Darren Dookeeram1,2, Francesc Serra Massansalvador2, Satesh Bidaisee3
1 Sangre Grande Hospital Eastern Regional Health Authority, Trinidad and Tobago.
2UNITAR/ UOC, Barcelona Spain.
3 Department of Public Health St. George’s University, Grenada.
School of Pharmacy,
University of the West Indies,
Trinidad and Tobago
Email: [email protected]
Copyright: This is an open-access article under the terms of the Creative Commons Attribution License which permits use, distribution, and reproduction in any medium, provided the original work is properly cited.
©2021 The Authors. Caribbean Medical Journal published by Trinidad & Tobago Medical Association
The Caribbean region, like the global community, has been significantly affected by the COVID-19 pandemic over the last year with marked mortality and morbidity. The region has several vulnerabilities that affect and impair a robust health and social response to such an intricate problem. The presence of multiple small island states with heterogenous governance and healthcare systems makes the response to a global problem individualized and small scale. This increases the likelihood of larger nations and economies acquiring healthcare consumables such as Personal Protective Equipment, testing equipment and medication ahead of the region. Economically, with several of the island states being dependent on tourism, the downturn in global travel and restriction of movement puts significant strain on efforts to sustain and rebuild. The focal question of this paper is whether a supranational entity in the Caribbean would have mitigated against these threats better than individual states. This is assessed through the lens of healthcare systems and should lead academics to a discussion on whether this is feasible and worthwhile.
KEYWORDS: Caribbean, COVID 19, pandemic, governance, supranational
The Caribbean can be described in geographical terms as a cluster of islands spanning 1,200 miles from the peninsula of Florida to the northwest coast of Venezuela (1). A political description of the area is less defined and hinges upon the imperial history of the region characterised by recurrent themes of enslavement, forced migration and imposed systems of governance since the 15th century (2). Centuries after, the remnants of colonialism in the Caribbean are evident with sharp divisions in language, culture and governance structure with a lack of cohesion amongst all of the islands in the region (3). This is reflective in the modern governance structures within the region with now independent states largely adopting structures similar to their former colonial sovereigns. This is especially marked within the English-speaking islands where some states remain with the Queen of England as their head of state and the republican states as members of the commonwealth (4). The first attempt to unify the governance structure of the Caribbean came in 1958 with the West Indies Federation but this was short lived because of the perceived inequity of trade agreements by the larger islands (5). The collapse of the Federation was noted to be multi-factorial. At the political level, it was seen as a plan by the British government to pass responsibility for smaller colonies to Jamaica and Trinidad and Tobago which became an economic concern for them both as this represented a threat to the limited labour markets that existed at the time (6). This was succeeded by the Caribbean Community, known as CARICOM, which was based on the key pillars of economic integration, foreign policy coordination, human and social development and security (7). It is important to note that despite the achievements of CARICOM since its inception, that the design was conceived as a community of independent states combined to pursue a series of objectives, measures and tasks that fledge away from a supranational entity and towards one of a multilateral association with measured integration (7). This intergovernmental cooperation is evident in the numerous organizations that have been formed, the foremost of which is the University of the West Indies which has grown from a subsidiary School of Tropical Medicine to an internationally relevant and expanding entity with a growing culture of academia and excellence (8). The success of the university is a positive sign of integration and intergovernmental efforts and is funded collaboratively by multiple islands. The lofty ideals for continued economic, political and security integration of the region face challenges and threats that are both external and internal as the region attempts to remain relevant with the massive economies of North America by establishing supranational policy for functional cooperation (9). To further complicate an analysis of the Caribbean is the presence of Cuba and neighbouring Venezuela which have aligned against the United States but retain some interaction with other governments in the Caribbean. While the hostile impact of the Cuban regime has softened over the last decade, there remains significant caution with Venezuela as an actor within the Caribbean region (10) (11).
Given the complex overlay of the geopolitical landscape and presence of embedded hostile actors, the important question of security in the Caribbean comes into focus. It is understood that security is a contested term that includes military considerations but has been broadened to include political, economic, societal and environmental aspects (12). The COVID-19 pandemic has been noted by the United Nations to be debilitating to nations and as having a “range of negative social, economic and political consequences” (13). The population adjusted health consequences of COVID-19 in the Caribbean has been similar to the rest of the world with specific vulnerability of the health systems because of limited capacity (14). The threat to security to the Caribbean caused by COVID-19 is two-fold, firstly, due to the resultant difficulty in dealing with a surge in the number of infections because of limited health system capacity and secondly, because of the economic fallout in a region that is heavily dependent on tourism and human mobility (15). The purpose of this paper will be to determine whether the island states of the Caribbean should adopt a supernational model of governance in the wake of COVID-19. The associated hypothesis is that the socio-economic security threat posed by COVID 19 in the Caribbean would have been less if a supernational system had been in place to allow a more coordinated and robust response to the pandemic.
