5 March 2020 5 March 2020 ISSN: 2560 -1628 ISSN: 2560-1628 17 March 202020 20 No. 4

ISSN: 20256020- 1628No. 4

WORKINGWORKING PAPER PAPER 2020 No. 5 WORKING PAPER

Report SeriesReport on SeriesChinese on and Chinese European and European Actions Actions Project Manager:Project Manager:WU Baiyi WU Baiyi

In FightingIn againstFighting Coronavirus against Coronavirus Disease (COVID Disease- 19)(COVID -19) Project Coordinator: Project Coordinator: CHEN Xin CHEN Xin

International Actions against the COVID-19 Pandemic and Chinese Response Fighting against the Novel Coronavirus Disease: China and Fighting against theZhang Novel Wenhong Coronavirus & Ruan Qiaoling Disease: China and

Europe Could Share Experience Europe Could Share Experience

He Zhigao He Zhigao

Kiadó: Kína-KKE Intézet Nonprofit Kft.

Szerkesztésért felelős személy: Chen Xin Kiadásért felelős személy: Wu Baiyi

Kiadó: Kína-KKE Intézet Nonprofit Kft.

SzerkesztésértKiadó: felelős Kína személy:-KKE Intézet Chen NonprofitXin 1052 Kft.Budapest Petőfi Sándor utca 11. +36 1 5858 690 Kiadásért felelős személy: Wu Baiyi Szerkesztésért felelős személy: office@chinaChen Xin -cee.eu china-cee.eu

Kiadásért felelős személy: Wu Baiyi

1052 Budapest Petőfi Sándor utca 11. +36 1 5858 690 office@china 1052-cee.eu Budapest Petőfi Sándor utca 11. china-cee.eu +36 1 5858 690

[email protected] china-cee.eu

International Actions against the COVID-19 Pandemic and

Chinese Response

Zhang Wenhong & Ruan Qiaoling1

This week has witnessed a big mess in the international efforts to fight against the COVID- 19 pandemic since its outbreak.

On 11 March 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic. Europe is witnessing an explosive tendency of the outbreak and becomes the epicentre of the pandemic. - U.S. The confirmed COVID-19 cases are increasing in the United States. The House of Representatives questioned Centers for Disease Control (CDC) whether its containment measures at the early stage were timely. Meanwhile, Trump’s pandemic containment policy becomes the focus of public opinion; - U.K. The British Prime Minister announced abandonment of active anti-pandemic, and introduced “herd immunity” strategy for the first time;

1 Zhang Wenhong and Ruan Qiaoling are from Shanghai Huashan Hospital. Zhang Wenhong is the director of Huashan Hospital’s department of infectious disease and of the Shanghai panel overseeing the treatment of COVID-19. The original Chinese version of this article was published on WeChat Official Account named Huashan Infection. The China-CEE Institute is authorized to publish the English version.

1 - Germany German Chancellor Merkel said that eventually up to 60% of the German population will likely contract the Coronavirus, but Germany has taken active steps for the battle of the ‘plague’ and its attendant panic; - France France does not have much determination and vacillates between the UK’s policy and German one; “the situation is neither too good nor too bad” (the French national anti-pandemic experts said to the author); - Italy Italy remains on the verge of losing control. China and other countries began to aid Italy, fulfilling the obligations commonly shared by the international community; - Overseas Chinese in Europe and the US: hesitating between going back to China to avoid the plague for the time being or staying to fight the pandemic locally.

We are really fortunate that we have achieved a periodical victory in fighting against the pandemic by taking decisive measures of nationwide lockdown of cities and launching high-level emergency response. More than one month has passed, the process of countries in their efforts to fight the pandemic is like the Olympic Marathon, where no much difference can be noticed when they started, but the difference is widened gradually at a later time.

Europe and America Fighting against the COVID-19

Countries’ statements on Coronavirus differ from one another, but the logic behind European and American anti-pandemic efforts is the same.

U.S. President Trump declares national emergency over Coronavirus (Photo from White House official website)

2 U.S. President Trump declares national emergency over COVID-19.

- Hospitals have been asked to activate their emergency plans - The Ministry of Health was empowered urgently, including: Ø Eliminate licensing requirements for some health-care device providers Ø Increase test points Ø Expand coverage of test reagents

- The private sector (companies) has been mobilized to fight the pandemic, including: Ø Google helps develop website for detection and monitoring Ø Wal-Mart keeps opening to ensure the daily needs of the people - It will take several days to produce test results now, - The waiting time for the test results will be shortened within 24 hours in the near future.

