Panic and pandemic: learning from history

The WHO Collaborating Centre on Global Health Histories, which is supported by the Wellcome Trust produced a seminar in early March 2020, looking at the unfolding COVID-19 pandemic in the context of recent history.

 

The full seminar can be listened to here: 

COVID19: Inter-disciplinary approaches (GHH Seminar 144, March 2020) 

Speakers: Dr Owain Williams (University of Leeds), Dr Fang Xiaoping (Nanyang Technological University, Singapore); Dr Kate Mason (Brown University)

This briefing draws upon the material and presentations at that seminar. 

 

 The COVID-19 pandemic silenced the world’s cities in the first half of 2020. Nobody knew what was going to happen, as industries shut down and people were sent ‘home’ (wherever that might be and whatever hardship going home might entail). Reactions around the world to the disease were mixed; some were extremely comprehensive, some were patently inadequate, and many are still to be assessed. Compliance with public health messages was much the same, both within communities and between communities.

 

Yet this is by no means the world’s first outbreak of seemingly uncontainable disease. Dr Owain Williams of the University of Leeds describes the quarantined cruise ships sitting in south-east Asia and off the coast of Japan as “a return to the yellow flag days of previous plague events”. China, where COVID-19 first emerged, has experienced both cholera and severe acute respiratory system (SARS) in the past 60 years. How did the country respond to these three epidemics, and what themes emerge?

 

Cholera

The current cholera pandemic (the seventh in global history) broke out in south-east Asia in 1961 [https://www.who.int/news-room/fact-sheets/detail/cholera]. The following year the disease broke out in Guangdong province and rapidly spread down the south-east coast of China. By 1965 cholera in the area was contained – reduced to a very small number of cases, monitored and treated – as the result of a programme of strict quarantine and isolation.

 

“When a cholera pandemic first broke out in Yangjiang County, Guangdong Province, in June 1961, the central government mobilised medical resources and personnel across the country to impose a cordon sanitaire around the affected areas in order to prevent further spread,” explains Fang Xiaoping, Assistant Professor of History in School of Humanities of the Nanyang Technological University, Singapore. “These interventionist response schemes in Guangdong established a general framework for controlling the cholera pandemic.”

 

Fang focuses particularly on the south-eastern Zhejiang province. A week after the first cholera case was confirmed in Rui’an County in July 1962, the provincial government partitioned the whole of Zhejiang into a series of concentric circles centred on the cholera-affected Wenzhou area. Major observations stations (for identifying confirmed and suspected patients) and temporary joint quarantine stations (into which confirmed and suspected patients were expected to move) formed quarantine ‘rings’ to contain the spread of the disease. The county and city governments divided the area within each ring into further quarantine zones, down to the level of districts and communes. 

 

In addition, the provincial government set up a comprehensive inoculation campaign. On 3 August 1962 directives from the provincial party committee ruled that the entire population in each county of Whenzhou prefecture were to be inoculated against cholera before 15 August – which meant that the local health services had to inoculate nearly three million people within only 12 days.

 

It was not always easy, Fang explains. “The emergency inoculation scheme in the summer of 1962 suffered, due to the poor coordination of local cadres and chaotic information on inoculation subjects.” But from 1963 onwards it was much more of a concerted campaign, with better-organised cadres and reliable inoculation registers. 

 

Two pandemics: building a public health system

Even with the initial stumbling-blocks, this cholera outbreak occurred at a period when China’s health system had started to develop its capacity for handling mass outbreaks of disease. “The medical system (which included the epidemic prevention scheme) did not emerge until the mid-1950s, just six to seven years before the outbreak of the global cholera pandemic in 1962,” Fan explains. As a result, this pandemic presented both considerable challenges, but also the opportunity to restructure and integrate the medical and administrative systems. 

 

For instance, officials in Wenzhou City, Rui’an and Pingyang counties were issued with a detailed timetable for reporting to the provincial health department (although initially, the national reporting scheme lacked adequate staffing and equipment). In 1963, hospitals and clinics set up outpatient departments for intestinal disease, in order to identify and test suspected cases of cholera. The government also committed to establishing complete statistical data on actual and potential cholera patients.

 

And importantly this was also a period when China was very much isolated from the rest of the world’s health community. “When the pandemic broke out in 1961, the People’s Republic of China was not a member of WHO and it remained isolated from the international epidemic reporting network”, Fan explains: although it did keep informed about the global pandemic surveillance network.

 

However, the public health infrastructure in China slowly deteriorated over the following decade, after the death of Chairman Mao in 1976. Finally, in the early years of this century, the Chinese government finally began reconstructing the system and setting up new Centers for Disease Control and Prevention (CDCs). “This was an explicit reference to the US CDC in Atlanta Georgia and was intended to evoke a highly modern scientific ethos,” explains Dr Kate Mason, Assistant Professor of Anthropology at Brown University. It was, she adds, “serendipitous timing” because in 2003 the country was hit by a new epidemic. The CDCs suddenly had a very clear purpose and mandate: containing and preventing SARS. 