Importance of the Question
The Caribbean is noted to be a diverse region with significant economic potential and the opportunity for growth (16). However, individual islands fade in comparison with regional blocs resulting in a stunted effort for diversification and a lower value in primary exports (17). From a realist view, the security of island states is heavily dependent on tourism to support the macroeconomic forecast and provide incoming cash flows. Therefore, as islands compete for tourists to patronize their markets, nationalistic notions become more prominent and economies become more polarized (18). Internally, each island state becomes charged with the responsibility of mitigating cyclical risks and uncertainties associated with the markets within which they trade (19). Haiti is an extreme example of the vulnerability of Caribbean states to becoming impoverished. Although multifactorial and borne out of internal conflict from colonial power, Haiti’s inability to create profitable trade relationships with other nations post-independence ultimately decimated the economy (20).
From an external view, security in the Caribbean region remains a topical global discussion because of the noted illicit activity that affects key global actors. It is thought that the Caribbean is a gateway and transit point between producers of illicit substances in the developing world of Latin America and downstream users in the developed world of North America and Europe (21). This is compounded by the current crisis in Venezuela which has displaced close to 10 million persons into neighbouring countries, including into the Caribbean (21). The external importance of the Caribbean region can also be seen in its natural reserves of oil and gas, which may not be as vast as members of the OPEC, but does represent a source of hydrocarbons to the developed world that is more reliable and less prone to state conflicts (22). Finally, because of the vast maritime resource in the Caribbean, navigational routes are pivotal for trade and represent a key element of access to the Panama Canal for cities of the east coast of the US to be able to trade with Pacific partners (23).
The COVID-19 pandemic has caused economic instability in the Caribbean region which threatens the security of the region and by extension has the potential to disrupt any of the key concepts outlined above making the stabilization of the region a priority of all island states. In a CARICOM review on the pandemic, the challenge faced by island states was described as an opportunity to rethink engagement as the region begins to rebuild itself (24). Although it has been noted as a conflicted term, security in all its variations has been seen in the literature to improve with cooperation and regional integration (25). This begs the question of whether the Caribbean response to the pandemic of 2020 would have been more robust had a supranational system of governance was in place instead of multiple individual actors facing the burden of a health and economic disaster. This paper will seek to argue that a supranational entity would not be the best solution moving forward and that a stronger multilateral association would be most feasible and functional.
To address the question of whether the COVID-19 experience should prompt the Caribbean to adopt supranationalism one must first appreciate health systems delivery and quality improvement as the base metric of this argument. The World Health Organization states that “integrated health services encompass the management and delivery of quality and safe health services so that people receive a continuum of health promotion, disease prevention, diagnosis, treatment, disease-management, rehabilitation and palliative care services, through the difference levels and sites of care within the health system, and according to their needs throughout their life course” (26). In a more actionable manner, effective engagement of the health system should include the appropriate provision of human resources, clinical guidelines, operational essentials and financial support for the health system be robust enough to accommodate surge and variation (27).
The expectations of the health system in the Caribbean to deal with COVID-19 can be similarly categorized with the understanding that during the pandemic healthcare remains an essential service. Systems were asked to create alternate and parallel service delivery systems for the treatment of suspected cases as well as continue the delivery of routine care. In order to accomplish this, the human resource element was expected to extend usual roles and realign according the evolving needs of the population, the clinical guidelines required continuous updating as more information was gathered from scientific rigor across the world, operational needs were expanded to mitigate risk by providing personal protective equipment, testing and expanding critical care capacity and finally the system was required to channel funding towards these changes (28). Responding to disasters in the Caribbean is a common occurrence because of the prevalence of natural disasters like hurricanes and this is often accompanied by financial and physical assistance from larger neighbours in the hemisphere (29). This was not fully feasible at the height of the pandemic because neighbouring countries were being similarly extended to capacity, thus leaving individual island states to respond in isolation, with their already burdened health systems, to an incessantly evolving problem. Additionally, COVID-19 has proven globally to have a debilitating impact on not only health systems but also on social development and the economy. This justified an accelerated financial allocation to the health response with an aim of curbing the spread of the disease (30). This dilemma of needing to allocate more resources but having limited access to disposable income prompted many countries to depend on international funding to sustain their health and economic responses at the time (31).
