National Status in a Global Pandemic: Is (Mis)handling COVID-19 a Turning Point or a Revelation?

The whole world was stunned and frightened by the steep increase in COVID-19 cases and deaths in the United States. COVID-19 seemed unstoppable in this country that has the most advanced medical science and technology. In the meantime, East Asian countries effectively controlled the spread of SARS-CoV-2 (the virus that causes COVID-19) with strict preventive measures: wearing masks, washing hands, and disinfecting.

SARS-CoV-2 was first discovered in December 2019 in Wuhan, China, where it spread rapidly. China began lockdowns across the country on January 23. This was just days before the beginning of the Chinese New Year season (January 25–February 7), when tens of millions of Chinese had traveled or were preparing to travel back home to spend the most important holiday with their families. All travels within cities and across the country became limited, and there were strict health regulations. Public transportation was heavily disinfected—when in operation. Everyone wore a face mask. Those who tried to get home in their own cars were prevented by local authorities with the support of residents, who refused to let outsiders into their residential communities and villages without health passes. The Internet became the place to complain and share opinions about the strict preventive measures. After spending the entire Chinese New Year season indoors and strictly following the preventive measures, China emerged from the lockdowns in March and people returned to work and normal life gradually with few COVID-19 cases.

The Chinese community checkpoints for COVID-19 in 2020 are reminiscent of the road blocks to village entrances during the 1911 plague epidemic in northeast China, known as the Manchurian plague, which took more than 60 000 lives.¹ At that time, China was a weakened empire that had been labeled “the sick man of the Far East.” National sovereignty hinged on China’s ability to control the plague, as foreign powers were about to expand their spheres in China in the name of health protection. The Chinese rulers of the time, the Qing dynasty, relied on modern medical scientists, who introduced harsh Western preventive measures and brought the plague under control.² Their successful fight against the plague secured China’s sovereignty.

In the following decades, Chinese modernizers included public health as a vital element of national development to fight off the “sick man” label and make China strong. They embraced science as the means to solve health and social problems and carried out many public health campaigns.³ Chinese people developed a strong sense of the chuanran (contagion) inherent in epidemics and internalized such public health behaviors as wearing masks and washing hands as prevention. A health mentality that connected personal health behavior to the well-being of the public during an epidemic also evolved. When they saw Americans not wearing masks amid increasing COVID-19 cases, Chinese people were horrified: did they not fear death? The US failure to control the virus led some Chinese netizens to speculate that it was a sign of national decline: the situation of the United States was like that of the late Qing dynasty; it had become the sick man of the West.

The United States is certainly not late Qing China, as it remains the most powerful country in the world. In this issue of AJPH (p. 423), Ruth Rogaski, an award-winning scholar of health history, notes that there are striking similarities between China during the Manchurian plague and the United States during the COVID-19 pandemic; namely, widespread drug addiction (opium in China, opioids in the United States), a pandemic, and an ineffective government. Rogaski’s comparison of the Manchurian plague and COVID-19 in light of the “sick man” trope highlights the direct link of national health, including epidemic control, with national status and world image.

When the United States shocked the world with its failure to control the spread of SARS-CoV-2, what did that shock reveal? Rogaski’s study suggests that viral tragedies, such as the Manchurian plague and COVID-19, are also opportunities for national health transformation, as when China took a new approach to public health in the 20th century. COVID-19 has exposed the deficiencies of the US health system. For example, millions of Americans lost health care insurance when they needed it the most, because the pandemic caused widespread job loss and the insurance was tied to their employment. Will this sad revelation spur health reform in the United States?

The Manchurian plague and COVID-19 have many similarities: both were airborne diseases, both spread fast via public transportation, and mask wearing was met with resistance by Westerners during both. During the Manchurian plague, Chinese doctors believed that the disease was airborne, and they mandated that health personnel wear masks as prevention. But Western medical doctors in Manchuria regarded masks as useless until the deaths of their colleagues alarmed them and changed their minds (Rogaski, p. 425). Ever since Wu Lian-de advocated mask wearing during the 1911 Manchurian plague, wearing masks has been considered essential in preventing airborne contagion for Chinese citizens.⁴ In the early months of COVID-19, authorities in the United States and Europe, along with the World Health Organization, dismissed the usefulness of wearing masks as an effective prevention against COVID-19.⁵ They changed policies only after COVID-19 cases and death tolls rapidly increased because of not wearing masks, and after East Asian countries proved mask wearing effective in preventing COVID-19.

Western media have reported mask wearing as peculiar to the cultures of Asian countries. In fact, mask wearing as a public health behavior in Asia came with the experience of fighting the 1918 flu pandemic, which took 50 to 100 million lives worldwide. Americans wore masks during the 1918 flu pandemic as a preventive measure and as a patriotic act during World War I. That experience, somehow, was not turned into a habitual public health behavior in the United States, as it was in Asia, to fight airborne disease. The emphasis instead has been on the development of vaccines and therapeutic drugs, creating dependence on the commercial products of medical science. Some people have put personal freedom above public well-being during the current pandemic, seriously undermining the effort to control the spread of the virus. Because new viruses always come long before scientists can figure out how to concoct new vaccines to counter them, preventive actions must be taken. The successful control of COVID-19 in many countries demonstrates that the most effective approach is timely government action to stop the virus at its outbreak with universal testing and holistic preventive measures.