 

SARS

Mason was in fact caught up in the SARS outbreak herself. “On 12 April 2003, I was evacuated from my post teaching English at Georgetown University in Guangzhou. I packed my belongings into two suitcases in a duffel bag, got on a bus, crossed the border into Hong Kong and flew with my N95 mask on back to the United States. And at the time I was perplexed by how a virus that up until that point had seemed so thoroughly unimpressive to my friends and colleagues in Guangzhou – which competed with scores of other microbes to cause disease in a tiny minority of Guangzhou’s millions of citizens and that inspired my neighbours to take little more drastic action than to open the windows or repeatedly wash the floors with vinegar – had nevertheless spurred enough panic back home for my sponsor to demand my evacuation back to the United States and my family to attempt to quarantine me.”

 

China’s central government finally admitted the scope of the disease and began instituting control measures, including quarantining entire villages, setting up neighbourhood watch systems to identify potential carriers and building new hospitals in a matter of days. “The WHO praised China's control efforts and credited them in part with the success of the global containment effort.”

 

Controls, freedoms and trust

These measures in China laid the foundations for the way this country responded to COVID-19. They also expose some of the wider issues involved in controlling the pandemic, both in China and elsewhere. “A debate has emerged about whether the nature of the Chinese state has, in a sense, given it a special ability to deal with pandemic events: whether that degree of state control is in some way a positive in this story of attempts to control coronavirus,” Williams says. “We've seen the large-scale deployment of military personnel by the Chinese state, forced testing and forced quarantine of citizens; and China has been roundly criticised by some people in the human rights and health community for its abuse of its citizens’ human rights.” 

 

Mason raises a further issue. There are assumptions of what is permissible and even expected, in China but less permissible elsewhere. “One of the big takeaways that the Chinese government got from SARS is that draconian actions are necessary to control a new virus if it does occur and that China will be praised by the international community if it takes such actions – but only if it does so within its own borders.” 

 

On the other hand, both Mason and Williams point out that many Chinese people themselves do not agree with the idea that these measures are in fact permissible. “Issues of trust and secrecy and cover-ups came to a head, especially with the death of Dr Li Wenliang (the first doctor who recognised and tried to warn about COVID-19, before dying of it himself),” says Williams. In reality, Mason adds, the idea that the Chinese government operates blanket disease surveillance is also far from accurate. “China’s health system operates as a collection of thousands of little fiefdoms at the local level with very little ability on the part of the central government to compel ongoing action in any one of these. What this means in practice is that the central government does not have a lot of power to make local officials report what they are seeing, when they don't want to or feel unable to do so.”

 

Information in the social media age

There is also one glaringly obvious difference with previous epidemics: the way that information has been consumed, perpetuated and manufactured.

 

“In 2003 people whispered of a strange new virus when the news of SARS was officially released and they complained under their breaths about local government responses,” says Mason. “But this happened at a relatively slow pace through word of mouth. In 2020, with hundreds of millions of Chinese citizens cooped up at home with nothing better to do than to look at their social media accounts, there was an explosion of online information, disinformation, and serious discontent the likes of which the Chinese government has not really ever had to deal with before.” 

 

None of this has been restricted to China, as the pandemic spread across the rest of the world: Williams describes it as “a crisis replete with misinformation, with conspiracy theories abounding everywhere”. In a number of different countries distrust of government messages – especially when those messages themselves are conflicting and/or hard to understand – have led to people flatly ignoring advice or rules about masks and/or social distancing (the effects of which have been seen, for instance, in the UK).

 

Health systems and preparedness

The unfolding story of COVID-19 isn’t over yet. Nobody knows what kind of ending it will have, or when that will be reached – or indeed whether it will remain a threat in some parts of the world while others are protected against it. 

 

Williams is particularly wary about the future. “There's a political economy of chronic and continued under-investment in health systems and institutions globally, regionally and locally across the world; and the United States is very much not an exception to that story. We are seeing chronic and continued under-investment in vaccines and prophylaxis. We have neglected health and global health at our peril and I think we will pay the price for that very soon. There's a real story here of politics of fear and neglect and misinformation.”

 

Radhika Holmström is a Wellcome Trust-funded writer and communications specialist working with the WHO Global Health Histories project at the University of York

The many strands of malaria elimination

The WHO Collaborating Centre on Global Health Histories supported by the Wellcome Trust has produced a series of seminars and webinars which look at different aspects of malaria control, and at how this can only be achieved through a combination of approaches.

