Public health in the EU: is Europe subject to Americanization?

VerfasserKurzer, Paulette

1 Introduction

Since the launching of the Single Market, the European Commission with the support of Europe's political leaders have sought to reach out to the people of Europe by promoting a "Europe of the Citizens" to neutralize the widespread disenchantment with the prevailing impression of a "Europe of Merchants". The first attempts to introduce a popular dimension to EU legislation dated from the 1984 summit at Fontainebleu where President Mitterrand of France and Prime Minister Craxi of Italy commissioned a report designed to identify areas where the EU could develop new policy dimensions closer to the concerns of ordinary citizens. In retrospect, this decision was the starting point for the gradual expansion of EU activities in the field of consumer protection, environment, and health. The EU's activities in these policy areas were given a large subsequent boost by the Amsterdam Treaty and Article 152, which extended EU competence to "promoting" in addition to "protecting" the health of EU citizens. The former Constitutional treaty did not focus on health per se, but it granted the Commission a stronger mandate to fight health threats such as tobacco and alcohol. In the new Reform Treaty Article 152 draws attention to the protection of public health concerning tobacco and the abuse of alcohol though fighting health threats, first mentioned in the defunct Constitutional Treaty has been deleted.

One way in which the EU has devoted itself to the interests of ordinary citizens has been through its forays into public health, and in particular its initiatives on tobacco control and obesity. Tobacco control emerged in mid-1980s and is still on the agenda since "tobacco is the single largest cause of avoidable death in the European Union," contributing to approximately 25 percent of all cancer deaths and 15 percent of all deaths in the EU (SANCO 2008). To address this health hazard, the European Commission has passed scores of legislative measures, such as requiring health warnings on cigarette packs, specifying maximum tar content in cigarettes, banning advertising of tobacco products, and collecting a repository of shocking images of the harm done to the smoker. (1) It also funds professional networks to encourage smoking prevention and cessation and it works to ensure that a range of other policies are consistent with tobacco control. In January 2007, the Commission published a Green Paper "Towards a Europe free of tobacco smoke: policy options at EU level" in anticipation of regulations to combat indoor pollution in the workplace and public spaces (European Commission 2007a). (2)

Of more recent vintage is the program to promote healthy diet and nutrition in the EU. In May 2007, the European Commission published a white paper on "A Strategy for Europe on Nutrition, Overweight and Obesity related health issues," which is a call for action to combat weight gain, particularly among children, and prevent future sharp increases in cardiovascular disease, hypertension, type two diabetes, strokes, certain cancers, muscular-skeletal disorders and even a range of mental health conditions due to poor diets and lack of physical activity (European Commission 2007b). The campaign began with an exploratory report, "Eurodiet: Nutrition & Diet for Healthy Lifestyles in Europe," which covered health and nutrients, the translation of nutrient requirements to food-based guidelines and effective promotion of these foods and healthy lifestyles (European Commission 2000).

The Commission, to be sure, has not received much encouragement to extend its activities into public health. Instead, the people of Europe assign low priority to community-wide health programs while many political leaders are extremely hesitant about furthering the reach of the Commission into any novel, undefined areas. In developing its public health initiatives, the Commission has responded neither to pressure from below (e.g., emanating from health-related NGOs) nor to pressure from above from the member state governments.

On the contrary, the DG Health and Consumer Protection (DG Sanco) and more generally the Commission have themselves taken the initiative in public health matters and served as the primary framers of measures on tobacco control and obesity prevention. How has the Commission and in particular DG Sanco invested effort and political capital in promoting tobacco control and healthy nutrition when their legal mandate is thin, the salience of tobacco control and healthy diet remained low across Europe for many years, and countervailing forces opposed to European regulations were firmly established? If member state's attention to tobacco control or healthy diet was minimal, where do the Commission's ideas, knowledge, framing, and objectives come from? The current atmosphere in Europe is radically different from the hopeful and optimistic mood of the 1980s when European institution building excited and galvanized the Commission and the political leadership (Ross 2008). Where and how does the Commission think up new areas of legislation when the Europeans themselves are not crying for an expansion of EU authority in these areas?

This paper addresses these issues by examining the cases of tobacco control and healthy diet campaigns. It argues that the Commission has tried to transcend its circumscribed mandate and lack of engagement by national groups, organizations, and experts by working closely with the Europe office of the World Health Organization (WHO), which provides not only health policy expertise but also political legitimacy. By forming a mutually beneficial partnership, the directorate general of Health and Consumer Protection appropriates the data gathering and analyses of the WHO to justify its own agenda, while the WHO has an intuitive interest in the success of DG Health and Consumer Protection thanks to the overlapping membership between EU and WHO member governments. Together WHO and DG Health and Consumer Protection form a powerful and respected advocacy team, working in tandem to solve health related harms common to all European societies.

The subsequent outcome of this collaboration resembles an advocacy coalition since the actors share strong beliefs about the efficacy of action to reduce the health impact of smoking and fatty/sugary foods. Both WHO and DG Health and Consumer Protection subscribe to core beliefs about the cause of the problem, its gravity, and potential solutions (Gutrich 2005; Sabatier/Jenkens-Smith 1999).

One unusual feature, however, is that much of the research and scientific understandings furnished by the WHO to the Commission, and vice versa, originally came from American public health networks and medical researchers. Joint collaboration between the WHO and EU, and the reliance on scientific knowledge to frame an agenda has resulted in the accidental 'Americanization' of European health campaigns. The rise of a pan European advocacy coalition is built around a consensus on priorities and action plans as the EU and WHO recognize their converging interests. But this European-global partnership is organized around a set of scientific terms and professional concepts with a distinctly American tinge.

In making this argument, it becomes clear that this paper fits into one of the two "camps" of literature on the EU's policy-making process. The first approach takes the view that the Commission, or more accurately officials in a particular Directorate General, craft their own proposals without much input from other agents or stakeholders. They then wait for the reaction of relevant actors such as national politicians, interest groups, lobbyists, and other governmental authorities. In this scenario, Europe's civil servants are the primary framers and take the initiative to propose laws and regulations (Jakbo 2006; Morth 2000; Nylander 2001).

An alternative view is to trace the rise of new programs to pressures from below or above. Calls for action prompt the Commission to consider different proposals and recommendations. Member state governments may assign EU institutions the task of monitoring, supervising and implementing policy proposals, or pressures from civic groups, economic interests, and non-governmental organizations may empower the Commission to move into unexplored terrain (Eberlein/Grande 2005; Pollack 2003; Tallberg 2006).

This paper falls into the first "camp" discussed above. As we will see below, active lobbying from above or below-by member states or by European NGOs, health voluntaries, and the medical community-was not the principal driving force. Instead, the impetus for pursuing these public health initiatives came from the Commission. To overcome its lack of political clout and visibility in these issues, Commission officials joined forces with other international health organizations to elevate their standing and collect further data and analysis.

The organization of this article is as follows. I first provide an overview of why EU public health operates in a vacuum and how tobacco control and nutrition nonetheless rose to the top of the agenda. In the second section, I explore the web of connections and contacts between the World Health Organization and the American public health and medical establishment. Third, I examine how the EU program is subject to Americanization. The final section concludes the paper.

2 Own it own: The Ascendance of Tobacco Control and Healthy Diet

As noted above, the Commission has not been subject to pressures to develop public health initiatives from above or below. Member state governments have not tried to stimulate EU-wide measures on public health for various reasons. First, providing medical services and managing the health care system has traditionally fallen to national or local authorities as part of a wider configuration of the social welfare state and funding systems. Moreover, many member states do not have a full fledged...

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