The Health Transformation Army

The first​ big leader to livestream a message to the virtual World Health Assembly on 18 May was supposed to be Cyril Ramaphosa, president of South Africa and chairman of the African Union, but something went wrong with the feed. Xi Jinping went first instead. We saw the president of China seated behind a highly polished table, in front of a mural showing rosy dawn creeping over the Great Wall. He promised billions of dollars to fight Covid-19 and invoked ‘planet Earth, our common home’. When the virus appeared in China, he said, his country had acted with ‘openness, transparency, and then responsibility’. Emmanuel Macron was next, bobbing and rubbing his hands as he spoke of humanity’s ‘fundamental right’ to health. Moon Jae-In, the president of South Korea, spoke of solidarity; Angela Merkel popped up to tell us wanly that the World Health Organisation was a good thing.

The assembly is the annual meeting of the member states that fund and supervise the WHO. The opening session of this year’s assembly, forced online by the worldwide lockdown, was anchored from WHO headquarters in Geneva. We were led on a claustrophobic internet tour of ministerial offices and oppressively large desks in three dozen world capitals, some of the speeches crackling and fuzzy, until, just after Canada and just before Honduras, we cut to Alex Azar, the emissary from the United States, sent to put Xi and the WHO in their place. He sat in front of a blank blue screen in rimless glasses and a light grey suit, his hair slicked down 1950s-style, bearing an uncomfortable resemblance to the late Donald Pleasence.

It took Azar, Donald Trump’s health secretary and a one-time pharmaceutical industry lobbyist and executive, less than three snippy minutes to deliver his boss’s message. The pith was the astounding charge that Xi and the director-general of the WHO, Tedros Adhanom Ghebreyesus, were to blame for the severity of the pandemic. ‘We must be frank about one of the primary reasons this outbreak spun out of control,’ Azar said.

There was a failure by this organisation to obtain the information that the world needed, and that failure cost many lives … In an apparent attempt to conceal this outbreak, at least one member state made a mockery of their transparency obligations, with tremendous costs for the entire world. We saw that WHO failed at its core mission of information-sharing and transparency, when member states do not act in good faith.

It was clear that the ‘member state’ was China. Trump had been trolling the WHO for weeks, accusing it of being a ‘tool of China’ – if it hadn’t actively helped China cover up the outbreak, it had at least helped China cover up the cover-up. Trump likes to present the World Health Organisation and the World Trade Organisation as two arms of a global system captured by China to take advantage of big-hearted, deep-pocketed American naivety. Again and again in April, he returned bitterly to the WHO’s disapproval of border closures as a way to contain epidemics. On 14 April, he froze US funding for the organisation.

At the end of March, the death tolls in China and the US were about the same, a little above three thousand. Two weeks later, when Trump was claiming in the Rose Garden that China and the WHO between them had raised the worldwide caseload by a factor of twenty, the number of dead in China had barely budged: the epidemic there was under control. In the US, more than 23,000 had perished. By the time of Azar’s address to the assembly barely a month later, the Chinese toll had crept up to 4638, and was flat, while America’s dead numbered nearly ninety thousand, and the figure was still rising.

That night in America – it was already first light in Geneva – Trump tweeted a letter laying out his accusations against the WHO, threatening to quit the organisation if it didn’t perform an unspecified act of repudiation of China by the middle of June. He didn’t wait that long. On 29 May, as part of another broad spectrum attack on China, he announced that the US would be pulling out of the WHO. ‘China,’ he said, ‘has total control over the World Health Organisation, despite only paying $40 million per year compared to what the United States has been paying, which is approximately $450 million a year.’

The Trump démarche, both the letter and the later statement of intent to quit, seemed extraordinary: for its timing (an attack on the world’s public health agency in the midst of a once in a century global pandemic); for the easily disproved fake ‘evidence’ it cited (the letter opened with a claim that the Lancet had warned of the virus spreading in China in 2019 – it hadn’t); and, circumstantially, for the transparency of Trump’s real motivation (to shift the blame for his weak handling of the crisis less than six months before the presidential election). In a way, the episode was extraordinary, a notable moment in the coarsening of the US government’s diplomatic voice under Trump. But it was also in keeping with a pattern in the management of global disease, a pattern that goes back long before Trump, and long before the WHO was founded in 1948. There is a recurrent Euro-American fear that infection will leak in from elsewhere on the planet, and a recurrent desire to build barriers against it. The pattern connects to the American dread of being subjected to anything resembling a world government. And it alternates between two ideals of healthcare: the tech model, in which health is seen as a set of individual problems to be fixed by intensive, preferably one-time scientific interventions (wipe out malaria with genetically modified mosquitoes!), and the communal model, in which health is deemed a rolling project of social reform, endless and universal, low-tech and labour-intensive, inseparable from questions of housing, poverty, sanitation, education, inequality, diet and work.

Disease knows no borders, we were told in speech after speech at the assembly: we must work together. But what does this mean? Can the WHO be the means to marshal a collective global effort, or is it doomed to cloak the reality that, in fact, there is very little solidarity between nations? Trump’s intervention in May didn’t help the WHO, and American withdrawal from the organisation would be a hard blow, but some version of the letter was expected, and there must have been a measure of relief among national governments that the US president had sucked from the gathering all the media attention that might otherwise have been directed at wider failures of co-operation. Far from increasing pressure on China, whose initial response to the appearance of the new virus was certainly not ‘open, transparent and responsible’, Trump’s eagerness to turn hysterically on the WHO itself actually eased the pressure on Xi Jinping at a time when, as we later learned, he was busy planning the suppression of democracy in Hong Kong.

