The Pandemic and Independent Countries

The Pandemic and Independent Countries

The failure of hegemonic neoliberalism, liberal denials and lessons from socialist systems

Table of Contents

PAGE

1. INTRODUCTION: THE pandemic and independent countries  6

2. How the pandemic defrocked hegemonic neoliberalism  67

3. COVID-19 and recovery: an early view    98

4. Wuhan and lessons from China    98

5. Cuba faces the Pandemic        112

6. A tale of two cruise ships      122

7. The Swedish model    128

8. Besieged Syria and the virus     150

9. Myths of the western pandemic deniers  160

10. Vaccines and the second wave  209

To the many selfless public health workers who helped protect literally billions of people during this difficult time, not least the many who laboured under economic siege and those who gave their lives in the course of this tremendous work.

1. Introduction: the pandemic and independent countries

Independent countries have used multilateralism for decades

to escape the dictates of the former colonial powers.

THIS BOOK BRINGS TOGETHER a series of research essays prepared during the COVID19 pandemic of 2020. I am principally a political economist but also have a background in public health. My studies of Cuba impressed on me the importance of humanism, science and social solidarity, and of what could be achieved by an organised people. After some study, between 2006 and 2014, I published ten academic articles on health systems and infectious disease, the Cuban response to HIV/AIDS, human rights in public health, health training and international medical cooperation (see Appendix). I also acted as an advisor in Pacific Island-Cuba relations and made a dozen short documentaries on Cuban medical internationalism and doctor training in East Timor and the Pacific Islands.

This book has a unique political-economic perspective, addressing the 2020 crisis through its impact on health systems and their associated political economic contexts. Its themes reflect on methods used in understanding contemporary social controversies. In particular, it draws on values of humanism and social solidarity, and of shared science, while identifying interests in debate, using diverse and independent sources and looking for corroboration across competing perspectives.

In its first theme the book argues that the COVID-19 pandemic exposed as never before the failings of the hegemonic neoliberal approach to public health. This is most obviously seen in the sad fact that many of the countries which had been rated highly in ‘preparedness’ for health crises (IPT 2020), actually performed amongst the worst. Those nations which had heavily commercialised their health systems also undermined key social values and weakened their capacity to respond collectively to public health crises. That weakness is at the root of the high death toll in the neoliberal states, led by the USA and the UK.

The second theme explains the response of a number of independent countries, notably China, Cuba and Syria, responses which show the importance of well organised and resilient social systems, relatively independent of hegemonic neoliberalism. Why these three? First, all of them had health systems which were substantially independent of the western neoliberal model; second, China set the initial benchmark for responses to the virus; and third, I had some detailed knowledge of the both the political economy and the health systems of Syria and Cuba. Social organisation, political will and independence were clearly important, especially in allowing the broader ideas of social medicine to take root. The responses of Syria and Cuba were also instructive because these were small countries labouring under an economic siege (US ‘sanctions’) which aimed to subjugate them. The fact that both dealt quite effectively with their epidemics, under these circumstances, is testament to the potential of small, well organised states.

The third theme addresses myths put out by a significant minority of western libertarians and populist liberals, those who simply denied there was a serious health crisis and, in some cases, argued that the pandemic was world-wide conspiracy. Relying primarily on claims of individual liberties, this form of western hyper-liberalism reacted against preventive health measures in an often arrogant and abusive manner. Their myth making tended to obscure the neoliberal failures and reinforce hostility to ‘dictatorial’ public health systems. The most obvious anti-scientific feature of pandemic denialism has been its disinterest in evolving knowledge about the disease or the growing death toll. ‘No worse than a flu’ was a common chant, whether the deaths were 8,000 or 800,000. Simplistic ideas, such as assuming that surviving a one-time contact with a new and unknown virus was enough to confer life-long immunity, were common. This failure to appreciate or respect scientific method and principles of public health deserves separate treatment.

There are a number of good books on the history of epidemics and pandemics, up to and including COVID-19. Richard Horton, Editor in Chief of the Lancet produced The COVID-19 Catastrophe, looking at what he calls the failures of ‘science policy’, or how so many western governments failed to heed the warnings, leading to reckless acts of omission which costs tens of thousands of avoidable deaths. There are many longer history tracts, such as Michael Oldstone’s Viruses, Plagues and History, Mark Honigsbaum’s The Pandemic Century: One Hundred Years of Panic, Hysteria, and Hubris, and more practically focussed works such as Jonathan Quick and Bronwyn Fryer’s policy oriented The End of Epidemics. Amongst others we could mention Adam Kucharski’s The Rules of Contagion: why things spread and why they stop, David Waltner-Toews’ book On Pandemics, and earlier works such as Laurie Garrett’s The Coming Plague: Newly Emerging Diseases in a World Out of Balance. Epidemics have been studied extensively.