Comments: Except for lockdown of the cities and community control, all other measures in the United States are consistent with China. That is, the U.S. tries to maximize openness of its medical resources.

The U.K. The U.K. is stepping into the second stage of its efforts to fight the pandemic: ‘delay phase’. On 12 March, the U.K. published its anti-pandemic plan. Prime Minister Boris Johnson officially announced at a press conference that the country stepped into the second stage of its efforts to fight the pandemic. After Boris’s speech on the press conference, an article was published and highlighted the essential part of the U.K.’s pandemic prevention strategy. Briefly speaking, the strategy is “not to strictly quarantine, but to allow the Coronavirus slowly spread, hoping that the majority population, after the occult infection, will be symptom-free or mildly infected. In this way, people will obtain universal immunity, which will bring the pandemic under control”. In other word, the U.K. tries to control the Coronavirus through herd immunity.

Italy The Italian case becomes a model of failure at the early stage of prevention and control. Currently, the total number of confirmed cases exceeds 20,000, and there is an increase of 3,497 new cases in one day. The case fatality rate has reached 6.8%. Medical resources are already running low and the state has announced the selective admission of patients.

3 Germany German Chancellor Angela Merkel said, “When people have no immunity to the virus, which is already there, and have no option for vaccine or specific medicine, then the population is facing a relatively high possibility of being infected (if the situation continues). Experts expect that up to 60 to 70% of the population will be infected eventually. So that’s why the R&D work of specific medicines and vaccines is so intense.” In fact, Germany is the country who prepares best in Europe in terms of medical resource reserves. Its medical supplies are currently sufficient to cope with new severe cases.

Comments: It seems that countries have different statements on the Coronavirus, but the logic behind the European and American efforts to fight the pandemic is the same, that is, maximally mobilizing medical resources that can be mobilized and facing the possible coming of a hyper- infectious disease. If countries’ medical resources can be effectively organized, they can face the challenge. In Germany, the current fatality rate is 0.2%. Only as a last resort, it will not order massive shutdown (like some regions in Italy and Wuhan in China). Because once the social activities stop, countries, without leadership of a strong government, will immediately face a greater difficulty, and eventually the number of deaths will far exceed the death toll caused by the disease itself. China’s research at the early stage has made us better understand the disease, and the case fatality rate is acceptable. If there is no medical run, the disease can be managed. But the premise is that medical resources will not run low.

The Contribution of Chinese Experience to the World

To date, it seems that China has achieved best results, because there are almost no new local cases (Wuhan will also bring the outbreak under full control soon). The academic teams of Professor Zhong Nanshan, Professor Wang Chen and Professor Cao Bin, and Professor Zhang Wenhong have exchanged with the international community several times and introduced China’s experience in fighting the Coronavirus outbreak. During the dialogue between Chinese and American doctors two days ago, the author introduced some strategies of prevention and control adopted in Shanghai, which is city with a population of 30 million. The joint prevention and control measures are impossible to be mimicked by other countries, but the quick response of hospitals, the rapid screening and detection methods of suspected patients, the rapid implementation of quarantine, and shorting the time for diagnosis and hospitalization are the key strategies to reduce the possibility of outbreak in hospitals and communities.

4 In fact, the United States has accelerated the training of various community hospitals and also improved the diagnostic capabilities of hospitals (included the supply of reagents and cost coverage). Germany has a more comprehensive strategy. Beijing and Shanghai are megacities, and China’s experience for this type of cities is to restrict citizens’ movements, to strictly preventing imported cases, to increase investment in medical resources, to screen suspected patients in time and to avoid medical runs. If medical resources are properly allocated, the fatality rate of the disease can be controlled around 1-2%, which is an acceptable fatality rate range.

The UK and Germany: One Strategy and Two Versions

Map of the COVID-19 pandemic in Europe as of 12 March 2020 (from Wikipedia)

While British Prime Minister Boris hopes to adopt “Herb Immunity” Strategy, German Chancellor Angela Merkel said that up to 60% to 70% of population may be eventually infected. In fact, these statements have caused panic among the public, not least among the overseas Chinese. If it’s true that so many people are infected, they will face a scarcity of medical resources. However, it is still a question whether people may confront with extremely high risks in that case. Basically, what the British Prime Minister and the German Chancellor have said has the same meaning. This disease is already a pandemic, and there is no way for these two countries to adopt the same prevention and containment measures as China did. China’s prevention and control model requires a lot of social resources, and we can't make it. Moreover, once the economy comes to a standstill, the cost that our societies have to pay may far exceed the disease per se. In fact, Germany and the United Kingdom did not do nothing. It is believed that Germany and the UK have taken the same action as the US did. The UK and particularly Germany have purchased a large number of respirators for standby application, which attracted very positive response. On the one hand, these European countries are gradually increasing hospitals and preparing for the possible