A supranational system in this instance would be defined as governance arrangements where sovereign states delegate some of their independent decision-making capabilities to a body or forum that stands above the nation state (32). The state as an actor loses the ability to veto and becomes bound by the majority decision of the cooperating states which moved away from realist into libertarian theory; an alternative of intergovernmentalism also exists where states retain some degree of sovereignty (33). In this context, the realist view is considered to be a pessimistic one where nation states persistently compete and are likely to enter conflict in the interest of self-preservation whereas the liberalist view is one of enhanced interaction and interstate cooperation and development (34). To answer the question of whether a supranational Caribbean system would have improved the COVID 19 response one should examine key elements of the response in terms of national security, health and the economy. The analysis of these elements in this order allows a picture of a response to this threat in terms of preventing transmission through limiting human movement, provision of treatment though the health system and protecting the economic interests of the state from the fallout of restricted movement and illness. The question would therefore hinge upon whether such integration of Caribbean governments into a supranational entity would have made the response more robust and effective.
In terms of the national security element, the majority of nation states were forced to fully or partially restrict movement through the borders in an attempt to curb the influx and subsequent spread of COVID-19. Notwithstanding this, many were forced to reopen in phases to allow their economies to benefit from the tourism industry despite the obvious risk (35). The major challenge to this has been the existing porous borders which is thought to result from high maritime traffic, largely unmanned coastal landings and the presence of Venezuelan refugees fleeing into the Caribbean (36). The supranational system in the European Union has been noted to boost border protection from undocumented movement of persons through migration controls and a similar argument can be made for the Caribbean (37). This comes with a unique human rights challenge that has already materialized in Trinidad and Tobago, where despite a fully closed border, Venezuelan migrants were detained upon landing and deported which caused national and international outrage (38). More significantly, unlike Europe, the borders in the Caribbean are entirely maritime with a markedly smaller sum total coastal protection and, therefore, even with pooled defence it would be unlikely to resolve this issue. It would therefore be more realistic to engage in multilateral partnerships to ensure maritime protection in nations that are most vulnerable. This would not reflect the situation for the majority of islands and therefore would not justify a more robust response.
In terms of the health element, key gaps have been cited in the response in the Caribbean by the Commonwealth Medical Association which included challenges with adequate and appropriate staffing, inconsistent practice guidelines, difficulty in securing testing and personal protective equipment (PPE) because of vulnerable supply chains, resource limitation, inconsistent data science (39). Firstly, in terms of staffing allocations, it has been noted that a coordinated response is more effective and the need for realignment is common during COVID-19 in terms of what service a provider is expected to deliver as well as at which institution (40). It therefore stands to reason that in a supranational system, this would be more efficient and coordinated and healthcare worker utilization would be more appropriate. Additionally, a supranational system would encourage healthcare professionals to deliver more standardized care if guidelines were established for the entire region as opposed to individual nation states. While this may exist to some extent through the University of the West Indies, it is not mandatory and leads to variation in service delivery (39). Secondly, as the pandemic escalated, large manufacturing industries of Asia were affected. As a result, there were direct and indirect risks to supply chains which became an increasingly glaring problem for health, agriculture and processing in the Caribbean (41). It has been noted that supply chains in the Caribbean suffered from inertia, lack of competitiveness and unnecessary logistic challenges which decreased the ability of the island states to procure vital testing and equipment materials available as larger economies easily outmanoeuvred the region (42). This is evidenced by the late rollout of vaccination drives in the Caribbean which started months after the larger economies of North America and is inextricably linked with a delay in returning to any normalcy in national function and wellbeing (43). This is a point strongly in favour of a system in which collective bargaining would unify the demand for the region and make it competitive in the world markets as a consumer. However, one must question whether the islands of the region would need to relinquish their sovereignty to accomplish this or if an alternative unified negotiation entity, such as ASEAN, would be equally effective to benefit from the economy of scale. Finally, the role of data science has never been more pertinent than during the pandemic because of its role in contact tracing, artificial intelligence modelling of disease progression in the world, telemedicine solutions, innovative treatment methods and public safety (44). It has long been noted, however, that the Caribbean has significant challenges to data science because of high upfront costs, variable availability and lack of political investment (45). Similar to the previous point, a collective state would have the ability to coordinate this effort better and would have benefitted from the use of data science in meeting the challenge posed by the pandemic. One must again question whether this could be achieved without relinquishing sovereignty. If one draws upon the mobile health experience in India, for example, individual states are allowed to function autonomously for their massive populations while integrating with other states effectively (46). While this example does not deal directly with issues of sovereignty, it does reflect that health data integration is feasible in a system of dichotomous governance. It must be noted though that a supranational entity would not be necessary to achieve this level of integration and multilateral intergovernmental partnerships would be equally effective.