 

The two seminars can be viewed here:

Can malaria be eradicated? The future of malaria control

(GHH seminar 148, 21 July 2020)

Speakers: Dr Ian Graham, Director of BioYork and Weston Chair of Biochemical Genetics at the University of York), Dr Karen Barnes (Professor of Clinical Pharmacology at the University of Cape Town and Co-Chair of the South African Malaria Elimination Committee), Dr Rajitha Wickremasinghe (Professor of Public Health and former Dean of the Faculty of Medicine at the University of Kelaniya in Sri Lanka)

 

Health Diplomacy: The bases for international and global health

(GHH seminar 164, 6 March 2020)

Speaker(s): Professor Sanjoy Bhattacharya (Professor in the History of Medicine, University of York, UK and Director, WHO Collaborating Centre for Global Health Histories), Dr Lakshmi C. Somatunga Deputy Director General (Medical Services(I)), Ministry of Health, Nutrition and Indigenous Medicine, Sri Lanka)

 

This briefing draws upon the presentations at these seminars, as well as additional conversations with Professor Sanjoy Bhattacharya.

 

“We need to recover the huge amount of information on what makes it possible to implement public health programmes,” says Professor Sanjoy Bhattacharya, director of the Centre for Global Health Histories at the University of York and of the WHO Collaborating Centre for Global Health Histories. “Countries need to recognise the importance of their own implementation histories and experiences and fund the recording of that because they are disempowering themselves by not doing so and falling victim to the idea that the only important ideas were at global rather than the national level. This is a critical history that engages with policy but tries to record all sides of the argument to see which of those ideas made a difference on the ground.”

 

To date, the world has eradicated one human disease [Smallpox]. It is becoming increasingly possible that malaria may follow suit. With a new vaccine showing some signs of success in reducing malaria in young children [https://www.who.int/malaria/media/malaria-vaccine-implementation-qa/en/], and an increasing number of countries being declared malaria-free, along with advances in treatment, the discussions about malaria have moved from control to elimination to the possibility of global eradication.

 

However, the disease is still responsible for hundreds of thousands of deaths every year, almost all of them in Africa and especially among young children. And as Bhattacharya points out, when malaria is finally eradicated, this will be the result of what has (and has not) happened in different countries, specific to those cultures and needs.

 

Effective public health: Sri Lanka

Dr Rajitha Wickremasinghe, who is Professor of Public Health and former Dean of the Faculty of Medicine at the University of Kelaniya in Sri Lanka, describes the reason why the country was certified malaria-free on 6 September 2016 as “nothing but good public health practice”. Along the way, there were definite peaks and troughs: by 1963 the disease had almost vanished from Sri Lanka but then returned (and during this period Sri Lanka also experienced civil war and a huge amount of violence and unrest).  However, in 2009 the country moved from a ‘control’ programme to an ‘elimination’ one, led by the Ministry of Health and two local NGOs and targeting different malaria species in succession. “The interventions were basically universal access to diagnosis and treatment, and vector control” (the use of insecticide-treated nets and/or residual indoor spraying, to get rid of the mosquitoes which transmit the malaria parasite).

 

Much of this good practice, Wickremasinghe explains, involved comprehensive access to control measures (which includes access to education that means people adopt those control measures). “We have an excellent public health system; we have good road connectivity and transport network; we have a literate population, and also there were no counterfeit medicines in the market. Even during the separatist war malaria commodities were provided to rebel-held areas.”

 

 It also involved coordination and a degree of flexibility over how health bodies spend donated funds. And, significantly, the period when a greater proportion of funding was spent on ‘management and other costs’ – in other words, human resources and technical support – rather than insecticides and spraying materials is when the rate of malaria decreased. This is an important counter to the widespread objection to ‘spending on administration rather than frontline costs’ that many potential donors raise.

 

In reality, Wickremasinghe says, “flexible funding which enabled them to do things that government regulations did not otherwise provide was more effective. A programme must be agile and able to respond to the on-the-ground realities.”  An integrated approach is essential, everyone agrees. And that approach has to focus on the people and communities who are at risk of the disease.

 

Experts in their own realities

“Communities are not all the same and of course, because of that, you can't have the same engagement strategy for all communities. There's no ‘one-size-fits-all’,” says Professor Karen Barnes of the University of Cape Town, who is also the Co-Chair of the South African Malaria Elimination Committee. “We've got some good tools that have advanced the control of malaria and aided its elimination in some countries, Sri Lanka included. But each of these tools really depends on community buy-in and community acceptance of what needs to happen. And community engagement must be bidirectional, it's not just a case of the government or the technical experts telling communities what to do; you have to find a way of hearing what the communities think – what they like, what they understand and what they need more of.” 

