* We argue that the COVID-19 pandemic response has been characterised by a Derridean ‘political autoimmunity’, undermining a sustainable and equitable protection of global health. * This self-harming immunisation politics has been driven by a coalesce of national borderism, which excludes people on the basis of national borders, and patentism, which privileges the treatment of wealthy countries and people who can afford the patented medicines and vaccines. * To globally counter these politically autoimmune strategies now and in the future, we argue to remind political leaders and patent holders of today of the classical physician’s Hippocratic oath, and to strive for a truly inclusive, pandemocratic health politics beyond national origin and income

van Enk, Ben

van Houtum, Henk

van Uden, Annelies

Utrecht University Repository

 1van Enk B, et al. BMJ Global Health 2023;8:e012293. doi:10.1136/bmjgh-2023-012293The political autoimmunity of the COVID- 19 response: how national borders and patents undermine a sustainable and equitable global healthBen van Enk,1,2 Henk van Houtum   ,2,3 Annelies Marleen van Uden   3CommentaryTo cite: van Enk B, van Houtum H, van Uden AM. The political autoimmunity of the COVID- 19 response: how national borders and patents undermine a sustainable and equitable global health. BMJ Global Health 2023;8:e012293. doi:10.1136/bmjgh-2023-012293Handling editor Seye AbimbolaBvE and HvH are joint first authors.Received 13 March 2023Accepted 2 May 20231Human Geography, Planning and International Development, University of Amsterdam, Amsterdam, The Netherlands2Nijmegen Centre for Border Research, Radboud University, Nijmegen, The Netherlands3Copernicus Institute of Sustainable Development, Faculty of Geosciences, University Utrecht, Utrecht, NetherlandsCorrespondence toProf. dr. Henk van Houtum;   henk. vanhoutum@ ru. nl© Author(s) (or their employer(s)) 2023. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ.INTRODUCTIONLooking back at more than 3 years of the COVID- 19 pandemic, a painful picture emerges. Although the virus itself does not discriminate on origins and affluence, the political response has severely done so, with counterproductive global effects. Already from the very beginning of the pandemic, affluent countries hoarded as many medical supplies as possible for their ‘own’ people at the expense of people in less affluent coun-tries, which has worsened and lengthened the impact of the pandemic.1 2 To learn the lessons of COVID- 19 and conceptually enrich the debate on the ethics of global health inequalities, we employ the lens of ‘political autoimmunity’, a powerful political applica-tion of the biomedical term developed by the philosopher Derrida.3 We argue that a sustain-able and globally equitable protection against future pandemics, would require countering the selfish and self- harming immunisation politics of high- income countries (HICs), driven by a toxic mix of national borderism and patentism.POLITICAL AUTOIMMUNITYThe concept of political autoimmunity, as a political translation of the biomedical term, was introduced by the philosopher Derrida to describe the process where a political hegemon ‘in quasi- suicidal fashion, ‘itself’ works to destroy its own protection, immunises itself against its ‘own’ immunity’ (Derrida,3 p94). In explaining his philos-ophy, he himself uses the example of the war on terror, started by the USA after the trau-matic event of 9/11. He argues that, in order to protect its ‘democracy’ and ‘freedom’, the USA has constructed an enduring global war against terrorists, which has led to the killing of many innocent people in Iraq and Afghan-istan, Islamophobia and hostile migrant poli-cies. And hence has led to the autoimmune weakening of the ‘democracy’ and ‘freedom’ that it aimed to protect. For Derrida, the typical political autoimmunitarian disorder can be recognised in five symptoms: (1) a response of a political power; (2) aimed at preventing the repetition of a traumatic event in the past; (3) in a struggle with pervasive, anonymous and invisible forces, which are regarded to be unavoidable; (4) in order to avoid, at all costs, an apocalyptic future, while at the same time, not fully comprehending the nature of the response and the imagined future, leading to a double incomprehen-sion; (5) and in this response, replicating and internalising the hostile logic, producing the very result which the entity intended to avoid.3 4 This Derridean theoretical lens allows us to distinguish the countereffective and unethical processes in the response to SUMMARY BOX ⇒ We argue that the COVID- 19 pandemic response has been characterised by a Derridean ‘political autoim-munity’, undermining a sustainable and equitable protection of global health. ⇒ This self- harming immunisation politics has been driven by a coalesce of national borderism, which excludes people on the basis of national borders, and patentism, which privileges the treatment of wealthy countries and people who can afford the patented medicines and vaccines. ⇒ To globally counter these politically autoimmune strategies now and in the future, we argue to remind political leaders and patent holders of today of the classical physician’s Hippocratic