'We don't do rabies'

When Alyssa McDonald was bitten by a stray dog in Romania, she was given excellent anti-rabies treat

"You want a babies injection?" asked the receptionist at my local GP surgery. "No," I explained as calmly as I could. "Not a babies injection, a rabies injection." "Oh ... I don't know about that," she said. "I'll have to check. Call back at six."

Two days earlier, at the end of a weekend trip to Bucharest, I had been walking through the city when one of the many stray dogs bit me - not badly, but hard enough to draw blood. I didn't really want the hassle of a trip to hospital, and I'd heard some horror stories about the Romanian ones. But then again, hospital was preferable to rabies. Virtually unheard of in the UK now, it still kills 55,000 people each year globally.

It is a particularly horrible way to die: within a week, sufferers become anxious and disorientated, developing an overwhelming thirst paired with an inability to swallow. Delusions, hallucinations and deranged behaviour (including thrashing, spitting and biting) follow; it usually takes another week or so before heart and lung failure lead to total paralysis, coma, and finally death. And once symptoms start to develop, rabies is nearly always fatal. So I was ready to put up with substandard treatment - I just wasn't prepared for quite how bad it turned out to be. And I didn't expect to find the NHS doling it out.

Dogs are a major nuisance in Bucharest. The rehousing programme during Nicolae Ceausescu's dictatorship forced many families to abandon their dogs, and now the city is home to about 200,000 strays. On average, strays bite 50 people a day; some of them carry tetanus and/or rabies. The city council has announced a couple of culls in recent years, but these programmes have never been extensive enough to tackle the problem. Fortunately, because the risk of being bitten is high, the city's hospitals are well set up to deal with the victims. The nurse I limped up to in Spitalil Colentina's anti-rabies unit spoke a little English, and within half an hour I'd been bandaged up, given shots for tetanus and rabies, and was out of the door with a prescription for antibiotics and directions on what to do when I got home. The days when rabies was treated with painful injections in the stomach are long gone; now you just need a series of five shots in your arm over the space of a few weeks. Easy.

The nurse gave me a leaflet containing information about the vaccine for my doctor in the UK. The entire service was free of charge.

As soon as I returned to London, I phoned NHS Direct to find out where to get my first follow-up shot. I was given the names of two NHS walk-in centres and a private Medicare centre before I was told that I could also see my GP.

"We don't do rabies," the receptionist at the first walk-in centre told me. "Tetanus we do, but not rabies." I called the second one. Then I tried again an hour later, and again an hour after that. Eventually I accepted that they weren't going to pick up, but I wasn't quite ready to accept the idea of paying for a treatment that I could get for free on the far side of the continent. So I skipped the Medicare option and phoned my doctor. Maybe I should have taken them up on that offer of a babies injection: I might actually have got somewhere if I had. When I called back at 6pm, the phone was engaged, and it stayed that way until the surgery closed at 6.30pm.

Life-threatening

Stuck for what else to do, I called the hospital closest to my office, St Thomas's in central London. Could they help me? The A&E receptionist was not keen. "Why didn't you call NHS Direct?" "I did," I explained, "and none of the options they suggested could help me. So now I am calling you, because I may have been exposed to rabies, and rabies is a life-threatening disease." "Where do you live?" I told her. "We're not your nearest hospital then, are we? You should have called the Royal London . . ." She was gracious enough to put me through to a doctor anyway.

"Yeah, we can do a rabies injection," the doctor told me. "But we shouldn't have to, really - you should be going to your doctor, because it's a community issue." I didn't ask why Romanian stray dogs are a community issue for Hackney Council.

So far, so incompetent. But the dismal service I'd received had nothing on what came next.

At A&E the next morning, I told the doctor what had happened, and about the five jabs the nurse in Bucharest had said I'd need. I didn't mention the antibiotics I'd been given for the wound itself; neither did he. Half an hour later, a student nurse appeared with a small syringe and the information leaflet from the vaccine, which she handed to me. She gave me the shot and smiled, "That's it! You're fine now." Really? What about the further three injections I'd been told I should have? "Oh, foreign hospitals are usually a bit overcautious with British patients. They're scared we'll sue." She assured me that I didn't need any further treatment, and that I was free to go. So I did. And I had got as far as the door when the doctor rang my mobile. He hadn't told the nurse to let me go, but since I already had, he just wanted to remind me that I'd need to see my GP for the remaining three shots.

I was confused - the nurse had said I didn't need any more treatment. "Did she? Oh, uh, then that's right." "Are you sure?" "Yes." I wasn't. But as I had the vaccine information leaflet, I could check: and like the Romanian one, it said I needed three more doses. (Not surprising, really, as that's the WHO's recognised regimen for rabies.) Why had the doctor needed me to tell him the dosage? When I went back to A&E and spoke to him, I discovered what had caused the confusion: he hadn't even read the information leaflet. And quite clearly, neither had the student nurse.

