It is the globalised world’s most localised emergency. An epidemic has become a pandemic faster in a globalised world, as we have experienced now. The outbreak of the new strain of coronavirus took just 70 days to be declared as a pandemic on March 11. But the effort to contain it has to be ultra-local.

It boils down to a physical distance of over three feet between two individuals just to stop it from spreading further. How a local health infrastructure mounts surveillance and testing in its neighbourhoods makes the difference as to how deadly this globalised scourge becomes. It is almost an intense personal fight to stop a fast globalising invisible virus.

In Italy, the health system was overwhelmed—considered the second best in Europe—and reported more fatalities than China. Here, doctors applied judgement as to which patient they should to treat and which ones they should leave to die. Most COVID-19 patients were old, and needed intensive care. But there was no adequate health infrastructure or facilities. The country banned funerals to avoid gatherings, so military transport was arranged to ferry dead bodies. The whole country is under isolation at present. In the US, it is an emergency like never before. Its healthcare system has not been able to manage the deluge of patients—by March 20, 150 people had died.

Though the Congress has passed the Families First Coronavirus Response Act to bear the testing costs for COVID-19, the treatment is turning out to be prohibitively expensive—27 million Americans are without health insurance and an average treatment costs around $35,000 per patient (based on cases reported). The Kaiser Family Foundation has estimated that even with insurance and in case of non-complicated cases, the treatment would cost around $9,763. With over 10,000 patients already under treatment, the country is proposing to adopt direct cash support to its affected citizens. This flags a caution as the march of COVID-19 moves to developing countries such as India and Africa. How would a lesser-developed healthcare systems in these countries react to the pandemic? With over 200 cases of COVID-19 infections, India is staring at an eruption of cases as screening and detection efforts have picked up.

The Indian Council of Medical Research says by mid-March, India was in the stage second of the pandemic: dealing with infection from people who travelled to countries with COVID-19 cases. The country is checking out and quarantining those who came in contact with the infected. But transmission is believed to have become domestic and untraceable waiting to show up in big numbers in a few weeks, to be specific by mid-April. This is inevitable, but the ongoing efforts to contain the infection can delay it. India has already imposed a travel ban for foreigners. Some 15 states have enforced closure of public gatherings. Five Northeast states have sealed their borders.

THE NEW HOTSPOTS

The focus on India as the next big geography of spread is valid given its 1.37 billion population and its dense distribution. There is a fear whether India’s weak health infrastructure would be able to manage a pandemic of this proportion. According to the United Nations Conference on Trade and Development, India is one of the 15 economies to be most impacted economically by pandemics. Given that tourism, services and other retail sectors will be affected the most due to restrictions on mobility, some 30 per cent of India’s workforce is staring at economic losses. This, in turn, will weaken people’s capacity to bear their health expenditure (see “Last Word”,).

Like India, Africa is also a secondary hotspot. The continent has over a billion population and underdeveloped health infrastructure. Till first week of March, the Johns Hopkins University’s real-time interactive map on COVID-19 didn’t show those scary red dots indicating infections in sub-Saharan Africa. But by March 10, the situation changed. In just 10 days, 33 African countries reported more than 600 cases and 17 deaths due to COVID-19. Just like in India, experts say, in Africa too, the virus is spreading across the continent undetected and even faster. “My concern is that we are sitting on a ticking time bomb,” says Bruce Bassett, a data scientist at the University of Cape Town, who has been tracking COVID-19 data since January. The response is showing up slowly.

Around 30 African countries have imposed travel restrictions from China and other countries with positive COVID-19 cases. For example, in Uganda, travellers from 16 countries must be quarantined at their own cost for 14 days. Angola has temporally banned direct travel from seven countries. China is Africa’s main trading partner. This has increased air traffic between China and Africa, says John Nkengasong, director of the African Centres for Disease Control. Mary Stephen, a public health expert at the World Health Organization (WHO) Africa Region, says they have assessed pillars of preparedness and response for Africa, and one of the pillars is their capacity of case management and availability of facilities.

