The Geopolitics of Disease

Laura Spinney. New Statesman, Volume 149, Issue 5508, February 2020.

On 28 January 2020 at the Great Hall of the People on Beijing’s Tiananmen Square—a symbol of the Chinese Communist Party’s political might—President Xi Jinping met Tedros Adhanom Ghebreyesus, the director-general of the World Health Organisation (WHO), to discuss the current coronavirus outbreak. “The epidemic is a devil,” Xi said. “We cannot let the devil hide.”

His words left Western observers puzzled. With nearly 60 million people already subject to quarantine measures in China, the nation’s leader seemed to be stoking fear by comparing the virus to a malign spirit. But he wasn’t doing anything of the sort. As the medical anthropologist and China specialist Christos Lynteris of the University of St Andrews told me, Xi’s words were targeted at a domestic audience—not at the WHO chief or the wider world—and were carefully chosen to reassure.

There’s a long tradition in China of comparing natural disasters, including epidemics, to demons, gods or spirits, and an equally long tradition of seeing them as heralding major political upheaval. One example is the Manchurian plague epidemic of 1910-11, which left an estimated 60,000 people dead. It remains vivid in the Chinese collective memory because of the many documentaries praising the plague heroes, such as the military doctor Wu Lien-teh, who fought to bring it under control.

At the time of that outbreak, China’s ruling Qing dynasty was weak. Its neighbours and rivals Russia and Japan had already run railway lines into mineral-rich Manchuria, in China’s north-east, and mandarins in Beijing were afraid that the epidemic would offer an excuse to invade more overtly, on the pretext of controlling the sickness. It was imperative that the Chinese bring the epidemic under control themselves—and so they did, mainly thanks to Wu, who had been trained in Europe according to the tenets of germ theory (the idea that germs can cause disease) and who imposed unheardof and draconian measures such as quarantine and cremation of plague victims.

The epidemic did not breach Chinese borders, and Wu was hailed a hero. His triumph did not spare the Qing rulers for long—they were overthrown in a revolution later in 1911, reinforcing the idea of epidemic as a harbinger of change—but it did cement an association in that country between quarantine and sovereignty. Mao Zedong’s 1958 poem “Farewell to the God of Plague” is well known in China, where it is taught in schools. In it, the Great Helmsman celebrates—prematurely, it turns out—the eradication of schistosomiasis or “snail fever” from large swathes of southern China.

When President Xi told the Chinese people that the devil could not hide, he was making both a public health statement and a political one. By evoking Wu and Mao he was reminding the public of the current regime’s strength and ability to manage the current crisis alone. The state’s gargantuan efforts to contain coronavirus—by putting mega-cities in lockdown and building hospitals in days—demonstrate that his weren’t idle words, as do reports that Beijing has ignored offers of help from the WHO and the US Centres for Disease Control and Prevention (CDC). But as we have learnt from historic epidemics, pathogens—organisms that cause disease—do not respect borders; the more we try to force them to, the worse the situation generally becomes. In a world moving ever closer to isolationism and returning to great power rivalry, it looks as if we’re going to have to learn that lesson again from scratch.

The WHO is itself the embodiment of this lesson. Inaugurated in 1946, it replaced a number of smaller international organisations including the health branch of the League of Nations, the international diplomatic group that collapsed at the start of the Second World War. The league was established in the wake of the First World War, but its health wing—which was set up in the early 1920s—was a response to the devastating flu pandemic of 1918-21, which killed an estimated 50 million people worldwide, as well as to the epidemics of tuberculosis and typhus that ravaged Europe in the immediate postwar years.

The WHO defines a pandemic as “the worldwide spread of a new disease” (an epidemic is confined to “a community or region”). It hasn’t called the outbreak of coronavirus a pandemic, but may do so yet. The 1918 flu pandemic broke out in spring in the northern hemisphere—though it was nicknamed the Spanish flu, its country of origin remains unknown—and circled the globe for the next three years. Only the most isolated places on Earth were left untouched—such as Antarctica and St Helena, a remote volcanic island in the Atlantic Ocean—and in general the poorest countries and the least well-off layers of society suffered most. India, for example, is estimated to have lost 18 million people to the disease—roughly the death toll of the entire First World War.

It was the most murderous pandemic in history in terms of absolute numbers. Serious cases looked nothing like ordinary flu. The bluish hue to the patient’s face recalled cholera, the bleeding from the nose and mouth resembled pneumonic plague. Flu is caused by a virus, but this was a relatively new concept in 1918, and most doctors thought they were dealing with a bacterium. With no diagnostic test, no vaccine, no antiviral drugs and no antibiotics—which might have treated the bacterial pneumonia that complicated the flu in fatal cases—they were almost completely helpless to fight it, and they often had, at best, incomplete knowledge of its impact elsewhere in the world.

The 1918 pandemic had long-term consequences. It is said to have accelerated the end of the First World War and interfered with the peace process, since it struck down many of the delegates to the Paris Peace Conference. It stalled the global economy and caused a wave of post-viral depression. In affecting mainly young adults—the average age of death in this group was 28—it impeded Europe’s ability to rebuild after the war, left legions of orphans and elderly people dependent on the state or charity, and shredded the fabric of societies everywhere. Reeling from the disaster, the world realised that countries needed to work together to combat such threats in future.