Rabies is hardly the UK's most pressing health issue, but the Health Protection Agency still treats about a thousand travellers each year who have been exposed to the disease abroad. Its line on treatment is unequivocal: as rabies is a fatal condition, the only available precaution - vaccination - must be used. The substandard treatment I received has serious implications for everyone who uses the National Health Service. In the end, my health was fine, but that doesn't excuse the level of service the NHS offered me. Being misheard, misinformed and passed from pillar to post is bad enough. But for two members of hospital staff to handle a less-than-everyday complaint by dishing out medication and advice without checking the facts is completely unacceptable, and potentially very dangerous. I contacted St Thomas's to ask for an explanation, but it was not prepared to comment unless I made a formal complaint.

According to research by the National Patient Safety Agency last summer, I'm not alone in receiving such poor service: almost 25,000 patients a year receive the wrong treatment in British hospitals. Whether the result is serious harm or just frustration and inefficiency, this is a pretty appalling track record. So, if you're looking for efficient, safe health care, try Romania. You might be less likely to end up foaming at the mouth.

This article first appeared in the 31 March 2008 issue of the New Statesman, Is Boris a fake?

Jeremy Corbyn. Photo: Getty
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Lexit: the EU is a neoliberal project, so let's do something different when we leave it

Brexit affords the British left a historic opportunity for a decisive break with EU market liberalism.

The Brexit vote to leave the European Union has many parents, but "Lexit" – the argument for exiting the EU from the left – remains an orphan. A third of Labour voters backed Leave, but they did so without any significant leadership from the Labour Party. Left-of-centre votes proved decisive in determining the outcome of a referendum that was otherwise framed, shaped, and presented almost exclusively by the right. A proper left discussion of the issues has been, if not entirely absent, then decidedly marginal – part of a more general malaise when it comes to developing left alternatives that has begun to be corrected only recently, under Jeremy Corbyn and John McDonnell.

Ceding Brexit to the right was very nearly the most serious strategic mistake by the British left since the ‘70s. Under successive leaders Labour became so incorporated into the ideology of Europeanism as to preclude any clear-eyed critical analysis of the actually existing EU as a regulatory and trade regime pursuing deep economic integration. The same political journey that carried Labour into its technocratic embrace of the EU also resulted in the abandonment of any form of distinctive economics separate from the orthodoxies of market liberalism.

It’s been astounding to witness so many left-wingers, in meltdown over Brexit, resort to parroting liberal economics. Thus we hear that factor mobility isn’t about labour arbitrage, that public services aren’t under pressure, that we must prioritise foreign direct investment and trade. It’s little wonder Labour became so detached from its base. Such claims do not match the lived experience of ordinary people in regions of the country devastated by deindustrialisation and disinvestment.

Nor should concerns about wage stagnation and bargaining power be met with finger-wagging accusations of racism, as if the manner in which capitalism pits workers against each other hasn’t long been understood. Instead, we should be offering real solutions – including a willingness to rethink capital mobility and trade. This places us in direct conflict with the constitutionalised neoliberalism of the EU.

Only the political savvy of the leadership has enabled Labour to recover from its disastrous positioning post-referendum. Incredibly, what seemed an unbeatable electoral bloc around Theresa May has been deftly prized apart in the course of an extraordinary General Election campaign. To consolidate the political project they have initiated, Corbyn and McDonnell must now follow through with a truly radical economic programme. The place to look for inspiration is precisely the range of instruments and policy options discouraged or outright forbidden by the EU.

A neoliberal project

The fact that right-wing arguments for Leave predominated during the referendum says far more about today’s left than it does about the European Union. There has been a great deal of myth-making concerning the latter –much of it funded, directly or indirectly, by the EU itself.

From its inception, the EU has been a top-down project driven by political and administrative elites, "a protected sphere", in the judgment of the late Peter Mair, "in which policy-making can evade the constraints imposed by representative democracy". To complain about the EU’s "democratic deficit" is to have misunderstood its purpose. The main thrust of European economic policy has been to extend and deepen the market through liberalisation, privatisation, and flexiblisation, subordinating employment and social protection to goals of low inflation, debt reduction, and increased competitiveness.

Prospects for Keynesian reflationary policies, or even for pan-European economic planning – never great – soon gave way to more Hayekian conceptions. Hayek’s original insight, in The Economic Conditions of Interstate Federalism, was that free movement of capital, goods, and labour – a "single market" – among a federation of nations would severely and necessarily restrict the economic policy space available to individual members. Pro-European socialists, whose aim had been to acquire new supranational options for the regulation of capital, found themselves surrendering the tools they already possessed at home. The national road to socialism, or even to social democracy, was closed.

The direction of travel has been singular and unrelenting. To take one example, workers’ rights – a supposed EU strength – are steadily being eroded, as can be seen in landmark judgments by the European Court of Justice (ECJ) in the Viking and Laval cases, among others. In both instances, workers attempting to strike in protest at plans to replace workers from one EU country with lower-wage workers from another, were told their right to strike could not infringe upon the "four freedoms" – free movement of capital, labour, goods, and services – established by the treaties.

More broadly, on trade, financial regulation, state aid, government purchasing, public service delivery, and more, any attempt to create a different kind of economy from inside the EU has largely been forestalled by competition policy or single market regulation.