Way back in August 2019, Africa’s preparedness for a pandemic came into focus. WHO had asked African countries to make “pandemic preparedness” more affordable for people on the continent in a new strategy document. Pandemic preparedness in Africa is estimated to cost $2.5-3.5 per person annually, according to the Regional Strategy for Integrated Disease Surveillance And Response (IDSR strategy), prepared by WHO.

Pandemics can be very disruptive. Even a moderately severe pandemic could have a potential global economic impact of $500 billion, or 0.6 per cent of global income. In contrast, the cost of adequately preparing for a global pandemic is estimated at $4.5 billion, or less than $1 per person per year. Unfortunately, according to WHO, most countries are grossly underprepared in infrastructure to mitigate a pandemic crisis. This indicates that the pandemic preparedness per person per year in Africa is expensive, rather than affordable. That’s why, investing in pandemic preparedness is an affordable public health good for Africa, said the IDSR strategy document. Charles Bigabiro, an expert in health economics, says, “Most of the countries are not ready, authorities are not yet aware of the pandemic and don’t have commitment to protect their population. They think the problem is for other countries.”

Assessing the facilities, WHO’s Mary Stephen says countries are now using facilities for other infectious diseases to manage COVID-19 cases. “Despite the fragility of the health system, countries have surveillance in place that is enabling health workers to detect the infected. If you look at some of the statistics that are coming out from China, we understand that 81 per cent of the cases are mild, 14 per cent are severe and 5 per cent of the cases are critical. So 19 per cent of the cases would require hospitalisation,” she says. “In the past, Africa has dealt with more than one epidemics like cholera, Ebola... so that the continent has great resistance and coping capacity,” says Michael J Ryan, executive director of WHO’s Health Emergencies Programme.

However, experts have expressed concerns about the late onset of the outbreak in Africa. This is mostly based on the contested hypothesis of COVID-19 thriving in colder temperatures and becoming milder in a hotter atmosphere. Going by the temperature in countries affected, it is clear that the most affected are colder than those least affected. Severely affected countries like South Korea, Italy, Iran and Spain had temperature ranging from 6-120 C during January-March. In sub-Saharan Africa, countries reporting COVID-19 like South Africa, Nigeria, Senegal, Togo, Cameroon and Benin had 20-320 C in this same period. For example, the peak circulation of flu in South Africa is in the winter season between April and July. But there is a catch. “In Senegal, the peak season is in the rainy season, from July to October. Many other African countries experience these peaks during the cold rainy season. This could mean that the preparedness of most African countries may soon be tested when these seasons come, especially as many more countries are confirming imported cases into the continent,” says Akebe Luther King Abia, research scientist, University of KwaZulu-Natal in Durban. There is no let-up in this scourge.

GLOBALISED VIRUS

“We have not seen a global epidemic like this in 100 years. Nobody has an experience of having dealt with anything like this in the past,” renowned historian-philosopher Yuval Harari said in a news show on CNN. He links it to recession, and the globalised nature of our existence. Either globalisation will have a multiplier effect on this pandemic or those favouring globalisation say pandemic would rather negatively impact globalisation. Differences apart, they agree on one point: globalisation is going to be a deciding factor in this pandemic. What the world was busy enjoying the benefits of globalisation, policymakers forgot the ill-effects of a free market world. Weak healthcare systems and their impacts are playing out at globalised scale. So, a near non-existent healthcare system in the US couldn’t manage an infection from an emerging economy like China. And before China clamped down in a massive scale to curtail the spread, two of its citizens had already landed in Italy, spreading COVID-19 undetected. Italy’s complacency in tackling infection domestically led to a wider spread, even in faraway India.

“It would be overly simplistic and inaccurate to describe globalisation as either “good” or “bad” for health,” wrote Kelley Lee, London School of Hygiene, in a paper, Globalisation: what is it and how does it affect health? Lee says spatial change is leading to increased migration of people throughout the world.

A global health security index did a country-wise assessment of pandemic preparedness and found that not a single country is prepared. Most countries lacked foundational health systems capacities vital for epidemic and pandemic responses. Of the seven categories, this was the lowest scoring category. The average score was 26.4 out of 100. About 131 countries, including several high-income countries, were in the bottom tier of this category. Only 11 per cent countries showed plans to dispense medical countermeasures during health emergencies.