Also relevant to any study of pandemic management is a full century of work on social medicine, including Howard Waitzkin’s The Second Sickness: Contradictions of Capitalist Health Care (2000) and Salvador Allende’s 1938 classic Chile's Medical-Social Reality. The late Chilean President, then a young Health Minister, famously set out his vision:

to reacquire the physiological capacity of a strong people, recover its immunity against epidemics; all of which will allow a better performance in national production while also providing a better disposition and spirit to live and appreciate life.

Allende’s classic and related resources are available at the excellent online journal Social Medicine: https://www.socialmedicine.info/index.php/socialmedicine/index

Understanding the COVID-19 crisis requires an interdisciplinary approach, of medical science, public health principles, civil rights and political economic systems. Science is important because, as epidemiologists like to say, if you’ve seen one pandemic, you’ve seen ... one pandemic (Van Beusekom 2007; Osterholm 2012; Horton 2020: 9). That is to say, even when looking for common patterns of contagion, there are unique features of each virus and its epidemic. One reviewer said COVID-19 doesn’t behave like flu, which doesn’t behave like Ebola (Spinney 2020).

The distinct character of each virus and disease has implications for understanding both chronic illness and ‘immunity’. In some cases, contact with a new virus might be widely overcome through natural immune processes. In other cases insufficient immunity is developed, without a vaccine, and that immunity is often not passed on to children, as with smallpox and measles. There may also be chronic-persistent infections, as with the retroviruses which cause HIV/AIDS (Oldstone 1998: 16-23). Further, those who dismissed COVID19 as just another flu did not seem to recall that some influenzas, like the 1918-19 ‘Spanish Flu’, have been extremely deadly (see Chapter Three).

The concept of ‘herd immunity’, which had been popular in eugenic circles in the 1930s, re-emerged as a neoliberal rationale for doing little in public health terms, except to allow some type of natural selection to take its course. There are serious uncertainties that beset this idea. In particular, combinations of antibodies and T-cell immunity in areas heavily infected with COVID-19 have remained quite low (Jones and Helmreich 2020; Pitt 2020; Woodley 2020b). A number of studies have examined non-specific and pre-existing immunity through T-cell reactivity, alongside specific antibodies. Given the highly contagious nature of the new virus it has been assumed that any ‘herd immunity’ requires very high levels (perhaps 85%) of immunity, through vaccination. No observed natural levels of antibodies or T-cell reactivity come even close to this (Pitt 2020; Doshi 2020).

The deadly impact of a disease is normally expressed as an infection mortality rate (IFR), lower than the proportion of those who present with illness, which is known as a case fatality rate (CFR). Once the initial COVID-19 CFRs of 3% or more came down we saw epidemiologist calculations of IFRs mostly between 0.5% and 1% (Mallapaty 2020; Elaheh et al 2020; Verity et al 2020). There are some outliers, saying it could be as low as 0.2 or 0.3% (Bhattacharya 2020), or from 0.2% To 1% (CDC 2020); with others as high as 1.3% (Basu 2020: 5). While it is possible that IFR estimates may fall further, over time, no responsible health official could simply cherry pick the most optimistic estimates because, if the estimates relied on were wrong, the official could be responsible for many thousands of avoidable deaths. That is why an epidemiological consensus remains important.

At the same time, responsible preventive measures must have a plan with a clear aim and specific targets for restoration of a more normal regime. The neoliberal systems of the USA and the UK, which delayed and then imposed erratic preventive measures, face the double dilemma of soaring deaths rates combined with seemingly endless ‘lockdowns’.

The IFR of the so called ‘Spanish Flu’ of a century ago, which killed tens of millions, has been estimated at between 1% and 3%; while the IFR of the 2009 ‘swine flu’ pandemic was between 0.001% and 0.007%, with 200 or 300 thousand deaths worldwide. Both affected younger people (CDC 2019). Nevertheless, as each new disease carries unknown elements, preventive steps are taken. In the USA the swine flu led to high alerts and school closures. A vaccine was produced after five months, but by that time the second wave of infections had already peaked (CDC 2019).

Virologists and immunologists have told us that this new virus is more contagious than deadly, but still up to ten times more deadly than a seasonal flu. Current data tends to confirm that. By late September 2020, that is seven or eight months into the pandemic, more than a million people were recorded as having died from COVID19. That compares to an average of about 400,000 per year from seasonal influenza (Paget 2020).

