. Washington switched from in-person to mail-in and drop-box voting.

On the other hand, it is sometimes difficult to insulate pandemics from politicization. When swine flu struck the United States in 1976, Gerald Ford’s campaign for president added mass immunization to its platform. As David S. Jones writes in the New England Journal of Medicine, “When people fell ill or died after receiving the vaccine, and when the feared pandemic never materialized, Ford’s plan backfired and may have contributed to his defeat that November.” Now, U.S. voters are factoring ability to respond to pandemics into their choice between Joe Biden and Bernie Sanders, the two leading Democratic candidates for president.

The ways that countries are able to respond to COVID-19 are also part and parcel of the existing political context. When COVID-19 hit Iran, for example, it hit a country already crippled by corruption, mismanagement, and the U.S. “maximum pressure campaign” of sanctions—conditions ill-equipped for pandemic response.

“Every time U.S. president Donald Trump threatened to withdraw from the Iran nuclear agreement, European companies were hesitant to invest in the country”, Dagres asserted. As the world combats COVID-19, U.S. sanctions on Iran remain ironclad. “U.S. sanctions have hampered Iran’s ability to purchase or access medical equipment or pharmaceuticals in the international market”, Sanam Vakil said to Middle East Eye.

Have we learned anything?

Yes and no.

Take the United States, for example. In 2014, Beth Cameron was appointed to lead the White House’s National Security Council Directorate for Global Health Security and Biodefense, which was established in a “I wish we had had this” moment after the Ebola scare the same year. In 2017, that center was dissolved by the Trump administration.

Because of this, “When this new coronavirus emerged, there was no clear White House-led structure to oversee our response, and we lost valuable time”, Cameron wrote for The Washington Post. “The job of a White House pandemics office would have been to get ahead: to accelerate the response, empower experts, anticipate failures, and act quickly and transparently to solve problems.”

Yet, dissolving post-pandemic initiatives after a cooling period is hardly an administration-specific response. “Theoretically, we should be really well prepared,” Goldmann told the Cairo Review. “But,” he continued, “in my experience, our memory and our state of readiness tends to…I don’t want to use the word deteriorate, but the urgency wanes over time. And every time we have a new threat—like H1N1, which turned out to be less of a threat than we initially thought it might be—we seem to have to relearn the same lessons over and over again.”

With each pandemic, preparedness (or lack thereof), varies in states all over the world. “Unlike Central Africa, Ebola was not a usual occurrence in West Africa; the necessary elements of community trust and public health decision-making weren’t in place to detect and stop it,” Cameron writes. This, combined with the recognizability of Ebola symptoms and the launch of the Global Health Security Agenda, enabled the U.S. to take the global lead in response.

Goldmann contrasts the readiness of the U.S. federal government to respond to COVID-19 with that of the country’s healthcare delivery system, which doesn’t have to mold itself to changing presidential administrations. In Boston Children’s Hospital, where Goldmann works, staff had been running drills to practice response to potential hospital overload.

There are lessons to be learned by comparing Italy and China, handling their time at the front lines of the pandemic very differently.

On Sunday, a video compilation surfaced of quarantined Italians imploring the rest of the world—particularly Americans and Frenchmen reluctant to stay inside—not to underestimate the virus. “This issue is more serious than most of the world believes,” one man said; indeed, than Italians themselves believed at the beginning of the outbreak.

“What is happening is much worse than you thought it was,” another woman echoed.

For Italians, measures to contain communicable disease, like social distancing, felt foreign. In China and the areas surrounding it, however, measures like wearing masks were already relatively common. Some experts, like Keiji Fukuda, see China as equipped with muscle memory of its response to the SARS epidemic. “Virtually everybody here has been through the drill,” Fukuda said to Today’s WorldView. Indeed, today was the second day that China recorded no new locally-transmitted cases, though global travel still poses a problem for transmission.

However, though China has been effective in limiting viral presence within its borders since lockdown was declared in Wuhan on January 23, it had a potential to respond even earlier that was hampered by government suppression. Ophthalmologist Li Wenliang sounded the alarm in December, when he began treating patients in Wuhan for SARS-like symptoms; shortly after publicizing his worries, Wenliang and seven colleagues were forced to sign an admission of rumor-mongering by the Chinese security police. Because the Chinese government was reluctant to validate Wenliang’s information—and thereby provide him with personal protection while treating patients—Wenliang passed away after succumbing to the virus on February 7.

By contrast, South Korea—which has the same memory of the SARS epidemic—has seen a “highly coordinated government response that has emphasised transparency”, John Power writes for This Week in Asia. They reported 600 new cases on March 3, and just 110 on March 13.

So, maybe the ‘muscle memory’ of some countries and institutions is better than others when it comes to responding to pandemics. As Goldmann succinctly summarizes: “All we can do now is to remind ourselves of lessons from the past, ramp up prevention and control measures (especially physical distancing) as quickly as possible, and remember this experience when we begin planning for the future.”

An earlier version of this article previously appeared in The Cairo Review of Public Affairs and has been republished with permission.