The pandemic has brutally shattered the belief that the private sector-led health services are efficient and responsive. At least, it makes the case for a more robust and public-funded response system when every country’s infection is globally contagious. In the face of COVID-19, Italy—a high income country—looks as helpless as any poor country without any semblance of an organised public health system. In the 1990s, Italy privatised parts of its healthcare delivery system. A comparison of mortality rate before and after privatisation found public spending was significantly associated with reductions in avoidable mortality rates over time, while greater private sector spending was not at the regional level. The country has also the second highest average life expectancy in Europe, reaching 79.4 years for men and 84.5 years for women (2011 data).

The US is facing flak from its own experts for not testing adequately and for delaying testing for about two weeks. The country couldn’t manufacture the test kits at the right time, thus delaying the most critical aspect of containing the virus spread. The White House, the Centres for Disease Control and Prevention and the Food and Drug Administration for long debated and discussed and delayed the kits’ manufacture. There was scarcity of kits thus letting out many with the virus freely moving around and transmitting it to others. This explains why 38 per cent of the US’ COVID-19 patients were below 55 years of age, unlike elsewhere. It indicates undetected patients and unbridled transmission, a scenario now feared in developing countries.

The pandemic also unveiled another aspect of globalisation. When it comes to profit or wealth, most countries adapt one mode. But when it comes to a global emergency, they just adopt the opposite of what globalisation means. Desirably, countries have sealed their borders. There has been selective stopping of trade. While WHO minced no words in criticising these restrictions, not a single public health expert was willing to say that this was a much-needed step. Whether or not this step led to containment would remain a matter of sharp debate, but what would remain undoubtedly a fact is that when a health emergency strikes, all principles of globalisations are thrown to the winds.

A few countries moved a step further. They stopped export of Active Pharma-ceutical Ingredients and PPEs. Despite continuous appeals by WHO, these countries showed their selfish attitude because on one hand, the ban on export may lead to access Personnel Protective Equipment in one country, and on the other, countries may badly be falling short of it putting their frontline health workers at risk.

WHO, while declaring the outbreak as global Public Health Emergency of International Concern prepared a global plan for the pandemic on January 31. The plan said WHO would require $637 million. By mid-March not even one-third has been collected despite vehement appeals that there is acute shortage of personal protective equipment and masks for the frontline healthcare workers. Till date, various countries and agencies have donated only $206 million. This shows how countries have decided to leave a global health body in the lurch when they were required to help. Harari in his interview clearly pointed out that if countries remain short-sighted and do not help other countries, they would end up only increasing their own risk.

The COVID-19 pandemic has brought out the fragile side of globalisation: a growing and imbalanced dependence on each other. Take China for instance. It almost controls the supply chain of goods of the world because it is the factory to the world. It seems a truck driver in China couldn’t join work due to COVID-19; the shipment of solar photovoltaic chips couldn’t reach India on time unsettling the country’s solar energy target. Thousands of fisherfolk in India’s coastal areas are losing their livelihoods because there is a curb on shipping due to the pandemic.

The global response has also proved that the pandemic might actually push countries faster towards deglobalisation. Many countries are already moving towards this phase to protect national interests. This is not the first time that a disease is derailing the process of globalisation—the Spanish Flu too had killed the first wave of modern globalisation. The difference is this time globalisation is truly global. A recent Bank of America report states that 80 per cent of multinationals have invested in plans to repatriate part of their production—known as re-shoring—a trend that COVID-19 could turn into a tidal wave.

However, globalisation has also made the exchange of critical information faster. China did the genome sequence of the virus within a record time of 20 days. It shared the sequence on publicly accessible platform. This helped researchers across the world to develop diagnostic assays. This was impossible had China not shared it. Very quickly, scientists in various parts of the world started collaborating on research on drugs and therapeutics. WHO is also leading multi-country trials of these products. The global scientific community is collaborating well and there is evidence for this. Vaccine prototypes exist and soon there will be human trials.

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