The Politics of Combating Infectious Diseases in Southeast Asia and the Middle East

Over the last 25 years, the world has seen a rise in the frequency of natural disasters in rich and poor countries alike. Today, there are more people at risk from natural hazards than ever before, with those in developing countries particularly at risk. This essay series is intended to explore measures that have been taken, and could be taken, in order to improve responses to the threat or occurrence of natural disasters in the MENA and Indo-Pacific regions. Read more ...
 

The global community continues to face threats from natural disasters. All states are vulnerable to these risks, but the consequences of disasters vary by region and by country.[1] One example of a national disaster is the spread of new and deadly pathogens. As people and goods cross borders for work, commerce, and tourism they bring the possibility of spreading diseases.  Likewise, viruses and bacteria mutate and evolve as they spread, thus they will continue to challenge human immune systems and medical science.

This article compares the local responses to the 2012-2018 outbreak of Middle East Respiratory Syndrome (MERS) to that of the Avian Influenza outbreak in Southeast Asia from 2003-2015. How well do countries cope with the spread of new and deadly diseases? Why are some countries better at addressing the problem than others? And, what does this tell us about larger questions concerning states’ abilities to provide public goods (in this case health security) to their citizens and about global systems to prevent pandemics? What this comparison demonstrates is that countries with the ‘strongest’ state capacity to make and implement policy are best able to confront disease outbreaks.

Conversely, states with the highest levels of corruption and bureaucratic competition for resources will have the hardest time successfully combating disease outbreaks. It is not surprising that developing countries often struggle to address disease outbreaks. These states may have poor public health facilities to begin with, a lack of access to updated technology, and weak mechanisms for transparency and accountability. Despite these factors, some states do respond reasonably well to threats to health security, while others do not. This article attempts to explain the difference.

Highly Pathogenic Avian Influenza (HPAI)/H5N1 in Southeast Asia[2]

Avian Influenza, the H5N1 strain, is highly pathogenic and poses a significant threat to human health and well-being.  H5N1 is spread through wild birds and farm-raised ones. People contract the disease from contact with sick birds. In very rare cases it seems that the disease may be transmitted from one person to another person.[3] The virus has a high mortality rate when contracted by humans. Southeast Asia presents the perfect conditions for an epidemic of Avian Influenza: back yard poultry raising is wide spread and popular and exists side by side with industrial farming; and the public health infrastructure across the region is relatively weak. The countries hit hardest by avian influenza include Thailand, Vietnam, Cambodia, and Indonesia.  We see a great deal of variation in how these four countries addressed the outbreak of H5N1. Thailand and Vietnam, after initially slow responses, changed course rather dramatically and were able to implement effective protocols for slowing and then halting the spread of the disease.  Cambodia and Indonesia’s efforts were much less effective. 

The World Health Organization (WHO) and the US Center for Disease Control (CDC) have developed ‘best practices’ for how to prevent the spread of the disease and how to slow or mitigate the spread of it. There is an effective vaccine for H5NI that can be used to prevent the spread of the disease; once the virus is detected. It is best to stay away from wild birds, and  those that raise chickens, ducks, and geese should cull flocks which may have been exposed; policies should be implemented to cut down or prohibit transporting bird flocks in regions where there are active outbreaks of H5N1; efforts should be made to separate domesticated/farm-raised birds and wild flocks; and communities need to be educated on safe handling instructions, hygiene, and rigorous cleaning of facilities, tools, etc. which might come in contact with infected birds, as well as how to identify the symptoms of the disease and prevent transmission of the disease once it is diagnosed.[4] 

WHO works around the world to identify and track pandemics, and coordinates with individual states and with regional organizations like ASEAN (the Association of Southeast Asian Nations) to monitor, provide advice, and assist countries to address with public health problems. They can help set up information sharing, furnish technical assistance, make recommendations, and provide oversight into compliance with protocols.[5]    

Southeast Asian nations face political and economic obstacles in effectively combating H5N1.  First, poor countries find it difficult to afford the cost associated with paying farmers to cull sick flocks, and to compensate adequately to make sure that they comply with culling orders (and have oversight capabilities to verify such a mandate). In addition, farmers who produce for export do not want to vaccinate their flocks, both because of the cost, but also because of European Union (EU) prohibitions against importing vaccinated poultry. The political dynamics are more complicated. Public health is a key element of human security, and states must be able to handle disease outbreaks or face the fear, anger, and mistrust of their citizens. Since pathogens easily cross borders, health security is linked to state security. One would think, then, that states have significant incentives to get their responses ‘right’ (i.e., to prevent disease outbreaks). However, that is no easy feat. An examination of how states in Southeast Asia have dealt with H5N1 shows that bureaucratic in-fighting, political competition, corruption, and weak governance, all hamper effective disease response.