Britain’s health secretary, Matt Hancock, delivered its message to the assembly. He spoke perkily, as if everything in his country was under control. In fact Britain is the country which, given its relative wealth and long warning time, has failed most grievously to protect its people against the first onslaught of the virus. Its failure lay primarily in its neglect of the low-tech, low-cost, labour-intensive public health methods and community mobilisation that successfully prevented disease in low-income countries: universal lockdowns, self-isolation, masking, quarantine and tracing – by people, not apps – of all those whom sick people have been in contact with. Yet in his short video message Hancock was speaking the old language of Americans and Europeans, coming up with a tech solution – in this case, a vaccine that doesn’t yet exist – to the world’s problems. ‘I’m proud that the UK is leading this work,’ he said, ‘that we’re the biggest donor to the global effort to find a vaccine, and that UK research efforts are leading the way.’ Hancock’s wasn’t the only speech at the assembly to prompt the thought that before there can be solidarity, a little humility would help.

Towards​ the end of 1826, Alexander Pushkin was playing chess with a friend who, as he put it, ‘knew a lot of the kinds of thing they study in universities while we were learning to dance’. The friend checkmated Pushkin with his knight and remarked: ‘Cholera morbus is at our borders, and in five years, it’ll be here.’ Like most of his peers Pushkin knew almost nothing about the disease, which was endemic in Asia but unfamiliar to Europeans. Four years later, in 1830, he went to his father’s estate near Nizhny Novgorod for what he thought would be a few weeks’ business. He ended up caught in a harsh and futile lockdown against the cholera epidemic that spread from Georgia and Astrakhan to European Russia that autumn.* Pushkin enjoyed the most artistically productive three months of his life; Russia was paralysed by a pandemic regime that sanctioned the shooting of quarantine violators and triggered a series of violent uprisings.

The disease spread to Finland and Poland. It was in Vienna by August 1831. From there it reached the German ports and travelled on to England, Ireland and France. This first incidence of cholera in Europe, with its horrible symptoms of constant diarrhoea and vomiting, is the novel pandemic that haunts Middlemarch. ‘All the world is in apprehension about the cholera pestilence, which, indeed, seems advancing towards us with a frightful, slow, unswerving consistency,’ Thomas Carlyle wrote as the disease entered Britain through Sunderland. Eventually it killed 52,000 in Britain alone. ‘Our other plagues were home-bred, and part of ourselves,’ an anonymous English doctor wrote:

We had a habit of looking on them with a fatal indifference, indeed, inasmuch as it led us to believe that they could be effectually subdued. But the cholera was something outlandish, unknown, monstrous; its tremendous ravages, so long foreseen and feared, so little to be explained, its insidious march over whole continents, its apparent defiance of all the known and conventional precautions against the spread of epidemic disease, invested it with a mystery and a terror which thoroughly took hold of the public mind, and seemed to recall the memory of the great epidemics of the middle ages.

The pandemic of the 1830s wasn’t the first great cholera outbreak of modern times. That had occurred a few years earlier, in British-ruled India, where a million or more people died. The prevailing attitude among the British in India – one which subsequently spread, with cholera, to the Euro-American world – was that cholera was of India and Indians, transmitted by means of deplorable Indian habits, from which innocent Europeans and Americans had to be protected. Yet what turned cholera from a series of restricted outbreaks among Hindu pilgrims in India into a global pandemic was the international movement of British troops and British merchant ships, which spread the illness across the subcontinent and on to Central Asia, Africa and the Middle East.

One way of protecting Europe from cholera, in other words, would have been for Europeans to avoid establishing rapacious and intrusive global empires. But they had established them. There was much European hand-wringing in the 19th century over the perilous sanitary consequences, to Europe, of the grand imperial transport projects for which Europe was largely responsible. The Suez Canal, according to a recent history of the WHO by Marcos Cueto, Theodore Brown and Elizabeth Fee, made Europeans feel ‘dangerously close to India’.† In 1900 the fear was the imminent completion of a railway line linking Berlin to Mecca, seen as a cholera hotbed.

Cholera, which returned to Europe repeatedly during the 19th century, was the subject of the first International Sanitary Conference in Paris in 1851. At intermittent meetings over the next three decades, against opposition from shipping interests, a system of marine quarantine was set up. Cholera receded as a threat, but plague and yellow fever were resurgent; a yellow fever outbreak killed as many as twenty thousand in the south-eastern US in 1878. In December 1907, 13 countries – mainly European, but including Brazil, Egypt and the US – set up the first embryonic global health agency, the Paris-based Office International d’Hygiène Publique (OIHP), to share information about epidemics between member states (a similar organisation, for the Americas only, had been set up a few years earlier). Whatever humanitarian intentions the OIHP had were clouded by the racist implementation of quarantine rules. Prevailing attitudes, Cueto, Brown and Fee write, ‘meant holding individuals, communities or nations (usually non-Caucasian) responsible for epidemics, an attitude that reinforced the cultural dimensions of European imperialism. Arab pilgrims were thus commonly portrayed as vectors of cholera … yellow fever was thought to be carried by immigrants from the Caribbean and bubonic plague by immigrants from China.’ The unspoken goal of the OIHP ‘was not the improvement of the health of the world’s people but the protection of certain favoured nations from the “grandes maladies épidémiques” originating primarily in less favoured ones’.