oath, and to strive for a truly inclusive, pandemocratic health politics beyond national origin and income.copyright. on March 21, 2024 at Utrecht University Library. Protected byhttp://gh.bmj.com/BMJ Glob Health: first published as 10.1136/bmjgh-2023-012293 on 29 May 2023. Downloaded from 2 van Enk B, et al. BMJ Global Health 2023;8:e012293. doi:10.1136/bmjgh-2023-012293BMJ Global Healththe COVID- 19 pandemic which, we argue, have shown clear symptoms of such political autoimmunity.THE SYMPTOMS OF AN AUTOIMMUNE RESPONSE TO COVID-19In order to understand, what we term, the political auto-immunity of the response to the COVID- 19 pandemic, we have to briefly go back to the extraordinary speed with which this disease spread across the world. The dangerous global outbreak of COVID- 19 was, understandably so, seen as a traumatic event, to use the concept of Derrida. This event, globally mediatised via dramatic images, resulted in the global conviction that ‘something’ had to be done to prevent, in Derridean language, an apocalyptic future in which this pervasive, anonymous, and invisible enemy would freely ‘flood’ the globe. A Derridean double incomprehension existed, however, about the nature of the response and the imagined future. Governments had to react quickly, while in the absence of empirically tested data, uncertainty and incomprehension of the precise characteristics of the new COVID- 19 abounded. What is more, prior to the pandemic, there had been little political attention for and debate on the structural viral vulnerabilities in our globalised modes of production and consumption.5–7 It is in this double incomprehen-sion, that an autoimmune political response emerged. To this political response, we turn now.THE FIRST AUTOIMMUNE PANDEMIC RESPONSE: NATIONAL BORDERISMDespite the pervasive and global outbreak, and multiple calls for global coordination and efforts by WHO, the response to the pandemic has by and large been myopi-cally national. Put differently, the dominant response of governments has been based on what we term ‘national borderism’, ‘the discriminatory practice that essential-ises and politicises the value of human beings depending on which border (id)entity they are born into, reside in and/or travel from’ (Van Houtum8 and Van Houtum et al.9 p21–22). The result of this politics of ‘our people first’ was that in different phases of the pandemic, HICs hoarded vital health resources in hypercompetitive international rat races, in which lower- income countries (LICs) stood no chance.10 11 This ‘national borderism’, meant to protect the ‘own people’, has had the autoim-mune outcome of putting their own as well as other citi-zens at more risk, as it prolonged and exacerbated the pandemic. It gave room to higher infection rates and more mutations globally.1 2 What is more, the holders of the very passports who were outcompeted in the rat race of vaccines were consequentially denied access to most HICs because they were not vaccinated.12 That poorer third country nationals were consequently perceived to be corporally dangerous to ‘the own people’, ‘importing’ dangerous variants of COVID- 19 into the country, has provoked only more xenophobia, racism, and healthcare apartheid in a time in which global solidarity between all human beings was vital in the response to a global pandemic.THE SECOND AUTOIMMUNE PANDEMIC RESPONSE: PATENTISMWhat made the first mechanism of borderism even more powerful and persistent, is that it directly fed into another exclusionary response, what we term ‘patentism’. The dominant idea in the provision of public health-care resources is that their allocation via private patents would be most efficient and effective. This idea of what is often labelled as ‘benign monopolies’ has been fiercely defended by a coalition of the political power of HICs and large pharmaceutical companies, in an effort to protect their own economic interests.13 It is a neolib-eral health system in which principally (1) the research and development (R&D) of vaccine producing firms is sponsored by taxpayers, (2) the property rights of their newly developed products are ensured by governments, creating a global public dependency on only a few private companies, and (3) the selling of their health resources to the highest bidder, while funnelling their resulting profits to tax havens, is normalised. The result of this threefold health policy is that it autoimmunitively legiti-mised and spurred the vulgar and price- increasing grab-bing and hoarding race for health resources. While there were repeated booster campaigns in HICs and there was even vaccine wastage, inhabitants of LICs were hardly able to get their hands on one vaccine dose, turning the latter into what Bauman called the ‘human waste’ of a profit- seeking system.1 14 This health policy of and for the well- to- do has again autoimmunitively lengthened the pandemic,2 10 knowingly undermined the global soli-darity that was needed to overcome the pandemic, and enlarged global health inequalities by design.CONCLUSION: TOWARDS A SUSTAINABLE AND EQUITABLE GLOBAL HEALTHLooking through a Derridean lens of political autoim-munity helps to sharply bring to light how the two domi-nant responses of borderism