Variable Responses

Thailand, Vietnam, Cambodia, and Indonesia all saw large numbers of human cases of Avian Influenza in 2004-2006. However, Thailand and Vietnam did significantly better stopping and slowing outbreaks from 2007-2016.

Figure 1. Human Cases of Avian Influenza

Sources: WHO Regional Office for Southeast Asia, “Surveillance and Outbreak Alert: Avian Influenza in 2013 and updated in 2017, www.searo.who.int/entity/emerging_diseases/topics/avian_influenza/en/; WHO Global Influenza Program, “Influenza,” and “Cumulative Number of Confirmed Cases for Avian Influenza 2003-2017, http://www.who.int/inluenza/en/ and http://www.who.int/influenza/human_animal_interface/2017_07_25_tableH5N1.pdf?ua=a1.

Political conditions in the four countries examined here help explain the variation in responses to H5N1: bureaucratic politics, relations between the central government and local organizations in charge of monitoring and active response; the role of interest groups and what their interests are in addressing Avian Influenza. A brief description of each country’s response highlights important differences.

By 2003 Thailand was one of the world’s largest poultry exporters, exports constituted 40% of poultry production in the country.[6] Poultry production takes many forms: backyard chicken and duck farming, small to medium sized commercial farms, large scale farms, both those that just raise the chickens, as well as vertically integrated farms that deal with all stages of production from hatcheries to post slaughter processing. When avian influenza first hit in 2003, the response was weak. As the number of cases climbed, it was clear that the government needed to do more; domestic and international pressure was mounting and there was fear that exports would be shunned in international markets. Prime Minister Thaksin Shinawatra held a series of high-level meetings with government officials from key ministries, including the Ministry of Agriculture and Cooperatives, Public Health, Commerce, and Foreign Affairs. Measures were enacted which followed recommendations from the UN Food and Agriculture Organization (FAO), WHO, and World Organization for Animal Health (OIE). There ensued a comprehensive culling of infected birds, cleaning and disinfecting equipment and facilities with infected birds, restrictions on movement of poultry, and a 90-day export ban from infected regions. Farmers and bird owners were offered high levels of compensation (80-100% of market value) for culling flocks, and compliance rates were very high.[7]

Why was Thailand able to implement these measures so successfully? For one thing, Thaksin had a high degree of support from the business community, and his supporters were firmly in control of the ministries involved in crafting and overseeing the response. For another, there was support from poultry exporters to get the policies right and to comply: their market share and business relied on this. Once large producers were on board, it was easier to force smaller farmers to follow suit. Additionally, Thailand has a relatively capable and effective bureaucracy; in Thailand, governance works. 

Like Thailand, Vietnam was initially slow to respond to the outbreak. But as the number of cases grew, the government took vigorous action. The government allocated significant budget resources to combat the disease, and cooperation with WHO and OIE improved. Vietnam chose to make use of vaccinations; and 212 million birds were inoculated.[8] In adopting these measures, the government was responding to internal and external pressure. The external pressures were from foreign investment and tourism, both important sources of revenue and reputation; and internally, the government wanted to avoid the risk of an economic downturn. The government relies on economic growth as an important source of political legitimacy. An economic slump would risk this quiescence. Vietnam agreed to accept assistance from international advisers, who trained local groups to recognize H5N1 and to take preventive measures to keep it from spreading. A massive campaign was launched to educate people throughout the country to combat the disease. 