In 1923 the OIHP gained a rival in the League of Nations Health Organisation (LNHO), based, like the League of Nations itself, in Geneva. The OIHP was abolished in 1946, its reputation destroyed after being folded into the Nazi-Vichy administrative system during the Second World War. In the spring of 1945, a conference was held in San Francisco to set up the United Nations. It hadn’t originally been scheduled to discuss a separate body for health, but a Chinese medic and diplomat’s son called Szeming Sze managed to push it onto the agenda, where it was overwhelmingly endorsed. Three years later, the WHO came into being. Each member state, regardless of size or wealth, would appoint three delegates to the World Health Assembly, which would elect the director-general, who would run the WHO’s day to day operations with a staff of international civil servants. A group of experts chosen by the assembly would mediate between the director-general and member countries.

Raymond Gautier, the Swiss medical director of the LNHO who drafted a plan for a successor agency in 1943, had imagined an organisation that would be able to enforce health rules with sanctions against countries that didn’t comply, but this never happened. The WHO has never had the power to compel a reluctant member nation. Its funding and staffing were small – 254 in 1949 – and its competencies both vague and potentially limitless. It had the remit to be the world’s watchman for infectious disease outbreaks, but it also had a stirring constitution written in the language of social justice, a ‘Magna Carta for health’ that declared health a universal human right, and defined it as ‘a state of complete physical, mental and social well-being … not merely the absence of disease or infirmity’. The WHO was obliged to do some concrete tasks, such as gathering epidemiological data and standardising the technical vocabulary of medicine. At the same time it was open to initiatives not only from countries desperate for help with hospitals or sanitation but from philanthropists keen to give it.

The​ organisation’s logo is the snake-twined staff of Asclepius against a map of the world, an arcane signifier that avoids commitment to any particular one of the organisation’s three priorities. Should the prime symbol instead be a syringe, to proclaim the power to solve ill-health, disease by disease, with technological fixes? Or should it be two hands clasped, to represent ill-health as the problem of a lack of social solidarity? Or a watchtower, to symbolise vigilance and defence against the menace of spreading infection? The Bill & Melinda Gates Foundation is the second biggest contributor, after the US government, to the WHO’s $2.4 billion budget. Gates is a believer in the tech fix. ‘I believe we are on the verge of taking historic steps to reduce disease in the developing world,’ he told the World Health Assembly in 2005. ‘What will make it possible to do something in the 21st century that we’ve never done before? Science and technology.’ The same philosophy was expounded a hundred years ago by the Rockefeller Foundation’s International Health Division, founded in 1913, which by 1933 was paying the salaries of half the staff of the LNHO. Tech fixes have had striking successes – the elimination of smallpox, a WHO-choreographed triumph – but also failures, notably the abortive effort to eradicate malaria in the 1950s and 1960s.

That failure, and the growing sense of the iniquity of importing Euro-American medical models into former colonies that couldn’t afford to run them or to scale them up, were the primary concerns of a joint WHO-Unicef conference on primary healthcare held at Alma-Ata in Soviet Kazakhstan in 1978. The conference ended with a declaration calling for community-level public health and better public services for everyone in developing countries. The declaration is a foundation text for those, like Tedros, the current director-general, who reckon there’s little point in saving a child from dying of malaria if they’re going to be killed by bad sanitation or lack of education. ‘People should not die because they are poor,’ Tedros observed after his election – a remark that might be taken as trite were it not for the great number of political movements in the world who live by the implicit premise that, actually, it’s their fault if they do.

Over the decades the US government has veered between the syringe and the watchtower. For much of the WHO’s existence it has put immense expertise and resources into global healthcare, from a mixture of motives – humanitarian, scientific, influence-seeking, image-boosting, or to support its medical industries. The US has provided some of the WHO’s most dynamic figures, notably Jonathan Mann, who led the organisation’s response to the spread of Aids in the 1980s. In narrative fiction and non-fiction, a stock figure has emerged: the brave, principled, maverick American researcher who leaves the safety of the homeland to plunge into the world of foreign disease. The real-life archetype, who appears in two bestselling books from 1994, Richard Preston’s The Hot Zone and Laurie Garrett’s The Coming Plague, is the medical researcher Joe McCormick. Here he is, in Garrett’s version, being asked by the WHO in 1979 to fly from the Atlanta headquarters of the US Centres for Disease Control and Prevention (CDC) to Sudan to investigate an Ebola outbreak:

McCormick hastily gathered supplies and the first assistant he could get his hands on … Dr Roy Baron. Within a matter of hours, the pair were on board a flight to Khartoum, and McCormick was giving Baron a rapid-fire lesson on Ebola, Sudan, field operations and self-protection.

Joe tugged at his dark brown goatee with anticipatory excitement, relishing a second chance to crack the mysteries of Ebola.

