The world is out of balance.
Paradoxically, the technological leaps of the last 20 years, when combined with fatal deregulation and disinvestment from public health systems, have created fertile ground for the emergence and rapid diffusion of deadly new pathogens: mass urbanisation, air transport, global heating and ecological degradation constitute a toxic broth for the spread of disease.
It’s happened before: The Spanish flu pandemic of 1918, the deadliest in history, infected an estimated 500-million people worldwide – about one-third of the planet’s population at the time – and killed an estimated 20- to 50-million people.
Since then, there have been periodic panics about HIV, Zika, Ebola, H5N1, Severe Acute Respiratory Syndrome (SARS) and Middle Eastern Respiratory Syndrome (MERS). By comparison with the 1918 flu or HIV, COVID-19 pales into insignificance. It is almost certainly not what respected science journalist and Pulitzer prize winner Laurie Garret called the “coming plague” in her 1994 book of the same name.
Facts not fear
The first cases of disease caused by what was at first called the novel Coronavirus (since renamed by the World Health Organisation SARS-CoV-2, causing COVID-19) were noticed by healthcare workers in the city of Wuhan, China, on 1 December 2019.
Three months later, there seems to be a consensus among scientists that while COVID-19 is highly infectious (it is spread by respiratory droplets), the case fatality rate at 2% is fairly low, less than SARS, or MERS – which, as mentioned, have also caused panics around the globe.
Scientists also agree that those with the greatest vulnerability are the elderly and immunocompromised. The actual threat to mortality, compared even with ordinary flu strains, as reported in an article carried recently in the Daily Maverick, is fairly small.
At the time of writing, an estimated 2,100 people of approximately 75,000 cases had died because of COVID-19. By contrast, HIV still caused 71,000 deaths in South Africa alone in 2018.
Pointing this out, however, is not to underestimate the seriousness of COVID-19. Under certain circumstances, a high infection rate, with a low case fatality rate, could still cause many deaths … but it is to urge that responses are based on facts not fear, public health not public panic. Scientists are keeping a minute eye on COVID-19 and – in one of the few positives brought about by this epidemic – there is an unprecedented sharing of information and new knowledge.
The Lancet, for example, has set up a free to access on-line COVID-19 resource centre that publishes the latest information: “To assist health workers and researchers working under challenging conditions to bring this outbreak to a close.”
Disease and democracy
As far as we know, COVID-19 has not yet arrived in South Africa. So, as we watch the unfolding response in China and other mainly developed countries, we have an opportunity for a serious discussion on how to ensure proportionality, equity, public health and human rights in our response to this and other communicable diseases.
Let’s start with human rights.
The violation of human rights has become a thread that runs through the aetiology, determinants of transmission, susceptibility to, prevention and treatment strategies for COVID-19.
Human rights affect viral aetiology because it is the failure of many states to protect the rights to what S24 of our Constitution calls “an environment that is not harmful to their health or well-being”, and to prevent “pollution and ecological degradation”, that is creating the breeding ground for new pathogens.
While researching this article, I heard a number of scientists tacitly praise the boldness of the Chinese response, as if a threat on this scale could only be countered by a massive, invasive response, the type “that only China is capable of”.
For a while, a mildly funny WhatsApp message even did the rounds contrasting how China and South Africa would respond to a threat like this: China would be decisive, South Africa would dither, hold workshops, commissions, consultations, indabas, disputes, and when we eventually tell the world we are ready, the response would be, “what virus? That was dealt with five years ago!”
The subtext was “thank God it started in China”.
Yet this reflects a profound misunderstanding among some people about the connection between disease and democracy – as well as about what is happening in China.
The fact that a number of recent viral outbreaks (H5N1 avian influenza and SARS), have started in China is directly related to China’s massive urbanisation, environmental destruction and weak, sometimes non-existent, systems of public health, environmental protection, or food regulation.
Their rapid transmission is also directly linked to China being an authoritarian one-party state, with no freedom of speech, media or protest. Those of you who really want to locate the COVID-19 crisis in China’s anti-democracy should read this essay by Xu Zhangrun.
And there’s a pattern of behaviour here.
As far back as the late 1980s, China tried (to this day) to suppress information about its HIV epidemic and how it initially spread as a result of poor peasants in Henan selling their blood for an income (what was called “the plasma economy”). The best report on this is by Asia Catalyst, an NGO.
