Workers wait for medical waste to be delivered to their storage facility at the Youan Hospital in Beijing on Feb. 14. GREG BAKER/AFP VIA GETTY IMAGES
Article initially published in Foreign Policy on February 14, 2020 and written by Annie Sparrow.
Outbreaks are inevitable. Whether they become pandemics – the uncontrolled spread of contagious diseases across countries and continents – depends on our response. Pandemics have always depended upon fast travel networks and dense populations, once relatively unusual, now a global norm from Nairobi to Jakarta.
The Ebola virus outbreak in the Eastern Democratic Republic of Congo is one such pandemic threat. After more than 18 months, just three cases are left. Yet Congo and many other deeply vulnerable countries in Africa and elsewhere are already screening for novel coronavirus, expected to be the latest scourge. The spectrum of illness the virus causes is now referred to as COVID-19, a label that looks more like a license plate than a diagnosis.
The coronavirus is still technically only epidemic—it has not yet moved in significant numbers outside of China. As of Feb. 14 there were over 60,000 confirmed cases in China and fewer than 500 cases in 24 other countries. Four of those countries report cases where infection occurred outside China and outside the reporting country. Transmission between humans has occurred in at least 12 countries, predominantly limited to intimate contacts.
Cases on a cruise ship of 3,600 passengers, involuntarily quarantined, jumped to 174, while the virus jumped ashore anyway. Residents of a Hong Kong building infected 10 floors apart raise concerns of transmission through buildings—and of considerable concern is the transmission to 11 people by an apparently asymptomatic British citizen. Today’s report of 1,716 infected healthcare workers in China already exceeds the global total of healthcare workers infected during SARS in 2002-2003.
Uncertainty is the defining characteristic of any new pathogen. Analysts cannot be certain of transmission: how far and wide it will spread. Contagion and lethality are not fixed quantities but variables that change according to control measures, demographics, and quality of accessible health care.
How should the world respond as the threat mounts that the virus will go global? China has quarantined over 80 million people. Door-to-door searches for suspect cases are warehousing people in makeshift quarantine camps. Mandatory cremation, already a touchy subject, is fueling further upset. Hubei residents are now into their fourth week of total lockdown, while restrictions are tightening across the rest of the nation. Mainland China has been quarantined from Hong Kong. Over 50 countries have implemented travel bans or restrictions.
Before moving further down this path of coercion and limitation, it is worth knowing how this became the norm and considering whether these kinds of measures are the wisest response. This helps to put pandemics into perspective. A pathological obsession with highly visible and fast-moving biothreats must not distract from attention to broader public health measures and access to modern medicine for the populations they infect.
The biomedical bias in epidemic control responses, with their emphasis on quarantine and monitoring, is one of social exclusion. Epidemiology has a xenophobic quality, and the political character of pathogens determines the pathway of pandemics. No state can fully control the course of a virus, but the decisions about who lives and who dies are shaped by models that may not be the wisest, or the most effective, ways of considering global health.
Outbreaks are caused by zoonoses—diseases that jump from animals to humans. As jumping the species barrier requires considerable personal contact, this was, historically, a slow process. Malaria, for instance, took millennia to jump from primates to humans. Yet in the last 50 years, more than 300 pathogens have appeared or reappeared, driven by climate change, desertification, increased interactions between animals and humans, weak health systems, population growth, and urbanization.
Typically, outbreaks are contained using public health measures of quarantine, isolation, surveillance, and vaccination. This disease-control approach targets a single pathogen at a time. This process began with plague, a bacterial disease primarily transmitted by fleas living on black rats. Plague struck rapidly, caused agonizing and degrading symptoms, and killed fast—typically within three days. With an average kill rate around 70 percent, there were sometimes too few living people left to bury the dead. The second great global pandemic of plague, beginning in 1347 and lasting until the 17th century, killed approximately 100 million people—a quarter of the world’s population at the time.
