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
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