Thirty years later, the response to COVID-19 has been hindered from the get-go by similar human rights violations.
For example, in a comprehensive statement issued on 31 January 2020, the Chinese Human Rights Defenders (an organisation based in Hong Kong and a lone voice monitoring human rights abuses in China), pointed out how:
“Lack of transparency in China’s authoritarian political system led to a failure in warning the public and implementing a rapid response to a public health crisis of this magnitude. The first case in Wuhan was dated on December 8, tied to the Wuhan Seafood Market, though there are now reports of even earlier cases. Authorities did not close the market until January 1 and didn’t disclose that the virus could spread through human-to-human transmission until January 20.”
We now know that the doctor who first tried to raise an alarm publicly, Dr Li Wenliang, was punished by authorities. His death because of the virus on 7 February 2020 is reported to have provoked massive sympathy and anger. Since then, however, media reports have further documented state coercion of millions of people in cities like Wuhan.
On that scale, it’s hard to hide.
The New York Times, for example, reported how when Vice Premier Sun Chunlan visited Wuhan, she said the city faced “wartime conditions,” warning that: “There must be no deserters, or they will be nailed to the pillar of historical shame forever.”
This is why, in the words of Xiao Qiang, Founder and Editor-in-Chief of China Digital Times, it is China’s “controlocracy” that has “primary responsibility for the coronavirus epidemic that is sweeping across that country and the world”.
Let’s be clear, saying this is not stigmatising Chinese people, but putting the responsibility on the Chinese government – South Africa’s largest trading partner, a friend of the ANC, and a country whose human rights violations we opportunistically choose silence upon.
As an aside, one wonders where we would be if the world had adopted the same approach to apartheid?
Panic and proportionality
In a recent comment in The Lancet, 16 global public health experts called on governments to abide by the legally binding International Health Regulations, which govern how 196 countries and WHO collectively address the global spread of disease and avoid unnecessary interference with international traffic and trade.
They point out how: “Article 43 of this legally binding instrument restricts the measures countries can implement when addressing public health risks to those measures that are supported by science, commensurate with the risks involved, and anchored in human rights.”
This was necessary because a response that is marred by disproportionality, panic and human rights violations has now spread with the virus from China. Governments the world over seem to be forgetting all the lessons of the world’s most recent pandemic, HIV, a virus which – according to UNAids – still causes 770,000 deaths a year, currently infects over 37-million people (a number that increases by 1.5-million a year), and continues to have a profound impact on public health systems and economies.
Unfortunately, even the WHO seems to have forgotten the lessons of Aids. Its Situation Report 25, dated 14 February 2020, lists the WHO’s six “strategic objectives for this response” – the protection of human rights is not among them. Similarly, a 2019 report from the Global Preparedness Monitoring Board, a body co-convened by the WHO and the World Bank, did not mention human rights in its seven actions for leaders to take.
If only these leaders would do their homework and learn their lessons.
Let us, therefore, recall that what activists taught governments and the WHO about HIV is that respecting human rights is necessary not only to protect individuals who are infected, but also to maintain a climate that will encourage people at risk to seek diagnosis and care, rather than avoid health services because they are afraid of stigma and punishment.
As a result of the activism and outrage against human rights violations against people living with HIV, UNAids pioneered a human rights approach to HIV prevention and treatment, that has saved tens of millions of lives.
Today, theoretically, HIV transmission could be eliminated and nobody needs to die of Aids-related illnesses. The only reason this isn’t happening is because of a lack of political will and declining funding – ironic given the resources suddenly being released for COVID-19.
Of course, the human rights approach to HIV needs to be tailored to different disease threats. But its fundamental principles must remain the starting point for any public health emergency. In the blunt words of Professor Larry Gostin, interviewed in this valuable report by Al Jazeera Plus: “You can’t wall off a germ.”
COVID-19 is a very different genus of virus to HIV. The latter is mainly sexually transmitted, making it more difficult to acquire, but also more complex to prevent. Because it can be spread so easily, COVID-19 justifies proportionate degrees of quarantine and isolation. Yet many of the responses we are now witnessing are disproportionate – they violate a range of human rights (dignity, autonomy, freedom of movement), and may ultimately make COVID-19 even more difficult to contain.
The disastrous decision to quarantine 3,100 people on a cruise liner, the Diamond Princess, is the worst case in point.
South Africa’s response
In an article in Maverick Citizen on 21 February 2020, Dr Tim Tucker writes positively of South Africa’s technical readiness for the likely arrival of COVID-19 in our country.