The resulting widespread panics drove the first organized attempts at public health over the following centuries. Naval blockades, military quarantines, and cordons sanitaires were used to isolate cities and even entire countries. Boards of health identified suspect cases in door-to-door searches and forcibly imprisoned the infected in pest houses, a nasty innovation designed to protect other citizens, and they required family members exposed to plague to adopt a household quarantine for 40 days. Compulsory burial of the dead was enforced. Social distancing was facilitated by carrying a 3-foot pole to keep others at a safe distance.
In the 18th century in Europe and the Americas, the spread of smallpox, a viral disease transmitted only by humans, was facilitated by increasing urbanization and crowded living conditions. It killed one-third of those it infected—and permanently scarred all survivors. The English physician Edward Jenner’s smallpox vaccine, developed in 1796, provided a new public health measure of mass protection from the 1800s on.
By the early 19th century the idea of contagion was catching on. Although tuberculosis was the leading killer, it was cholera, the latest emerging threat, that was most feared—striking suddenly with humiliating symptoms and killing within hours. Europeans who assumed Western civilization was immune to what they called “Asiatic cholera” were appalled when it arrived.
Cholera drove the filth theory of disease. This aimed to prevent diseases by removal of filth using emerging technology: drains, sewers, water pipes. Although successful in reducing mortality, filth theory was based on the narrowest vision of public health and came at the expense of dealing with the much broader causes of disease.
When a third cholera pandemic arrived, xenophobic Westerners became afraid Europe would be permanently infested with a disease they preferred to associate with filth and poverty. They scapegoated Muslims making the hajj as travel by ship became more common. In 1851, the first of 14 international sanitary conferences (distant precursors to the World Health Organization), saw French efforts to implement a travel ban on Muslim pilgrims from traveling by sea, going so far as to recommend using colonial power to seal off the entire Middle East, a quarantine effort that would have been at least commensurate with those in China today.
The beginnings of the modern consensus on public health standards came in 1892, after the opening of the Suez Canal for use by all countries in 1869 made standardized quarantine regulations necessary. Participating states approved and ratified the first of four International Sanitary Regulations, the forerunner of today’s International Health Regulations, which commit all governments to stopping the spread of infectious disease and other global threats.
In the second half of the 19th century, germ theory, promoted by the French biologist Louis Pasteur, was consolidated after the German doctor Robert Koch isolated first the bacterium causing tuberculosis and then cholera, and the Hungarian physician Ignaz Semmelweis pioneered disinfectant and hand-washing.
Germ theory led to the biomedical model of illness, which assumes that each disease has a specific cause. It also led to tropical medicine, a medical construct designed as an instrument of cultural and ideological hegemony. Diseases that had been barriers to European colonization fell under the assault of the new technologies, carving safer spaces for Western power out of fever zones.
In Europe and North America, hygiene drove a sanitarian movement that reformed urban living through public health programs that improved living conditions across a broad spectrum of diseases: safe water, sanitation, waste collection, sewage disposal, ventilation, and so on. In the tropics, metropolitan powers applied tropical hygiene. Public health campaigns targeted single diseases specifically chosen to protect Europeans against the most menacing “tropical” threats. This approach—the West’s selective xenophobic attitude toward the global south—mirrors the Sanitation Conference in 1851 and the international response to the coronavirus today.
Then, in 1946, the World Health Organization (WHO) redefined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This was a radical shift from the “absence of disease” definition used by the Sanitary Conferences.
To enable this positive vision, the 1946 International Health Conference extended WHO from a narrow focus of negative aspects of public health—vaccination and tools to combat infection—to the positive aspects: better food, physical education, medical care, and health insurance. Health and social measures developed through national public health systems would serve to create “a common front against poverty and disease” to protect all countries.
But this new model couldn’t survive the simultaneous onset of the Cold War. The superpowers preferred a model of global health cooperation grounded in the international politics of disease control. This exerted pressure on WHO to default to disease control, widely considered suitable for the focus on medical and scientific technologies.
Today, the international response is still focused largely on diseases posing a threat to the West, and the official focus is still on containment. Endemic diseases that kill far more people, such as malaria, cholera, and TB, receive much less funding and attention, and root causes are not addressed.