If the US does pull out of the WHO – and there is considerable scepticism that it will, even if Trump wins a second term – it wouldn’t be the first country to quit a UN organisation. The Soviet Union left the WHO in 1949, taking its Eastern European satellites with it, returning only in 1956 after the death of Stalin. Britain twice followed the US out of Unesco at the end of the last century. The suspicion that international organisations are stalking horses for world government is near the surface of American politics. The US declined to join the League of Nations; the US (along with China, India and Russia) is not party to the International Criminal Court; alone among member states, the US demanded at the WHO’s founding that it should be allowed to withdraw unilaterally with a year’s notice. Even if the US does leave, it won’t cut off aid to global health programmes. They’re too valuable for leveraging power and supporting the domestic pharmaceutical industry. When Azar addressed the assembly in May he took care to say that the US doesn’t begrudge setting aside $9 billion to fight Covid-19 around the world. The question is whether the US can really afford to undermine the WHO’s watchtower role as the early warning system, data clearing house and resource co-ordinator for pandemics; and what it will mean for the health security of the rest of the world if one part of the globe goes silent. After decades when it seemed that high-income countries no longer had much to fear from epidemics, a succession of novel viruses has appeared: HIV, Ebola, Sars and now Covid-19. Trump’s preoccupation with borders, immigration and, lately, cordons sanitaires is a throwback to the early days of the OIHP and the fear of cholera, when the emphasis was on the need to establish a disease barrier between ‘civilisation’ and ‘barbarity’. Under Trump the US is no longer moving between the syringe and the watchtower; it is a riled-up bald eagle with a bottle of pills in one set of talons and a roll of razor wire in the other. His position is that the US can and must do without WHO watchkeeping because, in respect of Wuhan, that’s exactly the role in which the agency has already failed. The truth is rather different.

Wuhan​ is one of the great cities of China, bigger than any European city apart from Moscow, but I knew nothing about it before the outbreak. I know a little more now, but my own city, the pre-Covid London of midwinter 2019, has become a remote, fantastical place. I look back at the first week of December. S. and I had just moved into a new house. Her sister came to stay. A friend came over to cook us coq au vin; he was in our kitchen for hours. I went to the pub with my family, and stood close to strangers at the bar. Nobody was masked. I watched the highlights of the Liverpool-Everton game. Tens of thousands of people roared from the terraces. We checked out a primary school for our son. Dozens of unmasked parents trooped into classrooms filled with children and unmasked teachers. Nobody washed their hands. It was my birthday; we got a babysitter; we met friends at a restaurant in Soho. Black cabs and Ubers seeded Frith Street with revellers. The boozing-rooms roared. Unmasked waiters leaned in. The skies were full of planes, underground and overground trains full of people. And at this time, somewhere in a great city in China whose name held no meaning for me, was an individual with a bad cough who was going to stop it all.

A WHO bulletin on 12 January said, citing the Chinese authorities, that the first patient reported symptoms on 8 December. An article in the Lancet in January by 29 Chinese medical professionals, including doctors from Wuhan, said the first symptoms in a patient appeared a week before that, on 1 December. In its first public statements the Wuhan Municipal Health Commission was adamant all the cases were linked to the local seafood market, and that there was no evidence of human to human transmission. But the Lancet article reported that only two-thirds of the patients could be linked to the market, and that the 1 December case could not. Nor were any links found between that case and any other cases; none of patient one’s family ever showed symptoms.

Patient one, in other words, probably wasn’t patient zero. ‘To be honest, we still do not know where the virus came from,’ one of the lead authors of the Lancet article, Bin Cao, wrote in an email to Science magazine. In March the Hong Kong-based South China Morning Post, citing leaked Chinese government data, suggested that the first identifiable case was actually in mid-November. In May Gao Fu, head of the Chinese Centre for Disease Control and Prevention (CCDCP), said no trace of the virus had been found in any animal samples from the market. Adding to the origin mystery are reports of early cases, or possible cases, in other countries. A retrospective test of a sample from a recovered pneumonia patient in France, who was swabbed on 27 December, came back positive for Covid-19. The patient hadn’t travelled abroad. The late Andy Gill, a member of the band Gang of Four, fell ill with what seemed to be pneumonia after coming back from a tour of China in November. The band didn’t gig in Wuhan, but did visit Beijing, Shanghai and Guangzhou. Gill died at St Thomas’s Hospital in London in February. His widow, Catherine Mayer, wrote on her blog that one of the specialists treating him told her there was ‘a real possibility that Andy had been infected by Sars-CoV-2’.

The first known cases in Wuhan were scattered between a number of hospitals. According to an account on the website of the Chinese National Health Commission, on 27 December, an unspecified private genetic testing company alerted staff at Wuhan’s Tongji Hospital that a sample from one of its pneumonia patients had tested positive for ‘coronavirus RNA’. Staff at Tongji called another hospital, Jinyintan, which had a specialist infectious disease unit, asking if the patient could be transferred there. Instead of alerting the national CCDCP, local officials kept the information within Wuhan and Hubei province. On 29 December, a senior specialist at Jinyintan, Huang Chaolin, was asked by local officials to investigate seven patients with inexplicable lung conditions at a third hospital, Hubei Provincial. What Chaolin found was worrying enough to prompt the transfer of the patients to Jinyintan in ambulances designed to prevent the leakage of potentially contaminated air.