The WHO coordinates the sharing of information about emerging pathogens, as well as the international response via the legally binding instrument of the International Health Regulations. But today’s WHO is chronically underfunded and widely considered to be less competent than the CDC in its international operations. This worries national health agencies, even as their governments withhold the money that the WHO needs.

A lack of funding isn’t the WHO’s only problem; it has also been criticised for its unwieldy structure, in particular its expensive regional offices, and for its bureaucracy and inertia in emergencies. There has been a long-running debate over whether the organisation should be overhauled or dismantled. In March 2019 the WHO director-general announced sweeping reforms, both of the organisation’s structure and its funding arrangements, but some observers say it’s not clear how these will resolve the WHO’s fundamental flaws. In the public health community, however, even the WHO’s fiercest critics believe in the need for a strong, independent global health agency. One of the main reasons they give is the resurgence of infectious diseases, and particularly the emergence of new zoonoses—human infections of animal origin. This has accelerated in recent decades, as an ever-expanding human population pushes into new ecological niches and encounters new pathogens. The burden of these diseases inevitably falls most heavily on the poorest nations, which are least equipped to deal with them. But as we are now seeing, the entire world is vulnerable. Antimicrobial resistance—the ability of bacteria and viruses to resist drugs, driven by their overuse in people and animals—is gradually eroding the therapeutic power of our antibiotics and antivirals. And widespread vaccine hesitancy isn’t helping either.

All international organisations become weak and prone to malfunction when their member nations—especially rich, powerful ones such as the US—shun them. This also applies to the World Bank, which has been criticised since 2012 for ignoring the threats posed by pandemics and antimicrobial resistance, and neglecting the need for greater investment in poorer countries (a notable exception is the $250m grant that the World Bank recently approved to the Ethiopia-based Africa Centres for Disease Control and Prevention). As the health economist Olga Jonas of the Harvard Global Health Institute puts it: “The world gets what it pays for.”

On 30 January, after it became clear that human-to-human transmission of coronavirus had occurred beyond China, the WHO declared a global health emergency. This enabled it to release a raft of new recommendations and resources for fighting the outbreak, but, significantly, does not provide the WHO with legal powers of enforcement. At the same time, the organisation advised that restrictions on the movement of people and goods are counterproductive during epidemics. Today, the consensus in public health circles is that contagion control measures such as entry and exit screening at borders are more effective, assuming they can be properly implemented. Many countries promptly ignored this advice.

Most of China’s neighbours have closed their borders with it, and many other countries have imposed travel restrictions. A day after the WHO announcement, the US imposed a 14-day period of self-quarantine on US citizens returning from China, while entirely barring entry for non-citizens arriving from the same destination (Australia has done something similar). Some feel the self-quarantine was already overly restrictive for people who may have been nowhere near the outbreak’s epicentre in Hubei province, but making a distinction between US citizens and foreign nationals is nonsensical—as absurd as the Spanish response to the 1918 flu, which was to restrict cross-border travel for Portuguese citizens but not for their own.

If anything, such discriminatory measures make the US more vulnerable, by further damaging relations with China, with which it is engaged in a trade war. The US has also rendered itself more vulnerable to epidemics in another way. Revisions to the so-called public charge rule, which are winding their tortuous way through Congress, will link an immigrant’s chances of getting permanent residence to the burden he or she places on the public purse—including health-care costs. This increases the likelihood that immigrants will avoid doctors and that infectious diseases will go unreported.

Epidemics and pandemics have always been political and have always involved the policing of borders. By the 18th century, the Habsburg monarchy had erected a cordon sanitaire from the Danube to the Balkans, in the form of a chain of fortresses, supposedly to stop infection entering from the neighbouring Ottoman empire. Serving also as a military, economic and religious border—a demarcation line between Christianity and Islam—it was patrolled by armed peasants who directed those suspected of infection to quarantine stations built along its length.

Though China no longer needs to fear invasion, it still has problematic borders. It considers Taiwan a renegade province, and has stated its intention to bring the island under its control. But on 11 January 2020 the Taiwanese re-elected a president in Tsai Ingwen who is strongly anti-unification, and the travel restrictions her government has imposed to keep the contagion out inevitably reinforce the border that China would like to abolish, and that Taiwan would like to make permanent. China refuses to let Taiwan join international organisations including the WHO, and recently the Taiwanese foreign minister criticised the WHO for describing Taiwan, which has recorded 20 cases of coronavirus to date, as part of China. There have been widespread and sometimes violent protests in Hong Kong over the past year against what the protesters perceive as China’s intention to strip the special administrative region of its autonomy. Hong Kong’s chief executive Carrie Lam steers a fine line between antagonising the protesters and antagonising Beijing. After hospital workers went on strike in Hong Kong in early February, demanding the complete closure of the border with the mainland, she tried to placate them with a partial closure—and once again a border that China would rather see erased became more pronounced instead. There have also been reports that protesters are citing the Hong Kong government’s mishandling of the outbreak as a reason to keep up their fight.

