This article, extracted from Prospects, (Feb 28th, 2020) touches on two of the most complicated or delicate issues in global health governance. By its original title – “The Unpalatable Lesson of Coronavirus: Dictatorships Can Be Effective” – the most delicate issue is the freedom/authority divide that divides the Western world and Others in managing global health crises. The author, an epidemiologist, is arguing, in the case of COVID-19, that “the discipline of public health inherently prioritises the collective good over individual freedom”. The second complication is what the title privileged here by the principle of localization in journalism raises. It is the fact that it would have been a pandemic by now if it had happened in Lagos or Dhaka, two global peripheries. That is to say that, under globalisation, underdevelopment anywhere in the world is a threat to international security. Raising these two issues in one article makes this an unusually interesting and, still, timely piece for both the world and countries that are just being enveloped by the epidemic. Read on!
When the World Health Organisation Director-General, Tedros Adhanom Ghebreyesus, declared Covid-19 a public health emergency of international concern, he urged countries not to restrict travel or trade with China. “It is a time for solidarity, not stigma,” he said, just two days after British Airways and other airlines announced they were suspending all direct flights to the Chinese mainland. He also repeated a clarion cry for transparency (“facts, not fear; science, not rumours”).
Meanwhile, out of the other side of Tedros’s mouth came praise for China’s response to the coronavirus, which began with suppression of reports of the outbreak, including those posted on social media by the unjustly vilified whistleblowing doctor Li Wenliang, who later died of the disease. When facts could no longer be written off as rumours, there followed the virtual shut-down of a city of 11m people, and draconian travel restrictions nationwide.
Tedros has taken flack for his apparently contradictory stance: calls for transparency and solidarity on the one hand, praise for Beijing’s authoritarian response on the other (roadblocks around major cities; potentially exposed people frog-marched to testing). Chinese social media is awash with images of him as the dog of President Xi Jinping. But his position highlights something we in the global health mafia do not admit: the discipline of public health inherently prioritises the collective good over individual freedom. Authoritarian regimes trample on individuals, but can also be good for public health.
Public and private welfare are not necessarily in conflict, and in the long run, too much trampling is bad for everyone. But at the start of an outbreak, when resources are scarce and knowledge scarcer still, the authorities are never going to have the luxury of engaging in broad community consultations that might lead to a fair balance of interests. Their first concern is bound to be to avoid unnecessary public panic (the charitable view) and/or (more realistically) to save face and avoid damage to the economy. Hence the counterproductive early cover-up. When they can no longer close their eyes to the possibility that a new pathogen poses a real threat, however, those rare governments that care about the public good and have the clout to impose their will tend to do so rather rapidly. They’ll do this even if it means sacrificing temporary freedoms, welfare or, in extremely unhappy cases, the lives of some individuals. Those sacrifices are emotionally devastating: witness the outpouring of fury over the injustice done to doctor Li—co-opted as a heroic whistleblower by the state only after his death, and long after it had tried to shut him down. But in terms of putting a brake on the spread of a pathogen of as-yet-unknown virulence, it behoves us to admit that they’re probably quite effective. When Tedros says “in many ways, China is actually setting a new standard for outbreak response,” he’s not just flattering Beijing.
Tedros’s two-faced messaging highlights another fact, too: the WHO can’t impose its will on its shareholder states, and tiptoes especially carefully around the more powerful of them. China will play ball internationally if and when it suits its interests. Chinese scientists quickly shared eye-watering amounts of genomic data, for example, not just to show off the country’s extraordinary capacity for sequencing, but also in the hope that others would use it to speed up the development of new diagnostic tests, therapies and vaccines. It has been stingier with clinical data, which is needed to predict the course of the epidemic, but which also tends to highlight weaknesses in local health systems. And there’s not a damned thing the WHO can do to get that data.
The current outbreak allows for an interesting thought experiment: what if the virus had emerged not in Wuhan but in Lagos or Dhaka? Firstly, it would probably have spread a lot further within its epicentre city before being detected, simply because the sick often wait longer to go to hospital, and because reporting systems are more fragmented than in China. Without the iron fist of a single ruling party, and with opposition politicians and a mouthy civil society defending individual freedoms and the rights of traders, transport workers and other sectors dependent on mobility, it would be harder to impose travel restrictions to contain the virus within that epicentre. That implies more spread across and between countries.
Limited local capacity for gene sequencing and clinical research would suck in overseas groups who would try to impose protocols and export samples. This would put up the backs of the local research community. Another lesson from Ebola: local governments might see an opportunity to charge for access to patients or samples. These things would delay development of diagnostics, therapies and vaccines. And the pharmaceutical industry might be slower to bring its firepower to ramping up production of commodities developed through publicly-funded research in states with smaller budgets than China.
Finally, those who do get infected would be more likely to die than in China, because there are fewer health facilities, with fewer trained staff and ventilators. A spate of deaths in Iran (equally authoritarian, much less well equipped) augers poorly for countries with even sparser resources. Other countries are also vanishingly unlikely to be able to knock up new facilities over a long weekend, as happened in Wuhan. Less reporting with more deaths translates into a higher apparent case fatality rate, more public anxiety, and yet more damage to local economies.
While it’s easy to criticise China’s heavy-handed response, the rest of the world should be grateful. At the very least, it has given other countries, such as the UK, that are not equipped with uncomfortably effective authoritarian tools, time to prepare to mop up any virus that escapes the Chinese net.