A fourth hospital, Wuhan Central, had admitted a worker from the seafood market with an unusually intractable fever on 16 December. A sample of fluid from his lungs was sent to the Guangzhou-based firm Vision Medicals for genetic analysis on 22 December. According to an investigation by the Chinese business news site Caixin Global, Vision Medicals found, as early as 27 December, ‘an alarming similarity to the deadly Sars coronavirus that killed nearly eight hundred people between 2002 and 2003’. Instead of sending a written report to Wuhan Central, Vision Medicals conveyed the news by phone. In an interview with the Chinese magazine People, subsequently removed from its website, the head of the A&E department at Wuhan Central, Ai Fen, said the consultant looking after the patient had told her: ‘That person’s diagnosis is coronavirus.’

The same day, a new patient was brought in to Central Hospital with the same unusual symptoms. Samples from his lungs were sent off for testing to another lab, CapitalBio of Beijing. At noon on 30 December, Ai was watching a CT scan of yet another pneumonia patient linked to the seafood market when a former classmate, now at Tongji, sent her a screenshot of a WeChat exchange warning against visiting the market because ‘there are lots of people with high fever.’ He asked whether this was true. Ai sent him a clip of the video of the lungs of her latest patient. Four hours later, Ai got a copy of the 27 December lab report. This time the coronavirus finding was printed on the page. After alerting her superiors, she drew a red circle round the part of the report identifying Sars coronavirus in the patient, photographed it, and sent the image to a group of medical friends and colleagues. It quickly spread online. Among the doctors who pushed the report on Chinese social media in those first hours on 30 December, eight were later punished by local security services for putting out ‘false information’, including the ophthalmologist Li Wenliang, who would later die of Covid-19. Ai was bawled out by her bosses for spreading rumours and bringing the hospital into disrepute.

Whether because of the unofficial warning Ai put out on the Chinese language internet, or because they’d been planning to do it anyway, local health officials issued a red alert that night, warning all local hospitals to be on the lookout for unusual pneumonia cases. That alert quickly joined Ai’s picture of the lab report on social media. A journalist from China Business News saw the posts and got confirmation of the story from Wuhan’s health committee. The next day, New Year’s Eve, a team from the National Health Commission arrived from Beijing to investigate. News organisations around the world, from the South China Morning Post to the Daily Mail, reported on a mysterious pneumonia-like illness in Wuhan that had infected 27 people. Although no one had died, and Wuhan health officials assured everyone that all the cases seemed to be linked to the now closed seafood market and there was no sign of human to human transmission, Hong Kong began to put its well-laid epidemic contingency plans into action.

On 2 January, the WHO activated its incident management system, and on 5 January, issued its first bulletin. By this time there were 44 cases. Reliant on the Wuhan authorities for information, the WHO bulletin repeated its insistence that there was no evidence of ‘significant’ human to human transmission of the disease, although it didn’t dismiss the danger: ‘The occurrence of 44 cases of pneumonia requiring hospitalisation clustered in space and time,’ it stated, ‘should be handled prudently.’

For all the impression China can give of being a monolithic state with a clear top to bottom chain of command, it seems to have taken the national authorities the best part of the first three weeks of January to get to grips with what the local authorities in Wuhan had been in denial about. The WHO, dependent on the information China chose to share, took a reputational hit. As it turns out, it was already known in Wuhan in late December that it was extremely likely inter-human transmission of the virus was taking place, and that the connection with the seafood market was shaky. In an interview in April with CGTN, China’s international state TV service, Zhang Jixian, the head of respiratory medicine at Hubei Provincial Hospital, explained that her first three Covid-19 cases, admitted on 26 and 27 December, were members of the same family, parents and son, living together. None had any connection to the market. At the time Zhang had made clear her opinion on whether human to human transmission was taking place by immediately ordering masks and other protective gear for herself and her team.

Yet well into the third week of January the official information coming out of China remained that there was no sign of human to human transmission, and the WHO, with no evidence to the contrary, sent out the same message. On 12 January the WHO relayed the Chinese line that, fantastically, no new cases had been detected for nine days. (We now know that, just among medical personnel, seven caught the disease in that period.) According to an article in the New York Times, citing a leaked diagnostic guide that has since been taken down from the internet, officials in Wuhan ruled on 3 January that local doctors couldn’t designate a patient as suffering from the new coronavirus unless there was some connection to the seafood market. On 14 January Science quoted Xu Jianguo of the CCDCP: ‘It is a limited outbreak. If no new patients appear in the next week, it might be over.’

China was praised by some, including Tedros, for the speed with which its scientists sequenced the genome of Covid-19 and shared it with the world. The first sequence was posted on 11 January by researchers from Fudan University in Shanghai: Japan and Germany came up with tests in less than a week. But had China built on the work done by its private genetics labs in December it could have sequenced and made public the genome even earlier. Instead, according to Caixin, on 1 January private testing companies were ordered by local authorities in Wuhan to stop all testing and destroy any samples they had. Two days later the National Health Commission issued a similar blanket order, muzzling private labs. Shi Zhengli, of the Wuhan Institute of Virology, who in 2005 proved the link between the Sars virus and bats, claims that she sequenced Sars-CoV-2 in less than four days. The information could have been sent around the world on 2 January, making it possible for other countries to start work on tests more than a week earlier, but China sat on it.