In terms of the economic element, the Caribbean was noted to have limited fiscal space even before the pandemic because of high debt to GDP ratios which impacted negatively on the ability of individual states to raise capital to drive economic recovery stimulation (47). It has long been noted that small and micro states are inherently vulnerable in large markets and can be taken advantage of by transnational corporations that seek to benefit from tax reliefs (48). This point of economic sustainability may be the most valid to support a supranational entity in the wake of the pandemic in that smaller economies may be able to boost their production and development in a manner similar to that of the European Union (49). In fact, member states of the European Union, with the exception of Greece, were found to have a 12% gain in per capita GDP justifying economic security of membership (50). In the wake of COVID-19, island states must consider this as an attractive way forward to deal with future challenges. Economically, some element of supranationalism may be beneficial as is seen in the European Union. However, in the post pandemic phase where all economies are forced into a recovery phase, it would be unlikely that nations would engage in alignments that would potentially weaken or slow their rebuilding. Therefore, the will to cede elements of sovereignty, especially economic sovereignty, would be unlikely.
The challenges with the formation of a supranational entity must also be explored in the wake of the pandemic. From the health perspective, while it would benefit the operational structures of the health service delivery systems, a significant hurdle would be the variability in available infrastructure. In the short term, this is not something that can be corrected to meet the needs of the pandemic and moving forward, would highlight the differing baseline that exists among the individual island states. Another challenge will come from the existing diversity within the Caribbean itself and defining what states could be included in a proposed supranational entity given that there is significant variation in background, language and cultural heritage. It would be a significant obstacle that some islands that have not gained republican status are supported to some extent by former colonial rulers and would pose a challenge to amalgamating these islands. Finally, with the presence of Cuba in the Caribbean, it would include an element of political uncertainty given the historical and existing political discord that the communist regime has posed in the Western Hemisphere.
In conclusion, to use the health response as a justification for full integration in the future would not be a sound conclusion based on the lack of compelling arguments that it would have significantly improved the region’s response to the pandemic. While the notion of a supranational Caribbean state in the aftermath of COVID-19 is an attractive one in terms of the economic stability, the arguments presented do not justify foregoing sovereignty of each island state. Beyond the argument described, a look at the EU’s response to the pandemic has not been markedly different to that of the island states with similar difficulties and arguably worse case-loads per capita. Nevertheless, the basis of this argument is whether the response could have been improved with an alternative form of governance and integration in the region as represented by CARICOM. The vulnerability of such a system is also noted in the Pacific Islands forum which loosely integrates 18 nations in the Pacific Ocean and which faced similar setbacks because of the pandemic. This leads to the question of whether nation states, in the face of a pandemic, are less vulnerable in blocs or as individual sovereign states (51). Although the COVID-19 experience cannot therefore be used as a justification to prompt the Caribbean to adopt supranationalism, but instead should encourage individual island states to engage in meaningful trade, form negotiation blocs and share data while at the same time ensuring national security against the threats of natural disasters, refugee crises and domestic issues. This would be similar to what is seen in South East Asia with ASEAN. This would be a more integrated form of what currently exists with CARICOM and would allow multilateral cooperation that could benefit all island states. The formation of a partially integrated system would allow for the benefit of group bargaining and sharing of strengths in the health systems without the need for states to forego their sovereign rights and their ability to ensure sustainability.
Ethical Approval statement: This was not applicable to this paper.
Conflict of Interest statement: This paper was originally conceptualized as a part of a Master’s in International Affairs and Diplomacy by the Corresponding Author at the UNITAR/UOC. The supervising professors are listed as co-authors and have contributed to the development of the paper. The Universitat Oberta dr Catalunya Barcelona Spain has given permission for this submission.
Informed Consent statement: This was not applicable to this paper.
Funding statement: This was not applicable to this paper.
Authors’ contribution: Each author contributed to the formulation, writing and editing of this paper.
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