A comparative look at the global efforts to control the disease will tell us much about the effectiveness of healthcare systems around the world and also help prepare us for the next bug.
By Michelle Nicholasen
Both a physician and a scholar on Iraq and the Middle East, Dr. Muhamed Hassan Almaliky treats cardiology patients with coronavirus-related complications at the Penn Presbyterian Medical Center in Philadelphia. At the Weatherhead Center he runs an annual workshop for undergraduates on the politics of disease. We asked him for his professional opinion about the coronavirus outbreak and the international response to the disease. His answers appear as part of our series on scholarship in the time of the pandemic.
Read the first part of our interview with Dr. Almaliky in A Closer Look at COVID-19.
Q: Which countries have demonstrated the best public health responses so far, in your opinion?
A: The greatest burden has fallen upon the most advanced liberal democracies and industrialized nations in the world, namely the US and western Europe, which combined have close to 80 percent of all cases and 90 percent of all deaths to date, whereas Asia—where the pandemic started—seems to have early control combined with relatively less mortality (7 percent of cases and 3.7 percent of deaths). This seems to be a function of public policy rather than public health infrastructure and effectiveness. The more strict social measures show fewer cases and early control of the spread. Social measures are in the domain of public policy, not public health. With respect to dying of the disease, it seems that out of every 100 cases, about 20 percent do not do well. The extent of saving those 20 percent reflects the effectiveness of health systems. Germany and Austria kept mortality to less than 4 percent; the US to less than 6 percent; while in Italy, France, Spain, Switzerland, the UK, and Belgium mortality has ranged anywhere from 10 percent to 18 percent. Besides China, two countries stand out in terms of deploying successful early measures, and those are Japan and South Korea.
Q: There seems to be something of a trade war over manufacture and shipment of personal protective equipment, or PPE. How are PPE manufacturers around the world juggling domestic versus international demand? What has this emergency taught us about supply chains related to public health needs?
A: Pandemics have always been looming. SARS and MERS were only warnings to what their likes could potentially be. Pandemics are one of the four major transnational threats, besides terrorism, climate impact, and nuclear war. Any of these could result in massive destruction and loss of lives. Given the warning has always been there, well-prepared countries do not wait until the crisis hits, and then go on scrambling for basic equipment. If governments had placed epidemics in their preparedness priorities, just like a terror attack, PPE would not have been an issue. Of course, nations are obliged to protect their own citizens first, but if a surplus exists somewhere else in countries where the infection has remitted, extending help for ending the pandemic globally is for the benefit of everyone. Though China has started opening its economy already, without the European and the American markets, what does that even mean? Global cooperation is for the sake of everyone.
Q: Are you encouraged by the global efforts to develop treatments and vaccines? How would new discoveries be shared across borders?
A: I would like to emphasize the urgent need for developing an effective vaccine even more so than treatment. The potential adverse economic consequences of the pandemic on millions of livelihoods around the world could be more devastating than the disease itself, especially for vulnerable societies and communities that rely on daily wages in informal economies. Vaccines will be the only measure that will ensure resumption of life and economic activities necessary for sustaining it. The more integrated research efforts and resources are, the faster we can reach a solution. The economic impact provides further incentive for governments to cooperate. Coordination, knowledge sharing, and transparency are some of these global efforts. It is also important to support and enhance the work of WHO as the only international health organization capable of organizing and managing efforts globally.
Emphasizing a vaccine must not take away from any efforts to develop effective treatment for the 20 percent or so of the cases with moderate to severe illness. Though some experimental antiviral medications such as Remdesivir have shown to be associated with better outcomes, the goal is to develop specific antiviral drugs in the likes of Tamiflu for influenza, which is known to halt the progression to severe illness if used in the initial phase of the infection.
Q: What if it's not possible to develop one in the next year or two, and instead takes many years—or even decades? Can we safely assume that the country that develops it will share it with the world?
A: Our world has never been so interconnected and interdependent like it is now. Not a single country can live and flourish in isolation of global trade, international travel, tourism, or education exchange to justify holding on to a vaccine, especially among advanced democracies where the pandemic has hit the hardest. Even in nondemocratic nations like China, holding on to vaccine implies economic suicide for a country that depends heavily on international trade for its economic growth. Again, pandemics are global problems that necessitate global solutions.
Q: Do you think there’s a public health and/or moral imperative to release nonviolent prisoners, or more importantly, migrants held in detention centers so that they will not create an outbreak cluster?
A: This is an ethical public policy question that can be placed in the context of the need for reprioritizing public policy options in the face of lethal global threats such as the COVID pandemic. Punitive and rehabilitative measures for the convicts must be outweighed against the risk of disease/death confronted in times of epidemics in crowded prisons. Otherwise, dying in prison from the infection is paramount to raising punishment to a death sentence. This logic applies even more appropriately to illegal immigrants held at crowded places. Pandemics are transnational and global phenomena that generate their own logic, resembling war times. But epidemics are, of course, no excuse to break law and order or disturb societal harmony and peace.
Q: What are some good examples of countries working together during this pandemic? And examples of those who haven’t? What repercussions does this have?
A: This epidemic can be looked at in the form of clusters: North America, Central/South America, northwestern Europe, southern Europe, central Europe, eastern Europe, and Russia, Africa, and the Middle East. Africa and South America have done much better than other clusters, followed by the Middle East (except Iran). Asian countries can provide a model for how they have been able to control the spread early on, including China, where the pandemic started. Large countries such as India, Indonesia, Malaysia, and Pakistan could have done a lot worse than they have so far given their proximity to the source country and the size of their population.
The fact that countries with the most robust public health and health systems in the world have shown the highest number of cases and most death ratios indicate that neither local measures were functioning well, nor transnational ones. But this will definitely provide hard-learned lessons for Europe and North America in rethinking their public health and health system designs and priorities locally as well as across their borders.
—Michelle Nicholasen, Editor and Content Producer, Weatherhead Center for International Affairs
Dr. Muhamed Hassan Almaliky is an Associate of the Weatherhead Center who runs the annual Center-sponsored “Politics of Disease” study group for Harvard undergraduates. He is a physician in the practice of internal medicine and cardiology at the University of Pennsylvania Health Systems, and a researcher on Iraq and the Middle East. He holds MPH and MPA degrees from Harvard University.
Image of a map of confirmed coronavirus (COVID-19) cases report worldwide globally. Credit: Shutterstock