A new political economy

Given that the UK will soon be escaping the EU, what opportunities might this afford? Three policy directions immediately stand out: public ownership, industrial strategy, and procurement. In each case, EU regulation previously stood in the way of promising left strategies. In each case, the political and economic returns from bold departures from neoliberal orthodoxy after Brexit could be substantial.

While not banned outright by EU law, public ownership is severely discouraged and disadvantaged by it. ECJ interpretation of Article 106 of the Treaty on the Functioning of the European Union (TFEU) has steadily eroded public ownership options. "The ECJ", argues law professor Danny Nicol, "appears to have constructed a one-way street in favour of private-sector provision: nationalised services are prima facie suspect and must be analysed for their necessity". Sure enough, the EU has been a significant driver of privatisation, functioning like a ratchet. It’s much easier for a member state to pursue the liberalisation of sectors than to secure their (re)nationalisation. Article 59 (TFEU) specifically allows the European Council and Parliament to liberalise services. Since the ‘80s, there have been single market programmes in energy, transport, postal services, telecommunications, education, and health.

Britain has long been an extreme outlier on privatisation, responsible for 40 per cent of the total assets privatised across the OECD between 1980 and 1996. Today, however, increasing inequality, poverty, environmental degradation and the general sense of an impoverished public sphere are leading to growing calls for renewed public ownership (albeit in new, more democratic forms). Soon to be free of EU constraints, it’s time to explore an expanded and fundamentally reimagined UK public sector.

Next, Britain’s industrial production has been virtually flat since the late 1990s, with a yawning trade deficit in industrial goods. Any serious industrial strategy to address the structural weaknesses of UK manufacturing will rely on "state aid" – the nurturing of a next generation of companies through grants, interest and tax relief, guarantees, government holdings, and the provision of goods and services on a preferential basis.

Article 107 TFEU allows for state aid only if it is compatible with the internal market and does not distort competition, laying out the specific circumstances in which it could be lawful. Whether or not state aid meets these criteria is at the sole discretion of the Commission – and courts in member states are obligated to enforce the commission’s decisions. The Commission has adopted an approach that considers, among other things, the existence of market failure, the effectiveness of other options, and the impact on the market and competition, thereby allowing state aid only in exceptional circumstances.

For many parts of the UK, the challenges of industrial decline remain starkly present – entire communities are thrown on the scrap heap, with all the associated capital and carbon costs and wasted lives. It’s high time the left returned to the possibilities inherent in a proactive industrial strategy. A true community-sustaining industrial strategy would consist of the deliberate direction of capital to sectors, localities, and regions, so as to balance out market trends and prevent communities from falling into decay, while also ensuring the investment in research and development necessary to maintain a highly productive economy. Policy, in this vision, would function to re-deploy infrastructure, production facilities, and workers left unemployed because of a shutdown or increased automation.

In some cases, this might mean assistance to workers or localities to buy up facilities and keep them running under worker or community ownership. In other cases it might involve re-training workers for new skills and re-fitting facilities. A regional approach might help launch new enterprises that would eventually be spun off as worker or local community-owned firms, supporting the development of strong and vibrant network economies, perhaps on the basis of a Green New Deal. All of this will be possible post-Brexit, under a Corbyn government.

Lastly, there is procurement. Under EU law, explicitly linking public procurement to local entities or social needs is difficult. The ECJ has ruled that, even if there is no specific legislation, procurement activity must "comply with the fundamental rules of the Treaty, in particular the principle of non-discrimination on grounds of nationality". This means that all procurement contracts must be open to all bidders across the EU, and public authorities must advertise contracts widely in other EU countries. In 2004, the European Parliament and Council issued two directives establishing the criteria governing such contracts: "lowest price only" and "most economically advantageous tender".

Unleashed from EU constraints, there are major opportunities for targeting large-scale public procurement to rebuild and transform communities, cities, and regions. The vision behind the celebrated Preston Model of community wealth building – inspired by the work of our own organisation, The Democracy Collaborative, in Cleveland, Ohio – leverages public procurement and the stabilising power of place-based anchor institutions (governments, hospitals, universities) to support rooted, participatory, democratic local economies built around multipliers. In this way, public funds can be made to do "double duty"; anchoring jobs and building community wealth, reversing long-term economic decline. This suggests the viability of a very different economic approach and potential for a winning political coalition, building support for a new socialist economics from the ground up.

With the prospect of a Corbyn government now tantalisingly close, it’s imperative that Labour reconciles its policy objectives in the Brexit negotiations with its plans for a radical economic transformation and redistribution of power and wealth. Only by pursuing strategies capable of re-establishing broad control over the national economy can Labour hope to manage the coming period of pain and dislocation following Brexit. Based on new institutions and approaches and the centrality of ownership and control, democracy, and participation, we should be busy assembling the tools and strategies that will allow departure from the EU to open up new political-economic horizons in Britain and bring about the profound transformation the country so desperately wants and needs.

Joe Guinan is executive director of the Next System Project at The Democracy Collaborative. Thomas M. Hanna is research director at The Democracy Collaborative.

This is an extract from a longer essay which appears in the inaugural edition of the IPPR Progressive Review.

 

 

This article first appeared in the 31 March 2008 issue of the New Statesman, Is Boris a fake?