Pathogens follow familiar routes. Germs are frequent flyers. So the extent of global contagion and risk of sustained transmission and endemicity depends on global cooperation.
The international response to the coronavirus outbreak is just the latest example. Although many Western countries benefit from the latest biomedical diagnostics and finest available medical care, much of the world lacks adequate health care.
The failure to invest in public health and access to health care means much of the world remains ill equipped to detect viral threats, protect front-line health care workers, prevent nosocomial transmission (which occurs within medical establishments), and treat those who fall ill.
Because of such factors, the kill rate of a virus depends in significant part on the quality of health care in a country, while its contagiousness is enhanced in health facilities lacking effective infection prevention control measures such as gloves, goggles, gowns, and patient isolation. This increases the risk of nosocomial infection of both patients and health care workers.
Today, the coronavirus disease may not be the first priority for health care workers or communities without access to health care.
Weak health care systems in many countries have hospitals that lack constant electricity and running water. Few can guarantee oxygen therapy, let alone offer intensive-care treatment. This means there is little incentive for people who are ill to voluntarily present for testing for the coronavirus, even when testing is available.
The limited number of diagnosed cases does not necessarily mean that the global spread has stabilized at the current 24 countries or that no local spread is occurring. Africa’s lack of cases, despite a high flow of traffic with China, is likely due to the continent’s lack of diagnostic capacity. So too may be Indonesia’s and Pakistan’s, among others.
If the virus makes it through the local summer in Africa or Indonesia, year-round transmission can occur. That would increase the likelihood of the coronavirus becoming endemic and epidemic, like malaria. And the virus would cause annual outbreaks every flu season, posing a sustained threat.
Although great hopes are being placed on a vaccine, a deployable vaccine is at best a year away. Vaccines are effective measures to prevent childhood illnesses. However, they can also divert us from public health measures that are as—and sometimes more—important. It was clean drinking water, sanitation, sewage control, and less crowded living that led to huge advances in human well-being, producing longer and healthier lives—not vaccinations alone.
And if we had the vaccine tomorrow, would it work?
Vaccines don’t protect us—vaccinations do. The anti-vaccine movement dates back to the smallpox vaccine, which despite its enormous success encountered public resistance. The near-global surge of measles and other vaccine-preventable diseases is a barometer of distrust in vaccines and authorities. That’s a particularly critical question in China, where a range of scandals have driven mistrust. The emergence in several countries of vaccine-derived poliovirus (a live polio vaccine that mutates into a virulent form) reflects critically low rates of vaccination. And in a weakened and poor population, vaccine uptake, and hence immunity, is compromised by severe malnutrition, malaria, and other diseases. Vaccines are also expensive—as is the process of distributing them.
Congo’s ongoing Ebola outbreak illustrates the difficulties this involves. For the first time, we have diagnostics, a vaccine, and effective treatment. Yet the epidemic persists, with a mortality rate still at 65 percent. Although Ebola is the first epidemic in a conflict zone, the biggest problem is not insecurity but lack of public trust in the response.
The biomedical model subordinates people to the disease. The world needs a model that puts people first. Just as individual health is not the absence of disease, at a societal or even global level, the health of a population cannot be defined by the absence of outbreaks.
This long-standing obsession with disease control and biomedical bias diverts from the importance of access to health care. This is international dereliction of duty that is inimical to the control of global threats.
Under Director-General Tedros Adhanom Ghebreyesus, for whom universal health care is a mantra, WHO can transcend this exclusively disease-centric approach and reinforce the need for systemic reorientation in how the international community responds to threats.
Right now, there is no putting the coronavirus back in the bottle. It is time to expand from firefighting to fireproofing. Even if containment limits the spread of disease, other outbreaks will keep happening, as long as animals’ diseases keep jumping to humans.
Pandemics are the single biggest threat humanity faces. The question is: Do we collectively care enough to exercise our collective will to prevent them?
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