COVID-19: an overview of the government’s economic priorities so far

Paul Anand highlights the key economic policies announced in response to the ongoing pandemic and assesses their likely implications. He concludes that existential threats to economic systems seem not to be as rare as we believed, and so economists ought to be giving more thought to how we respond to them.

The novel coronavirus pandemic has seen policy-makers shift from pondering whether COVID-19 will have much economic impact to, within two or three weeks, scrabbling around to find policies that address existential threats to economic systems around the world. The economic priorities and problems that emerge are doing so on a daily basis, and it will now be clear to many that conventional policy actions simply do not apply, even if basic underlying principles do.

Businesses

At the time of writing, the major economic challenges concern the likely effectiveness of a series of (fiscal) policies announced by the UK government. Initially, the government and the Bank of England seemed to be focussed on supporting businesses and announced a range of measures including loans to tide businesses over. But it is already becoming clear that the devil is in the detail.

There is still a huge amount of uncertainty about how long social distancing will last – perhaps it will be three weeks or three months; in the UK, emergency powers have been requested for two years. As a result, the massive £350bn package of support – which includes business loans – risks being substantially ineffective. Company directors are being asked to take out loans, but where companies have costs and close to zero revenues for several months, they could face the prospect of being without profits for two or three years. For these reasons, banks offering loans even with substantial underwriting by government will not able to easily judge whether and when many businesses will be clearly solvent.

Inequality

I regularly collaborate with the UN and the World Bank, where the concept of human development is an important driver of economic thinking. The UN has an index which monitors health education and gender equality as well as national income, providing this war a focus for what economies need in a way that goes ‘beyond GDP’, a need that economists have increasingly recognised in recent years. From this perspective, COVID-19 is a human development crisis in the making which also demands immediate policy attention.

In the past few days, one UK charity food bank has reported a quadrupling in referrals over the space of a week. At the same time, other food banks and organisations trying to arrange food deliveries for the most vulnerable have reported thefts of food. Supermarkets have been addressing some of the challenges by creating particular times when older people or front-line workers can shop. These latter initiatives are welcome, but local government does need to be empowered to address the issues of hunger that some families are already facing.

There are also huge short- and long-term implications for education and labour markets. The closure of schools challenges both children’s learning and schools’ abilities to offer learning online. But it also throws into sharp relief the extent to which businesses depend on schools for childcare and we should expect the losses of national income to be significant if closures carry on for several months.

Furthermore, there is evidence that those who find it difficult to enter the labour market for the first time because of economic recessions are scarred and achieve poorer economic outcomes over the longer term. This is yet another source of inequality that we should try to combat.

Healthcare

In terms of health and health services, shortages of protective equipment in the NHS are contributing to staff shortages, as doctors and nurses self-isolate or go sick. Matt Hancock has suggested this reflects a logistics problem but whatever the reason, this is a serious constraint on the country’s response and one that makes understandable the reason thousands of NHS staff have complained about the lack of appropriate masks and gowns.

Currently, medics are also suggesting that by early April there will be a need to make decisions about who gets access to a ventilator. The government has, for several weeks, said that it will purchase all the ventilators that suppliers can produce but there are limits to how quickly their production can be ramped up. The fact that doctors and nurses are being invited out of retirement and back into work is an indication of just how dramatic the demands on the service are expected to be and highlights also the fact that other aspects of healthcare will suffer.

Salaries

The pandemic has created unexpected calls for economic policy responses. Over the course of three budgets in nine days, Chancellor Rishi Sunak has acknowledged that this is not just another recession and this is not a time for ideology. Rather, he has shifted to a position where he is listening and responding to the existential risks to large numbers of jobs, to whole industrial sectors, and to vulnerable groups within society. The offer to underwrite 80% of worker salaries up to £2,500 per month is a potentially sizeable and welcome signal that livelihoods should be the focus of economic policy because they support workers and businesses at the same time. In normal times, policies for both seem to be siloed and disconnected – but we cannot afford to think like that right now.

That said, support for the self-employed and those in the gig economy on zero-hours contracts has been slower to work out. There are some five million workers classed as self-employed in the UK and another million working on zero-hours contracts; these cover a diverse set of groups – from high-paid celebrities to working mums and taxi drivers. When they stop work, currently many are entitled to £94.25 per week, a figure that Matt Hancock accepted that he could not live on.

The issue caused some confusion, particularly in the construction industry where many workers have wondered if they should carry on working on the grounds they cannot work from home and need to put food on the table. As a result, the London underground, supposed to be running for emergency workers with passengers keeping two meters apart, has been crowded and remained a hotspot for transmission that undermined the first days of the three-week lockdown.

Following the initialy delay, on March 26 the Chancellor announced a scheme that would give such workers 80% of normal earnings up to £1,700 per month and subject to a means test of no more than £50,000 per year to ensure benefits are targeted to those in greatest need.

Rents and mortgages

There are also issues concerning rents and mortgage repayments that affect most of society. The agreement between the government and the banks that those paying rent or repaying mortgages would be able to have a three-month holiday was welcome a couple of weeks ago. But it now looks certain that those living on low incomes in high-cost cities like London will need much more help if we are to avoid a rise in evictions further down the line.