Politically, disease control tends to be a no-win situation. Unfortunately for the decision-makers, it’s not just humans who confound their plans; pathogens have a habit of wrong-footing them, too. After a mild “herald wave” of infections in the early months of 1918, that receded around June tin Europe, the influenza responsible for the ensuing pandemic returned with increased force at the end of August, and most of the deaths were recorded in the 13 weeks between mid-September and mid-December 1918. Australia put in place a highly effective, countrywide quarantine that kept that second, deadly wave of illness out, but the authorities lifted it too soon, letting in a third wave in the early months of 1919 that left 12,000 Australians dead.

Even if, as some figures suggest at the time of writing, the rate of new coronavirus infections may have slowed in China, it would be dangerous to assume the worst is behind us. Two other coronavirus outbreaks—severe acute respiratory syndrome (SARS) in 2003 and Middle East respiratory syndrome in 2012—had no herald waves, that we know of. They also had different transmission and death rates to each other, and apparently (though it’s hard to say at this stage) to the new coronavirus, lately dubbed Covid-19. Each new virus behaves differently, and they can also mutate, changing their behaviour mid-epidemic.

Viruses are more agile than us: whenever a new one emerges we’re effectively responding to the last one. The WHO was widely perceived to have overreacted to the 2009 outbreak of swine flu, so it proceeded more cautiously when Ebola struck West Africa in 2014—and was duly criticised for its slow response. Memories of SARS are still vivid in China, and both the government and the population learned from it. The first cases were reported in Guangdong, in southern China, in November 2002. Over the next eight months SARS went on to infect around 8,000 people in 26 countries, and to kill close to 800, with most of the fatalities occurring in mainland China and Hong Kong. People were reminded that epidemics are to be feared, and the Chinese government discovered that it could no longer rely on unquestioning obedience to its diktats—especially if it was secretive about the true extent of the outbreak. In an information vacuum, fear and rumour spread, and riots erupted across the country.

Unfortunately, the government didn’t take away the most important lesson from SARS, which was the need to introduce evidence- based regulation of the live animal or “wet” markets that are the source of many zoonoses. On 22 January this year it temporarily banned trade in wild animal products, but we know these bans don’t work, because when one was imposed during the SARS outbreak it led to the explosion of a black market in such products. This is not surprising, given that Chinese people rely on wet markets for up to 60 per cent of their food, and millions of farmers rely on them for their livelihood. These are some of the reasons why the WHO relies on anthropologists such as Christos Lynteris to guide its response.

China is not alone in lurching from overreaction during a crisis to complacency once it has passed. To prepare the world to withstand future pandemics, the WHO keeps pointing out, we need to commit collectively to a number of long-term measures—especially investing in poorer countries.

Perhaps this time our governments will listen. On 10 February the investment bank Morgan Stanley reported that the outbreak in China, the world’s second largest economy, could be an obstacle to recovery in world growth. Supply chains have been disrupted globally, though it’s not clear how much this is due to the disease itself, and how much to counterproductive containment measures. A relatively small amount of funding for health infrastructure in developing countries, and a rational approach—including the scientific regulation of wet markets—could have prevented much of the damage inflicted by coronavirus.

Meanwhile, an unprecedented experiment in disease containment is under way in China. Will it work? “The cardinal rule of public health is to act based on the best available evidence and to deploy the least restrictive measure necessary to safeguard the public’s health,” wrote Lawrence Gostin, who directs the WHO’s Collaborating Centre on National and Global Health Law, on 3 February. Gaining the community’s trust is also key to a good outcome.

In the past, China’s response to disease has been highly restrictive. The government seems to have been more open this time—the rise of social media has made secrecy harder to maintain than it was in 2003—and so far people appear to have been broadly compliant. But there is frustration. There was indignation on social networks after the “whistleblower” doctor, Li Wenliang, died of Covid-19 infection on 7 February, having raised the alarm about a mysterious new virus back in December 2019, and subsequently been detained by police for spreading false rumours. And many have wondered why—if the government’s plan is working—Wenzhou, a coastal city 700km from the epicentre of the outbreak, was locked down on 1 February.

Medical historians have long noted that democracy is unhelpful in epidemics, when swift, decisive action is needed, and this outbreak is certainly putting an alternative governance model to the test. It has its own flaws. Chinese leaders have historically boasted of their ability to conquer disease as a sign of strength, but what happens if the disease wins? President Xi has concentrated power around himself, which makes him a more likely target of blame for an angry, frightened populace if the experiment fails. Perhaps that’s why he has retreated from the public eye recently, allowing his lieutenants to be seen managing the situation.

On 8 February the New York Times quoted a political writer in Beijing, Rong Jian, who compared the damage to the regime’s legitimacy caused by this outbreak with that caused by the Tiananmen Square massacre of 1989. Let’s hope Xi can bid farewell to the god of plague. Either way, we will have to wait and see what the consequences of this outbreak will be for Xi Jinping, China and the world.