Scientists say that, more than just a respiratory disease, it attacks vascular systems, creating inflammation (Raghab 2020) and vascular leakages (Teuwen, Geldhof, Pasut and Carmeliet 2020; Matacic 2020); and that while naturally developed specific immunities to COVID-19 have been recorded in Europe, they only reach about a 10% level (Habib 2020; Pitt 2020; Rolander 2020). There is also evidence of up to 30% with some sort of non-specific immunities (ECDC 2020). However the low levels of COVID-19 antibodies demonstrated so far, and uncertainties over how immunity works creates great doubt over the potential for any sort of natural ‘herd immunity’ (WHO 2020); nor is it known how long any such immunities might last (Woodley 2020b; Poltorak 2020).

As with any epidemic of severe illness, there is a sequel of many who survived but are left with chronic illness (Couzin-Frankel 2020). By late July there was only one peer reviewed study of long term illnesses from COVID-19, from Rome; but there are many reports of lung damage, heart damage, brain inflammation and neurological conditions amongst COVID19 survivors (Wark 2020; Marshall 2020). A number of these are amongst young, healthy, active people (Couzin-Frankel 2020). Some large studies have begun to follow the many thousands of survivors, over time.

Transmission is also still under study. While it is assumed that symptomatic persons are the main vector of contagion, and that there is both tactile and airborne contagion, debate persists about the extent of asymptomatic and pre-symptomatic contagion. In June the WHO recognised there was still uncertainty on this question, and that there had been some estimates of as much as 40% asymptomatic transmission. One Australian study suggested that asymptomatic coronavirus cases account for around 15% of COVID-19 infection, but that these people spread the disease at a ‘considerably lower rate (Woodley 2020a).

Public health specialists and epidemiologists must combine these understandings with the best available evidence on contagion and population vulnerability, to develop preventive strategies. Amongst other things they look at particular reproduction rates (R) for diseases, in both contagion and control (Kucharski 2020: 54-59). Yet all their suggested strategies are mediated by political economic systems which often have quite pre-determined approaches. Social medicine approaches, like that of Allende, have their own, wider views of social solidarity. In contrast, we live in a world which, from the last quarter of the 20th century, had rapidly commodified and degraded public health services. This is part of a global neoliberal project which has created grave consequences for how societies address health crises, and for how we understand those crises.

For those reasons this book maintains focus on its three themes: the neoliberal failures, the importance of independent countries and the myths thrown up by western liberalism.

If we do not recognise the underlying ideologies that reshape political economic regimes, including health systems, we are at risk of mistaking symptoms of the crisis for causes. The best example of this in the COVID-19 crisis was the polemic set up between the ‘lockdowns’ of the USA and the UK and the relatively limited restrictions imposed in Sweden. This false dichotomy misses the common neoliberal features of all three: maximum individualism and commercialism in health services, privatised systems and neglect or abandonment of preventive health. It misses the fact that neoliberal leaders in the USA and UK also tried to avoid quarantine measures as long as possible, thereby delaying responses and aggravating their epidemics. The Anglo-Americans only imposed quarantine restrictions in a delayed and clumsy manner, when infections and death were alarming their health systems. The ‘anti-lockdown’ crowd missed important contradictions within those states, for example the serious tensions between the CDC and the Trump Administration. They also missed the contradictions between neoliberal states and the World Health Organization, not least the Trump Administration withdrawing US funds for the W.H.O..

After seven months, the worst COVID19 outcomes in terms of infections and deaths were in the highly privatised health systems of Europe, the USA and Latin America. Here ‘privatisation’ means a combination of private for profit health care, greater commodified treatment focus, less preventive care, lack of agency coordination and greater ‘consumer choice’ in insurance or service providers. Table 1 below shows the ‘worst outcome’ countries, those (at 9/9/20) with more than 500 deaths per million population, compared to the World average and the rates in China and Cuba. While this data (in fact any international data comparisons) has its problems, it is the best we have so far. We have to account for those uncertainties as best we can. High levels of testing in most listed countries make the infection data better than it was earlier in the year.

WHY WERE THE WEALTHY countries so poorly prepared? Health care in Europe steadily privatised during and after the 1980s, alongside a decline in the growth of public spending (Maarse 2006: 1008) and a neglect of principles associated with public and preventive health. Rachel Tansey (2017) has prepared a valuable article on the ‘creeping privatisation’ of health systems in Europe, during and after the 1980s, even in those countries where (unlike in the USA) there remained some sort of universal service guarantee.  This marketisation of healthcare was aided by European Commission policies and accompanied by trading health for profit, with the growth of public private partnerships alongside public spending cuts (Tansey 2017). Yet the prevention of contagious diseases was clearly one of the elements of public health which could not be properly regulated by commercial market principles (André and Hermann 2009: 129-130).

It is not just that many European countries (e.g. Britain,