Protecting the Commons in the Age of COVID-19

By Michael Gordon, MD, MSc, FRCPC

The idea of the Commons goes back to the Englishmen William Forster Lloyd (1794-1852) and Garrett Hardin (1915-2003) who framed an understanding of the idea that; the common property such as grazing lands which was expanded to much of the world’s goods must be shared in a way that does not disadvantage others who should benefit from the resources that the Commons provide.¹ It was focused first on the grazing lands in Britain that were not private and the tendency of one person or farm to take advantage of the grazing sites to the detriment or exclusion of others. Over the years the concept has expanded to include for example the air, water, forests, scenery that should be for the benefit of all.

In more recent time, it has become clear that many of us, including governments and in most western societies if not elsewhere, have developed the notion within the construct of private property that has encompassed what might be interpreted as being part of the Common. With the progression of capitalism in the western hemisphere, the idea of ownership of resources that are necessary for the national best interests of a population has been adopted as the engine that drives the economies of most western nations.

But even within that social and economic structure, there appears to be an important niche for the concept of the Commons with some people and leaders pushing for more in the public domain in contrast to more in the private domain—hoping for a mix that promotes national security and wealth and population prosperity. We witness, however, major disparities in how the previous designated Common’s properties have gradually become part of the private domain of individuals and jurisdictions.

Following physician William Harvey in 1665 when he discovered and elaborated on the circulation of the blood, Microscopist Jan Swammerdam discovered red blood cells. In 1665, English Physician Richard Lower kept dogs alive by transfusing blood from other dogs. In 1818, British obstetrician James Blundell performed the first successful transfusion of human blood to a patient for the treatment of postpartum hemorrhage. In 1901, Karl Landsteiner, an Austrian physician, discovered the first three human blood groups.

In 1941, the Red Cross began the National Blood Donor Service to collect blood for the US military. Soldiers injured during the Pearl Harbor attack were treated with albumin for shock. Since the end of the second world war there have been dramatic advances in the blood donation and transfusion systems world-wide.²                 

One has to consider blood a special human resource potentially part of the Commons that often helps save lives and must be used very judiciously.         

When I moved to Boston in 1968 to do a medical internship my apartment was near the famous Kenmore Square, the “green giant” wall of Fenway Park stadium, home of the Boston Red Sox. They finished 4^th in the American League pennant quest the year I lived there. I could hear the roar of the fans from my apartment during night games or on weekends if I was not on hospital duty.

I lived in the basement of a brownstone row house and the floor above had a private blood donor service. In those days it was legal before the FDA forbade the practice to the favor of the American Red Cross and non-for-profit agencies with the latter using blood for the purpose of removing the cells to obtain plasma. When I left for work, I would note the donation clientele waiting in line outside the clinic, which included many patrons that appeared to be at the lower end of the socio-economic population. Some I recognized as “frequent flyers” even though there were limits on frequency of donation. They were paid on the spot after they gave the blood. I was not used to that arrangement as having trained in Scotland. There, the health care system was part of the National Health Service (NHS), and blood donation was all in that service through the Scottish National Blood Transfusion Service (Scotblood).

That bizarre arrangement whereby the donation of blood to save a life was made into a commodity, came home to me one night when one of my patients—a twin that had donated a live kidney to his brother was bleeding from the kidney removal surgery. I and another intern where on duty. The donor brother needed blood—it was the intern’s duty to get the blood, usually through one of the donor services as existed above my apartment. I spoke to the other intern and expressed my hesitancy to call that commercial provider based on the clients from whom they obtained the blood. Although Hepatitis was a known risk from blood transfusions at the time, one cause was called Australia antigen (later hepatitis B) for which at the time there was no test to see if it was in the donated blood.

After I explained my concerns, I proposed a plan to my co-intern and we agreed to “bleed” each other for a unit of blood giving two units of fresh blood which we hoped would stem the internal bleeding. We did it in a small procedure room and the two units were ready in the special transfusion bags that were in stock. We hung the blood and watched the patient diligently and rejoiced (quietly) as his pulse and blood pressure returned to normal levels. He stabilized and from thereon showed no further evidence of bleeding.          

The next morning my chief of medicine called me into his office for what I thought was going to be a compliment for my decision, but rather reprimanded me (and my colleague) for not following protocol and potentially putting my health at risk by donating a unit of blood. A premise I could not fathom—as a 27-year-old healthy male a unit of blood being removed would not likely cause a problem that two glasses of orange juice would not correct. The kidney donor stabilized. His sibling recipient survived and lived for many years despite the lack of immunosuppressant medications that did not exist at that time.

The question that this encounter raised for me was, “why was donated blood not part of a medical service that served all in need as it was in the UK?” Since I have been in Canada, I have become accustomed to a health care system as I witnessed in the UK and many other countries in Europe, that are for the most part accessible to all citizens and residents without any out-of-pocket payments other than for some special circumstances which are often contentious. It is not that it is “free,” but it is part of a universal health care system paid for out of general taxation revenues. All of our citizens share in its funding and in its benefits.

In many ways, that arrangement reflects the concept of the Commons, but in this instance, the “medical commons.” We do medical research and our discoveries belong to the world population even though there are those who by financial arrangements are willing to deprive some members of the public, and many may not have access because of social or financial circumstance. Just imagine if the Salk vaccine only went to those with funds to pay for it—the polio epidemic would not have ended as fast as it did. As a teenager during that epidemic, I recall the newsreels showing thousands of people in iron lungs because they could not breath as an effect of polio.

Recently as part of the worldwide coronavirus pandemic, Americans have tried to buy the rights to a potentially effective vaccine tested by the Germans for use as a priority in the United States. Thus far, the German prime minister has turned them down, but a partnership between two large pharmaceutical companies has just been completed with the commitment that any success would be shared world-wide.

Recently a couple in Vancouver were discovered to have made more than $100,000 buying up vast quantities of Lysol wipes and selling them at a huge profit online. They were finally exposed and explained their scheme on the basis of them being “hustlers,” and knowing that the shortage was causing panic buying. They were shut down and now have thousands of canisters in their garage that they cannot sell. On a very small scale, this an example of citizens not respective of the concept of the Commons—financial benefit at the expense of others during a world crisis.

There are many different aspects that go against the concept of the Commons like potable water, which we know virtually disappeared in Flint Michigan as the rule of the Commons was ignored for political/financial purposes, or even the use of fossil fuels as demonstrated by the rampant air pollution in parts of the world and the disappearance of polar ice. I feel that the rule of the Commons should be the 11^th commandment—thou shalt protect the Commons. 

The coronavirus epidemic may challenge us to rethink the idea of protecting the Commons. I think Moses would have gone along with that.

Dr Gordon is a geriatrician and ethicist; formally medical director and head of geriatric medicine at the Baycrest Health Science Centre in Toronto. He trained in medicine at the University of St. Andrews in Scotland and in medical ethics at the University of Toronto. He has traveled and lectured widely and is a medical writer having published a number of books the most recent ones being Parenting your Parents: Straight talk about Aging in the Family—co-authored with Bart Mindzenthy.

References:

1. Protecting the Medical Commons: Who Is Responsible? [published online July 31, 1975]. N Engl J Med. 1975; 293:235-241. DOI: 10.1056/NEJM197507312930506
2. Advancing Transfusion and Cellular Therapies Worldwide. Highlights of Transfusion Medicine History. https://www.aabb.org/tm/Pages/highlights.aspx. Accessed March 2020.