At a press conference in April, Michael Ryan, the WHO’s emergencies chief, revealed that the WHO had first learned of the outbreak not from the Chinese authorities but from ProMED, a non-profit network of observers who scan the internet for disease reports. One of ProMED’s spotters drew the attention of a ProMED editor in Brooklyn to the first social media posts from Wuhan on the morning of 31 December, China time. Ryan hinted strongly that the Chinese government didn’t give the WHO the formal response required by the International Health Regulations until the last possible minute, that is, 48 hours after it was requested.

Recordings of WHO meetings obtained by the Associated Press show how frustrated its leadership was in private. Recalling the Sars outbreak of 2003, Ryan told colleagues: ‘This is exactly the same scenario, endlessly trying to get updates from China about what was going on. WHO barely got out of that one with its neck intact.’ By 8 January, when the Wall Street Journal reported that China had sequenced the viral genome, Ryan was seething: ‘We’re two to three weeks into an event, we don’t have a laboratory diagnosis, we don’t have an age, sex or geographic distribution, we don’t have an [epidemic] curve.’

On 14 January Maria Van Kerkhove, head of the WHO’s emerging diseases section, said that limited human to human transmission was possible, ‘but it is very clear right now that we have no sustained human to human transmission.’ Not until 20 January, three and a half weeks after Zhang Jixian masked up at Hubei Provincial Hospital, did China concede that human to human transmission of the virus was taking place. By this time Wuhan’s hospitals were swamped with hundreds of coronavirus patients, protective equipment was in short supply, and medical staff were dying; the disease had spread to Guangdong, Beijing and Shanghai; and cases had turned up in Thailand, Japan, Korea and the United States.

Before the outbreak, the most popular destinations for travellers from Wuhan were the first three of those countries, along with Taiwan, Singapore, Malaysia and Australia. All of them – mindful of previous viruses that originated in China, particularly the original Sars – reacted quickly to the first news of Covid-19. Working on the assumption that human to human transmission was possible, if not likely, they began screening passengers at airports, set up systems to trace the contacts of anyone who was infected and, as soon as the viral genome sequence was made available, started to test. In many of these places, mask culture was already a thing. So far, all these countries have weathered the first wave of the virus well. Even relatively wealthy countries – the ones that later suffered the worst death tolls, notably Britain and the US – seemed in the beginning to be doing the right thing: treating the epidemic as if it might be a highly infectious disease that could spread from person to person, whatever China was saying. In this they were following WHO advice: it never said that human to human transmission was ruled out, only that there was no evidence. Rather belatedly, on 17 January, the CDC began screening flights from Wuhan; Britain followed suit five days later, and so did Italy at about the same time.

One of the paradoxes of the Covid-19 story is that the US, Britain and other European countries began to lose control of the situation soon afterwards, at the very moment China stopped being the bad citizen of global health and instead became an examplar. On 23 January, just before the great annual travel rush of the Spring Festival, China locked down Wuhan, a city of 11 million people. Soon afterwards it began its epic campaign to speed-build new isolation hospitals to quarantine thousands of coronavirus patients. On 30 January, shortly after Tedros flew to Beijing to meet Xi Jinping, the WHO declared Covid-19 a ‘public health emergency of international concern’, but by that time the scale of China’s response spoke more eloquently than any WHO official declaration could of the disaster that was unfolding.

Much of the subsequent US criticism of the WHO, and of Tedros in particular, stems from this period, when the director-general was effusive in his praise for China and ignored the country’s early blunders and secretiveness. ‘The speed with which China detected the outbreak, isolated the virus, sequenced the genome, and shared it with WHO and the world are very impressive, and beyond words,’ he said. ‘So is China’s commitment to transparency and to supporting other countries. In many ways, China is actually setting a new standard for outbreak response.’ Occasionally Tedros’s eagerness to give credit to China led him unwittingly to repeat things that turned out to be untrue, such as when he said, on 23 January, that the outbreak had been detected because the Chinese government, post-Sars, ‘put in place a system specifically to pick up severe lower respiratory infections. It was that system that caught this event.’ Such a system, elaborate and seemingly foolproof, did exist – but the authorities in Wuhan still managed to bypass it. The actual ‘system’ that picked up the event was concerned citizens on social media.

In part, Tedros was perceived to be over-praising China because the rest of the world’s media were still picking over the chaos and deception of the early weeks; the first signs of China’s fightback seemed from the outside, as one Italian put it later, ‘like science fiction’. But much of the resentment at Tedros’s warm words for China was based on a misunderstanding of WHO’s role and powers. Lacking any means to force countries to give it information, but desperately needing to get it, it is obliged to fall back on consensus, persuasion and flattery – in other words, diplomacy. The half-hearted cover-up by Wuhan’s local health officials showed what happens, on a national scale, when leaders fear humiliation. Theirs were not the actions of people who expected to be rewarded for the speedy delivery of bad news. ‘You have to keep positive incentives for countries to report,’ Devi Sridhar, a professor of global public health at Edinburgh University, said. ‘If there are negative incentives – WHO comes out and grabs a headline saying “They did it badly” – what other countries are ever going to come forward and report when they have an outbreak going on?’