 

These are the people, she points out, who are “experts in their own realities”. “These are communities that know how bad malaria is. Most people know someone who's died from malaria and they've often had malaria themselves.” (Conversely, areas where malaria rates are low, community buy-in requires a lot more work: communities have, after all, plenty of other concerns that they worry more about than malaria.)

 

Barnes was involved in the Lubombo Spatial Development Initiative (LSDI), a government initiative between Mozambique, South Africa and Eswatini (Swaziland) aimed at enhancing economic development in the area, a key component of which was malaria control. It used a combination of approaches – indoor spraying (the malarial mosquitoes in the area rest predominantly indoors) and/or the use of bed nets to prevent the disease, rapid diagnosis if someone is suspected to have malaria and combination therapies including the drug artemisinin for treatment. All of these require people at risk, or who contract malaria, to take their own action – not least because they need to finish a full course of treatment, rather than stop as soon as they feel better and save the remaining medication for later. “We also needed community engagement to support the very important surveillance necessary to understand how people respond to treatment. Are they cured? Are there factors around a homestead that might put them at more risk of malaria? Have the number of malaria-transmitting mosquitoes been reduced?” 

 

Those experts in their own realities are the people who can bring about real change: for instance,  138 community members in the LSDI volunteered to have window traps on their homes to monitor the number of mosquitoes in their area. However, that only happens if they believe that it’s worth doing and they trust the people doing it; indoor spraying, in particular, involves taking the risk of letting a stranger into the home and in other areas people may refuse this. 

 

In Mozambique, local communities have selected people to be trained as community health workers – either unpaid or with minimal pay. These health workers are trained in carrying out malaria tests, in the correct use of drug treatments, and in recognising when sick people in their community need to make the long journey to the hospital. As a result, many people do not need to leave the local area to travel to a clinic or health centre; the programme is being brought directly to them.   

 

The limitations of treatment

There is also a major concern that the major treatment on offer may become less effective. Dr Ian Graham, Director of BioYork and Weston Chair of Biochemical Genetics at the University of York, has worked on producing hybrid variants of the Artemisia annua plant which can be grown by small-scale farmers. The plant itself has been used as a fever treatment for over 400 years, but it is the specific artemisinin molecule (identified by Chinese pharmaceutical chemist Tu Youyou, who was awarded the Nobel Prize in 2016 as a result) that is usually highly effective, and needs to be produced in larger quantities. It is also most effective as part of combination therapy, and it is very important to keep it as such. 

 

“Artemisinin derived drugs are the most effective treatment for malaria but we already know that the parasite causing the disease can mutate and develop resistance to these drugs, which represents a major public health threat,” Graham explains. “The main way to combat resistance developing is to use artemisinin in combination with partner drugs, as this prevents parasites that manage to mutate and develop resistance to one drug taking hold. Herbal treatments containing artemisinin, using the drug as monotherapy or not completing a full course of combination therapy treatment can all increase the risk of resistance developing. It is essential that we do everything we can to prevent resistance from becoming established, especially in sub-Saharan Africa where local emergence of resistance has recently been reported.”

 

“Artemisinin resistance is a global threat,” says Barnes. “If artemisinins don't work well then, it’s not just that they clear the parasites more slowly. There’s also an increase in the malaria parasites (called gametocytes)that transmit malaria. That means a potential increase in malaria transmission. There’s also more pressure on the other drugs that are being used in the combination treatment, so these partner drugs start to fail too. There are some places in Southeast Asia where there are quite frightening levels of treatment failure: over half the patients treated were not cured by the recommended artemisinin combinations. And we are now getting isolated reports from elsewhere in the world. The impact on malaria cases and deaths if such artemisinin resistance spreads to the Indian subcontinent or sub-Saharan Africa or South America are quite frightening to think about. We'll stop talking about elimination for a long time if that happens.” “It is important to keep looking for alternatives,” Graham agrees. “We are in an arms race with the malaria parasite, which given the opportunity will almost certainly develop resistance.”

 

 

No scope to stand still

Artemisinin resistance is not the only reason why malaria control or elimination programmes have to be, as Barnes says, “dynamic, not static”. In areas where control programmes lose funding and support, the rate of malaria goes up – and that is in areas where communities are very happy to play their part. 

 

In addition, malaria is by definition a very mobile disease. Mosquitoes do not observe regional or national borders. In any case, the borders in many places, like southern Africa, are extremely porous – they are lines drawn up by previous imperial rulers, rather than any division that local people themselves would recognise. This is why regional collaboration like the LSDI, and collaboration between malaria programmes, is essential. 

 

The global plan for elimination is a genuine, and a realistic, goal. However, it will only be achieved if those coordinated, integrated and dynamic programmes are continued – and if they involve the people who are at most risk of malaria themselves.

 

 

 

Radhika Holmström is a writer and communications specialist working with the Global Health Histories project at the University of York.