5 increase in the number of patients with severe illness. On the other hand, they expect that the arrival of the peak of the pandemic can be delayed as much as possible. As long as the outbreak, which is theoretically supposed to reach its peak in one month, is controlled and reaches its peak in 3 months, the incidence rate decreases with the arrival of summer, and then the number of cases that may occur within one month can be distributed over 12 months of the year. In doing so, the pandemic can be addressed step by step and its cases can be reduced to zero. Relying upon the existing medical resources, the world will eventually be able to contain the pandemic.

Source: CDC Stacks, Interim Pre-pandemic Planning Guidance: Community Strategy for Pandemic Influenza Mitigation in the United States—Early, Targeted, Layered Use of Nonpharmaceutical Intervention, Atlanta, GA: US Department of Health and Human Services, CDC, 2007, https://stacks.cdc.gov/view/cdc/11425.

Then, how can the peak of the disease be reduced? It should be possible by reducing the density of social contact, quarantining limited populations, and avoiding super transmission. However, Europe and America differ from China. They neither have powerful governments that can initiate joint prevention and containment actions with the crowd, nor can they rapidly detect patients and implement quarantine strategies to reduce transmission through 800 outpatient services as the island country Singapore did. What should they do then? Apparently, they tell people the worst scenario, namely, 60-70% of the population may be eventually infected. Under this background, they announce a series of measures to ban large-scale activities, and the public will give their understanding of these measures. The living environment in European and American countries is relatively open, and many people are living in independent houses. As long as the public reduces their participation in large-scale public activities and work from home during the peak period of the

6 outbreak, and students take online classes (UK universities have implemented online teaching), these measures can greatly control the disease transmission. During this period, by greatly enhancing the hospital’s response capacity (what China has done is already a good example), the collapse of medical resources could be maximally avoided. So why is the situation in Italy out of control? It is because of the lack of vigilance against the Coronavirus at the early stage, which gave rise to serious community transmission in a short term. The out-of-control of Italian “let nature take its course” containment strategy is a good lesson for other European countries.

Can the UK’s “Herd Immunity” Strategy Be Reliable?

What is “herd immunity”? Herd immunity is also called community immunity. That is, when most people are immune to the pathogen that causes the disease, the other non-immunized individuals can thus be protected and avoided being infected. According to the theory of herd immunity, when a large number of individuals in a population are immune to an infectious disease, or the number of individuals who are susceptible to the disease is quite small, the chain of transmission between individuals will be interrupted. In general, people obtain herb immunity after being vaccinated. One instance is that the successful development and vaccination of smallpox vaccine immunized (entire) humans from it, which eventually eliminated the infectious disease (speaking of the pox inventor, Jenner is British). Or the herb immunity is obtained when the population has been widely exposed to or infected with the virus, such as the flu. Unfortunately, up to now, no coronavirus vaccine has been successfully developed, and thus people fail to obtain herd immunity.

Source: https://ivaccinate.org/3-charts-show-vaccines-triumph-over-preventable-diseases-for-5- decades/herd-immunity/