and patentism to the global COVID- 19 pandemic, although intended as immunisa-tion, have proven to be a toxic and counterproductive mix. It has put more people at risk, has prolonged the pandemic, created a hotbed for new mutations, led to more victims, aggravated economic disparities, led to more xenophobia and racism, and drove more wedges between human beings globally. It is important to realise that these strategies do not exist outside a political will that has normalised them. This implies that it is also in humanity’s disposition, now, more than 3 years after the outbreak, to learn the lessons for future pandemics and start countering this autoimmune political mindset of borderism and patentism and make room for a new and different normality, that is both sustainable and equi-table. For this, we would argue, what is called for is a truly global and inclusive response: not for citizens of nation- states, but for human beings globally. Furthermore, copyright. on March 21, 2024 at Utrecht University Library. Protected byhttp://gh.bmj.com/BMJ Glob Health: first published as 10.1136/bmjgh-2023-012293 on 29 May 2023. Downloaded from van Enk B, et al. BMJ Global Health 2023;8:e012293. doi:10.1136/bmjgh-2023-012293 3BMJ Global Healthit is high time for a transition to no longer see health resources such as vaccines as private commodities but as global public goods. COVID- 19 has shown that solidarity across politicised and wealth differences between human beings is and cannot be a matter of empathy alone: it is also a crucial part of the solution. In that context, it is good to remind national politicians and pharmaceutical companies of the classic Hippocratic oath of physicians and its latest update by the World Medical Association that argues to treat people independent of their ‘age, disease or disability, creed, ethnic origin, gender, nation-ality, political affiliation, race, sexual orientation, and social standing’’ (Parsa- Parsi,15 p1971). To this end, we propose to add to this principle of non- discrimination a person’s wealth, which has been so influential in the deci-sion who receives critical healthcare during the COVID- 19 pandemic. The classic Hippocratic oath was grounded in, what the ancient Greeks called agape, a radically inclusive love for mankind for the pandemos (for all people).7 11 14 It is perhaps this classic, ethical grounding of health treat-ment, a pandemocratic approach for a pandemic, that can inspire us to help create a transformative, global governmentality and halt the proliferating autoimmune strategies of national borderism and patentism in global health now and in the future.Twitter Henk van Houtum @henkvanhoutumContributors BvE: investigation, co- conceptualisation, draft- writing, reviewing, editing. HvH: project idea and design, main conceptualisation, investigation, draft- writing, reviewing, editing, project administration, supervision. AvU: co- conceptualisation, reviewing, editing. The authors are listed in alphabetical order.Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not- for- profit sectors.Competing interests None declared.Patient consent for publication Not applicable.Provenance and peer review Not commissioned; externally peer reviewed.Data availability statement The data supporting the findings of this study come from publicly accessible sources which are mentioned in the article.Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non- commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.ORCID iDsHenk van Houtum http://orcid.org/0000-0003-3719-143XAnnelies Marleen van Uden http://orcid.org/0000-0002-9378-3248REFERENCES 1 McMahon DE, Peters GA, Ivers LC, et al. Global resource shortages during COVID- 19: bad news for low- income countries. PLOS Negl Trop Dis 2020;14:e0008412.  2 Hunter DJ, Abdool Karim SS, Baden LR, et al. Addressing vaccine inequity – COVID- 19 vaccines as a global public good. N Engl J Med 2022;386:1176–9.  3 Derrida J. Autoimmunity: real and symbolic suicides. In: Brault PA, Naas M, eds. Philosophy in a time of terror: dialogues with jurgen habermas and jacques derrida . Chicago, IL: The University of Chicago Press, 2003: 85–136. 4 van Houtum HJ, Bueno Lacy R. The Autoimmunity of the EU’s deadly B/ordering regime; overcoming its paradoxical paper, iron and camp borders. Geopolitics 2020;25:706–33.  5 Morse SS, Mazet JAK, Woolhouse M, et al. Prediction and prevention of the next pandemic Zoonosis. 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Decolonising human rights: how intellectual property laws result in unequal access to the COVID- 19 vaccine. BMJ Glob Health 2021;6:e006169.  14 Bauman Z. Wasted lives: modernity and its outcasts. Oxford, 2003. 15 Parsa- Parsi RW. The revised declaration of Geneva: a modern- day physician’s pledge. JAMA 2017;318:1971–2. copyright. on March 21, 2024 at Utrecht University Library. Protected byhttp://gh.bmj.com/BMJ Glob Health: first published as 10.1136/bmjgh-2023-012293 on 29 May 2023. Downloaded from 

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The political autoimmunity of the COVID-19 response: how national borders and patents undermine a sustainable and equitable global health

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