By February, when a WHO fact-finding mission toured China along with a group of Chinese specialists, China’s campaign to suppress the virus was in full swing. The official report produced afterwards makes disconcerting reading. On the one hand, it ignores the clumsy deceits of China’s first few weeks. On the other, it spells out what China had gone on to do, the things we now know countries like Britain, Italy, Spain and the US could have and should have copied in time to stop the outbreak gaining a foothold. Across the country China mobilised tens of thousands of contact tracers – nine thousand in Wuhan alone. It pioneered the use of lockdowns to break the transmission chain. And it created a system of mass monitoring and diagnosis to identify and isolate as many cases as possible.

Well within the time-frame to make a meaningful difference in Britain, the US, Brazil or Italy, the WHO began energetically promoting the Chinese approach of suppressing the virus, rather than mitigating it. Bruce Aylward, the Canadian who led the non-Chinese group on the WHO mission, said when he returned at the end of February that governments preparing to let the epidemic simply wash over them had ‘lost before they started’ and ‘needed to change their mindset’. He said he doubted whether the Chinese could suppress a previously unknown virus without drugs or a vaccine, but added that ‘they have taken very standard and what some people think of as old-fashioned public health tools and applied these, with a rigour and innovation of approach, on a scale that we’ve never seen in history. They have taken case finding, contact tracing, social distancing, movement restriction, and used that approach to try and stop a new emergent respiratory-borne pathogen.’ There was, of course, a lot of technology in the Chinese effort. While British conspiracists were torching mobile phone masts in the belief they were the source of the virus, China was using its 5G network to give ultra-fast wireless data links to contact tracing teams in remote rural areas.

Even as the UK and US ended up, late in the day, chasing something like the Chinese approach, with its emphasis on public health and communal effort, Donald Trump and Boris Johnson were stressing a different route to pushing back Covid-19: the tech fix. With Johnson, it’s been ventilators, prospective vaccines, phone apps and antibody tests. Trump speaks of undiscovered vaccines too, but also returns to conspiracy medicine: the idea of an already existing pill that makes you well, or an ordinary household substance that those in the know can use, like one of those clickbait remedies on a website sidebar – ‘Doctors Don’t Want You to Know about This One Simple Trick to Beat Covid.’

The divide between communal health advocates and tech fixers represents a deeper choice: between actions that aim to help an individual, so may indirectly help everyone, and actions that aim to help everyone, so may indirectly help the individual. Lockdown requires each individual to accept personal constraints for the sake of the community, even when they are not themselves ill. In theory, the tech fix can be for everyone, too, but because it is a thing to be obtained, rather than a constraint to abide by, it comes trailing issues of priority, price, privilege, exclusivity: what device, what pill, what treatment, what test can I get for myself, my family, my friends, to protect them?

The WHO has sometimes leaned towards the tech interventionists, but in Tedros Adhanom Ghebreyesus, the organisation has found a leader from the community health tradition. He doesn’t share the transactional, individualistic, Trumpian view of medicine and his election was bound to create tension at a time when the American nationalist right was already disposed to see the WHO as a project aligned with its ideological enemies. Even before the pandemic they saw Tedros as China’s man. ‘The US has never really been at peace with the WHO. I mean it’s not a new thing,’ Seye Abimbola, editor of the journal BMJ Global Health, told me in a call from Sydney. ‘There’s always been a history of some kind of suspicion that it’s socialism.’

As head of the WHO, Tedros represents many firsts: the first black director-general, the first African, the first not to be a medical doctor, the first to come from one of the five large countries – India, Nigeria, Democratic Republic of Congo, Bangladesh and Ethiopia – where half the world’s extremely poor people live. He was born and grew up in Asmara, in what is now Eritrea, at that time the Red Sea coast of Ethiopia. His parents came from further south, in Ethiopia’s Tigray region. While he was a small child, Emperor Haile Selassie still sat on the throne; his schooldays were during the Marxist-Leninist regime of Mengistu and the Derg; while he was at university in Asmara, studying biology, many Tigrayans and Eritreans were fighting an insurgency against Mengistu. After graduating Tedros worked for a while at the Ethiopian health ministry, before being awarded a WHO scholarship to study for a masters in immunology at the London School of Hygiene and Tropical Medicine. His time in London in the early 1990s coincided with a change of power in Ethiopia when a coalition of rebels, with Tigrayan insurgents in the forefront, overthrew Mengistu. When he went back, still in his early thirties, he drew attention in the Euro-American world for his research into malaria in Tigray. He earned a PhD in public health from Nottingham University and in 2005, just as the Ethiopian economy under the late Meles Zenawi, a former Tigrayan insurgent leader, was beginning its extraordinary decade of East Asia-inspired economic growth, he became the country’s health minister.

Tedros took control of a radical programme of public health reform that Zenawi and his allies had brought into national government from their experience running rebel provinces with zero resources. It was community-centred and woman-centred, and as much about education as doling out pills. The first phase was one year’s health training for thirty thousand high-school graduates, most of them women, who were then deployed in pairs to villages across the country. Tedros led the creation of a network called the Health Transformation Army, which aimed to designate one member of every family as a good health advocate. When the Lancet interviewed Tedros in Addis Ababa in 2011, he cited as an inspiration the Alma-Ata declaration of 1978 and its revolt against the tech-fix world of the shiny hospital. ‘Our focus is primary healthcare,’ he said. ‘We really want to be helping communities help themselves by expanding public health services in villages … What we are saying to the world – even to the developed countries – primary healthcare is the answer.’ The programme showed remarkable results. From the time of Mengistu’s overthrow to 2015, child mortality was cut by two thirds, maternal mortality by 71 per cent, HIV infections by 90 per cent and malaria deaths fell by 73 per cent.