The COVID-19 pandemic created a twin economic and human development crisis that standard economic thinking is not well-suited to. The Chancellor is to be applauded for moving quickly and dramatically in the right direction but there is still much evidence of what behavioural economists call anchoring and adjustment – that is, failing to adjust enough because our actions are often based on small incremental steps from where we start. The signs from China suggest severe measures can be effective over a three-month period and it remains to be seen whether Johnson’s libertarian inclinations will allow him to pursue the strategy, even though it seems to be supported by most. Existential threats to economic systems are not commonplace, of course, but experience of the financial crisis, the climate crisis, HIV and AIDS, as well as war is beginning to suggest that economists should give more thought to policies and analysis of such situations, which are perhaps less rare and unusual than we might have thought.

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About the Author

Paul Anand is a Professor of Economics at the Open University and Research Associate at Oxford University and London School of Economics.

 

 

 

All articles posted on this blog give the views of the author(s), and not the position of LSE British Politics and Policy, nor of the London School of Economics and Political Science. Featured image credit: by Mick Haupt on Unsplash.

 

European health systems and COVID-19: Some early lessons

COVID-19 is putting unprecedented pressure on European healthcare systems. Tamara Popic draws together some early lessons, arguing that the crisis should prompt a rethink of the direction of healthcare policies across Europe, and that the principle of solidarity must now move to the forefront as countries seek to mitigate the impact of the outbreak.

The spread of COVID-19 has put new pressures on already strained national health systems across Europe. In Italy, the country reporting the highest number of deaths linked to the virus in Europe so far, hospitals are facing severe crises trying to deliver the necessary care, while doctors are making heart-breaking decisions on how to distribute scarce resources. The usual stereotypes of Italian dysfunctionality notwithstanding, the 2018 Bloomberg ranking of the countries with the most efficient healthcare systems around the world places Italy fourth. The Italian population also ranks as the second healthiest population in the world. As one of the most efficient health systems and one of the healthiest populations in the world is struggling under the pressure, there are at least two lessons that could already be learned from the present crisis.

All that glitters is not gold

First, European governments should re-think the direction they have pursued with their healthcare policies over recent decades. A breakdown of coronavirus risk by demographic factors shows that those most likely to die are the old and the sick, population groups most dependent on the public healthcare system. Yet, European health systems in 2020 are less public than they were 30 or even 10 years ago. The logic behind these developments, guided by the New Public Management approach, has been that scaling down of the public sector would make health systems more efficient and responsive to the population’s needs.

The consequence of this approach has been a slow but steady reduction of public spending for healthcare. OECD Health Data show that since 1990 public spending as a share of the total spending for healthcare has decreased in most European countries. In some countries in Eastern Europe the decline has been even higher than 30 per cent.

While this trend has produced a variety of effects, a reduction of hospital capacity is one of the most important. As hospitals deliver costly specialised care and as European hospitals are still predominantly public hospitals, one of the key cost-containment measures has been to reduce the number of hospital beds. The figure below shows there has been a significant decline in curative hospital beds since 1990 across the whole of Europe (with the notable exception of Finland). In Italy, the number of beds per 1,000 people declined from 7 in 1990 to 2.6 in 2015. The tragedy is that these beds are now among the most needed elements of healthcare system capacity in the context of the present crisis.

Figure: Curative (acute) hospital beds per 1,000 of the population (1990-2015)

Source: OECD Health Data 2019

A call for solidarity

Second, the current crisis underscores the key principle of public healthcare – solidarity. A reduction of public spending for healthcare across Europe was paralleled with a series of policy measures that involved privatisation and the introduction of market-like instruments in the provision of medical care. In the hospital sector, these measures involved the privatisation of hospital beds and changes in the model of hospital ownership, including transformation of public hospitals into private-for-profit hospitals and joint-stock companies. The logic, similar to the one applied to reductions in public funding, has been that replacement of the public sector led by the state with private and competitive, market-oriented care provision would make health systems more efficient and responsive.

However, research shows that these types of policy changes have contributed to the creation of two-tiered healthcare systems. In this kind of system, access to necessary care is dependent on one’s capacity to pay for it and solidarity granted by the public system is eroded. And this is happening at a time when the general trend in inequality has spared neither our health nor our health systems, as countries face persistent inequalities in health and in access to healthcare services.

If these developments were not worrying enough, then the current health crisis caused by the coronavirus demonstrates that solidarity matters now more than ever. A quick look at the United States reminds us that having universal access to care is key in responding to the present crisis. News that the UK’s NHS will use private beds for virus sufferers may have seemed encouraging at first, but the subsequent announcement that private hospitals will be charging the NHS £300 per bed suggests that solidarity risks disappearing at the time when it’s most needed. Having resilient, well-funded public health systems with universal access to healthcare is key not only for solidarity, but also for national if not global salvation. It’s time to come together.

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Note: This article was first published on LSE EUROPP. Featured image credit: Marcelo Leal on Unsplash.

About the Author

Tamara Popic is a Research Fellow at the Max Weber Programme of the European University Institute.

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