A number of senior clinicians I talked to confirmed that healthcare workers have been trained on diagnosis and care protocols; we have the best pathology services on the continent; isolation units already exist; Tucker says “social contacts of confirmed cases would be screened and/or self-quarantined until they are shown to be negative”.
For this, the Department of Health should be commended. However, Tucker also warns that “we do not yet know what effect the very poor living conditions and the role of other infections such as HIV, TB and malaria in much of Africa will do to influence the spread and seriousness of future COVID-19 epidemics in Africa”.
This is why we cannot be complacent.
While we became a world leader in protecting the human rights of people living with HIV, we failed in our response to XDR and MDR Tuberculosis (TB) where, for a long time, the government’s response was to lock people up in isolation hospitals and violate a host of rights. As predicted, this response did nothing to help reduce the transmission of MDR/XDR TB.
In the face of a panic that COVID-19 might induce, we should not repeat these mistakes.
What we need now is accurate information about risk, transmission and treatment, as well as the countering of inaccurate information and stigma that is spread as a result of fear.
In the medium term, COVID-19 (however it pans out), is an argument for strengthening primary health systems, investing in infection control and having a health plan that is properly budgeted and has the requisite human resources.
Currently, we fail on each count.
Solidarity for (n)ever: Politics and disease
Finally, let me say that COVID-19 should require us to examine our souls as much as our bodies.
Once upon a time, it might have seemed incomprehensible that there should be so little outcry, or show of solidarity, with the millions of people in China, being subject to quarantine, invasive searches, intimidation and mass surveillance.
The ease with which the Chinese government has shut down whole cities and the fairly muted response by the human rights community, bodes ill for our readiness to counter this type of state terror in future. Amnesty International, for example, has only put out an “explainer”. Human Rights Watch appears to have said nothing. Local groups like the Treatment Action Campaign (TAC) are silent.
So far, it has been left to academics, with an occasional outburst from an activist on Facebook, to criticise the human rights violations.
This seems indicative of an acquired mental illness: The globalised loss of human-to-human empathy and solidarity. Ironically, easy access to the frontlines of gross human rights violations be they in Idlib, Syria, or Wuhan – has now inured people to gross human rights violations. It has led to the “normalisation” of horror.
Donald Trump and Vladimir Putin must be watching this dystopian spectacle with envy. If only they could deploy artificial intelligence with such ease, shut down whole cities, send out drones to monitor and marshall populations. Dystopia has arrived.
In this regard, COVID-19 is an indictment of the current state of health, human rights and inequality.
China may prove able (this time) to “successfully” use coercion to compensate for the weakness of its health systems. But elsewhere in the world, there is a price to pay for the weakening of public health systems, the failure to achieve the Declaration of Alma-Ata on primary healthcare, the human resources crisis.
The response to COVID-19 illustrates that in the late neo-liberal order, all diseases are equal, but some diseases are more equal than others. The response to COVID-19 contrasts sharply with the response of other disease threats, such as HIV and TB, which are facing major funding constraints. Non-communicable diseases, like mental illness and cancer, are tearing through whole populations and meeting little resistance.
This proves yet again that it is not a disease threat per se that garners resource and medical mobilisation, but a disease threat to the economy and the cash cows of the elite. Viruses on planes, or cruise liners, running down the arteries of global commerce, impossible to keep out of first-class, is different from a virus running through marginalised and vulnerable populations, or the slums of the poor.
To contain this virus, governments are quick to spend billions on closing cities, closing airlines, airlifting and quarantining citizens. They will even risk the stability of the global economy to contain this threat.
Yet COVID-19 and other disease threats all trace back to the economy of inequality, to the sustained period of austerity where basic health systems have been starved of resources; systems for sanitation (which made such a difference to longevity in the early 20thcentury), have been eroded.
The COVID-19 crisis is one more argument for ensuring the realisation of socio-economic rights, such as the right of everyone “to the highest attainable standard of physical and mental health”; rights that otherwise hang like decorative baubles on so many constitutions.
It’s cause for a new social mobilisation for the human right to health, like the one activists catalysed for HIV treatment. That is why, whatever the outcome of the unfolding tragedy of COVID-19, it should be a wake-up call to the global human rights community. MC
Mark Heywood is the editor of Maverick Citizen and a social justice activist.
Wild rats still enjoying running wheels.