Tedros​ became director-general of the WHO in 2017, after a difficult period as Ethiopia’s foreign minister. He was the beneficiary of the WHO’s first open leadership election; previously the choice had been made in backroom stitch-ups orchestrated by countries with deep pockets. In 2017 the system was changed to one country, one vote. Theresa May’s administration put a lot of effort and resources into backing a British candidate, the WHO insider David Nabarro; it’s thought he was also the Trump team’s choice. The campaign became quite ugly – Tedros was accused by critics of downplaying a cholera outbreak in Ethiopia and of complicity in repression there – but the mud failed to stick. ‘He got the African support,’ Abimbola said. ‘Having got Africa, the only thing you needed to get was China, and if you can get China and Africa you’ve won the election. So he got China and also got China’s people, to put it indelicately, and then he won it.’

The Alma-Ata declaration was made not only in reaction to the failure of the WHO’s attempt to eradicate malaria but was part of a turn towards the idealised glow of Mao-era China’s barefoot doctor programme. The spirit of the barefoot doctors haunted Tedros’s work in Ethiopia and haunts, perhaps, the villages of Hubei in the era of Covid-19; it isn’t surprising he found China’s coronavirus campaign congenial. The Health Transformation Army, I was told by Sarah Vaughan, who came to know Tedros in the course of thirty years’ research in Ethiopia, ‘was basically a kind of health extension programme using women through a classic party cell mobilisation system, a one to five system, where one woman would have five followers and each of them would have another five followers. And the idea was a sort of triangle with the party in the vanguard, the state providing the resources and the technical people, and the population mobilised, so it was a sort of inclusive consensus, everybody behind the Great Leap Forward. Tedros was put in as the internationally acceptable face of a system which was delivering outcomes in a way that pleased the donor community, but it was using the party political structure to do that. It was a totalitarian system in the technical sense of the word – a benign dictatorship to engineer better community health.’

Vaughan described Tedros as a technocrat ‘without an ideological bone in his body’. I wondered whether his apparent surprise at the horror in the Euro-American world that greeted his appointment of Robert Mugabe as a goodwill ambassador – quickly rescinded – was simply the reaction of a man whose lifelong habit has been to isolate health work from all other forms of politics. This attitude might sound cynical, or naive, but it could just as well be seen as a rebuke to the neoliberal idea that democracy, in the shallow sense of elections, and minimal barriers to trade are sufficient in themselves to allow low-income countries to prosper. Before Alma-Ata, before Mao’s barefoot doctors, there was Britain’s National Health Service – which Tedros has also eulogised, along with other European manifestations of communally-funded medicine. He was elected on a platform that included getting a billion more people enrolled in universal health coverage.

The true significance of Tedros’s election, and of Trump’s attack on the WHO and China, may be as markers of how radically the world has changed since the WHO was founded, and of the refusal of the nationalist Euro-American right to accept that change. In 1950, Europeans and Americans constituted more than a quarter of the world’s population; now they make up less than 14 per cent. The combined population of just two African countries, Ethiopia and Nigeria, is almost as large as the population of the US. In 1950, two-thirds of the world economy was Euro-American; now it is less than two-fifths. Abimbola told me of the ‘groundswell of noise’ from educated Africans that had propelled Tedros to the director-general’s post. ‘There are hundreds of thousands of us,’ he said. ‘Mostly middle-class, low or middle-income-country people who have the time, the attention, the resources, the exposure and the scepticism to see what is wrong, and to be willing to spell it out.’

At the beginning of the coronavirus epidemic it was gravely expected that the Euro-American countries would hold firm, with their sophisticated healthcare systems based around high-tech hospitals, while the disease would cut a terrible swathe through Africa. The question of solidarity, or the lack of it, would come down to how much or how little the rich countries were willing to give the less well-off. So far it hasn’t happened that way. The formerly colonised countries, with their thinly resourced health systems, have been spared the worst; it is the old colonisers, with their ventilators and ECMO machines, that have suffered. Senegal has had far fewer deaths than France, the Democratic Republic of Congo far fewer than Belgium, Kenya far fewer than Britain.

That may yet change. More remarkable is the way the epidemic has exposed a lack of solidarity within Western countries themselves. The debate about the path of global health improvements – the balance between individualistic tech fixes and community health – turns out to be meaningful within countries as well. Nowhere has this been clearer than in Britain, where the expectation each winter is that hospitals will struggle to treat the surge of frail old people; the elderly are pushed back into under-scrutinised private care homes, or into a community care and public health system whose budget to help them has been cut to the bone. When the virus came, this dynamic intensified. Tens of thousands of old people were sent home or into residential care without being tested for coronavirus. They infected others. Many died. The Alma-Ata declaration, with its advocacy of community healthcare and wariness of high-tech hospitals that poorer countries can’t maintain, has found a grotesque echo in Britain, where despite efforts at reform, politicians and public remain complicit in the fantasy that ‘healthcare’ equates to hospitals, doctors, drugs and machines, and ‘community’, meanwhile, has become a euphemism for ‘You’re on your own.’