7 There are also some theoretical bases behind the British government’s adoption of this strategy. The first one is epidemiological theory, namely, universal immunity can form a steady state. A fact about the New Coronavirus is that most infected patients are symptom-free or mildly infected, and they can be cured, without treatment or symptomatic treatment, on a self-limiting basis. In addition, the British government reiterated at a press conference that the mortality rate for the New Coronavirus is 1%. Therefore, by relaxing the prevention and containment policy, the UK government expects that people obtain immunity on a self-limiting basis after being exposed to the virus. The hospitals could concentrate on critically ill patients. In other word, the hospitals spend the cost on preventing critical cases from dying rather than on preventing from being infected. In doing so, countries want to make sure that social and economic development will not be sacrificed due to strict containment measures, and the cost of fighting the pandemic will be minimized as much as possible. This is the logic behind the British strategy. However, even though the “herd immunity” method seems to be feasible in theory, there are still many uncertain factors in practice. In the Chinese case, China has made every effort to protect its citizens from infection. Regarding the prevention and containment measures, China has quickly reduced the spread of the virus among the communities in a short period of time, even at the expense of economic development. Besides, China then quickly restored social order and tried its best to recover social and economic activities. However, considering China’s strong determination and the cooperation of its people, this is not an operation that every country can mimic. If the outbreak cannot be ended in a short time as China did within 2 months (It happened to be the time for Chinese Spring Festival, which created the best opportunity for a reasonable shutdown of social and economic activities), the British government is well aware of the cost of social shutdown. Thus, the strategy of “herd immunity” has its own theoretical basis. The British strategy is based on the fact that most people are asymptomatic or only mildly symptomatic after being infected by the virus, and thereby people gain immunity in a general level. However, this strategy is risky for individuals, because some mild patients will suddenly progress to a critical state without warning signal. At the meantime, it is extremely difficult to treat critical patients. According to Wuhan’s experience of its early stage and the current pandemic development in Italy and Iran, we know that the biggest risk is an uncontrolled pandemic. Once it spreads rapidly, the number of severe patients will increase. If hospitals are incapable of giving adequate response, medical resources may collapse. If the situation is well controlled, hospitals can smoothly transition to a normal state of management concentrating on critically ill patients, and Germany is a model of success in this case. The strategy of herd immunity is actually not just a scientific issue, but it may also involve ethical issues. Meanwhile, there may also be huge hidden dangers. Under the help of modern scientific and technological development, we hope that more people can get the right to better

8 survival rather than face the “survival of the fittest”. When we face an infectious disease with a certain proportion of deaths, and when it is possible to be controlled with scientific prevention and containment measures, the herd immunity strategy may accompany some ethical risks. The “Clinical Ethics” recommendation issued by the Italian Society of Anesthesiology and Intensive Care also suggests that medical personnel, not necessarily following the “first come, first served” principle, should consider “longer life expectancy” as a priority factor in assessments. However, this measure should be implemented only after all relevant parties have made every effort to increase the available resources (ICU resources in this case), and it is the last resort when medical resources are severely scare. Therefore, China do definitely not adopt this kind of medical treatment based on “longer life expectancy”. Nearly 50,000 medical staff went to help Wuhan from different parts of China. This is because they were actually unwilling to face the situation, where critically ill patients cannot receive medical treatment. Seen from the fact that countries are actually accepting the widespread transmission of the COVID-19, the subsequent development of the virus is not optimistic. Those countries (e.g., the UK) who take the “let nature take its course” measurement against the pandemic will become pathogen-exporting countries and bring greater risks for these areas whose medical resources are much less developed.

China Facing the Second Challenge: Risk of Imported Cases

Most countries Most countries in the world have adopted American-style containment measures to “reduce the peak of morbidity and mortality and make the pandemic curve is smoother and more stable,” said Roy M Anderson of Imperial College London in his article published on The Lancet.

9 Regarding this type of prevention and control measures, Germany is ‘the model student’. Germany controls the spread of the outbreak by relying on the management model of pandemic influenza, universal education, reduction in social activities and family self-protection measures. At the same time, hospitals step up preparations for medical resources for critically ill patients. So far, Germany is doing well. However, there are still many uncertainties regarding whether other European countries, such as Italy and Spain, can do well in this way. Once medical resources run low, there will be greater uncertainties. China has come across the darkest moment. It was believed that if China brought the outbreak under good control, the world would also be able to control it at the same time. For example, East Asian countries such as Singapore, Japan and South Korea did very well. However, now Europe has become the new epicenter of the pandemic, which accompanies huge uncertainties. In the following time, China faces the risks of imported cases. According to the current pandemic situation at the global level, it is almost impossible for this pandemic to end this summer. If the outbreak in Italy and Iran continues to evolve in depth, the risk that the New Coronavirus cannot be controlled within this year will be greater over the time. In the next stage, China is facing huge pressure of controlling imported cases. The biggest challenge facing Shanghai at present is the large number of overseas flights. Shanghai expert team said that we have to be ready for the second challenge. Currently, the National Health Committee of China has urgently notified local authorities to strengthen the construction of infectious disease departments across the country, including fever clinics, observation wards, clinical microbiological testing and so forth, which are already in the arrangement. Relying on China’s strong public hospital network and China’s CDC’s rapid direct reporting system for known infectious diseases, China will surely succeed in the second challenging period, but the battle may not be ended in the short term. People across the country must be mentally prepared to “fight the pandemic on the one hand and promote production on the other hand”.

Translators LANGJIA Zeren, Ph.D., Institute of European Studies, Chinese Academy of Social Sciences; China-CEE Institute CHEN Siyang, M.A., Institute of European Studies, Chinese Academy of Social Sciences; China- CEE Institute

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