Vietnam is a unitary state that has considerable coercive power (through mass organizations, control of the media, etc.) to effect compliance with political and economic campaigns. The comprehensive nature of the Communist party made it more likely that the campaign would be effective if those at the top of the political hierarchy wanted it to be, which after 2005 they did.[9] 

The Cambodian response to Avian Influenza, unlike that of Thailand and Vietnam, was extremely weak. Although the initial number of those infected was low, and the international health community allocated significant resources to help Cambodia, the country’s response remained ineffective. Cambodia received $45 million from international donors to prevent the spread of the disease, and yet the number of cases increased through 2014.[10] Although Cambodia is not a poultry exporter, the tourism industry is important to the country’s economy. Despite this, Cambodia chose to combat the disease primarily through public health campaigns. They did not mandate culling, nor did they offer compensation to farmers for culling. Why? It seems that the government was skeptical that farmers would comply with culling orders; moreover, there was a preference for spending money on projects that would provide graft opportunities for public sector workers. As S. Ear has observed, “The siphoning of aid flows to fuel patronage networks is a well-known phenomenon in Cambodia, and the avian influenza response has added to this dynamic. Well-connected officials, linked to political networks and the ruling party are able to benefit, with aid efforts directed to certain areas and activities.”[11] Some of these activities included publishing pamphlets about Avian Influenza and public service announcements for TV (not withstanding how few Cambodian households have access to TV…). Cambodia also suffers from weak state capacity, where policies enact by the central government in Phnom Penh may have little effect in peripheral areas. The country’s physical infrastructure is also deficient: poor roads, schools, and health clinics make adherence to public health protocols a daunting task.

Indonesia also suffered from a poor response to the virus. Some of the problems in Indonesia stemmed from poor coordination between the central government in Jakarta and local governments. Even within Jakarta there was in-fighting and bureaucratic competition for resources. Minister of Health Supari announced that Indonesia would not share samples of the H5N1 virus with the WHO, and the Ministry announced the shuttering of NAMRU-2 (US Naval Medical Research Unit 2) in Jakarta. NAMRU, one of the most sophisticated medical labs in Indonesia, was jointly funded and operated by Indonesia and the United States. In explaining the decision to close NAMRU, Minister Supari claimed that WHO and NAMRU 2 had been using Indonesian samples to create vaccines which were manufactured and sold elsewhere, thereby enabling others to profit. However, there is an alternative explanation for these actions: The Ministry of Health was competing for funds and attention with Ministries of Forestry, Agriculture, and Industry. These three Ministries were better funded and more powerful. The Ministry of Health, in refusing to cooperate with WHO and in closing NAMRU-2, at the very moment that Avian Influenza was spreading, may have been jockeying for power against other bureaucracies.

Despite Indonesia’s infighting, the country did continue to send virus samples to FAO, and attempts were undertaken to implement effective measures against H5N1. There are many community-based programs run by NGO’s in partnership with both national and local government agencies to combat avian influenza. Coupled with bureaucratic difficulties are low levels of compensation for culling flocks, and resistance by agribusinesses to strict monitoring and compliance with best practices.[12] 

How well countries deal with public health problems, or any threats to human security, is directly related to governance. Governance can be defined as the ability of the government to address crucial needs of their citizens. Can a government create and maintain an infrastructure (i.e., roads, bridges, electricity, ports, etc.) to promote a functioning and dynamic economy? Can a government create and sustain a system of public education to educate citizens for the 21st Century? Can a government provide for the health and well-being of their citizens? Shahar Hameiri and Lee Jones argue that weak governance explains poor responses to threats like avian influenza[13] and the examples of Thailand and Vietnam’s turnaround, improving responses to H5N1 contrasted with poor responses from Cambodia and Indonesia certainly back up this argument. Thailand and Vietnam are better overall at policy implementation and providing public goods to their citizens, so it should not be surprising that combating infectious diseases is included. Likewise, countries responded to H5N1 in ways that reflect how well or how poorly national governments can assert control and preferences over local governments, and how corruption effects policy implementation. 

Although disease response varies in Southeast Asia, the region does have organizational resources which might help improve combating diseases in future outbreaks.[14] Southeast Asian countries, through the Association of Southeast Asian Nations (ASEAN) have agreed on AASMER, the ASEAN Agreement on Disaster Management and Emergency Response. AASMER has created a mechanism for countries to work cooperatively on disaster reduction and humanitarian relief.[15] In the future, these tools may help contain the spread of new disease outbreaks.    

Middle East Respiratory Syndrome (MERS)       

MERS-CoV, Middle East Respiratory Syndrome Coronavirus, is a severe acute respiratory illness.  It was first reported in 2012 in Saudi Arabia. Those who contract the disease present symptoms similar to pneumonia and other severe respiratory illnesses. All subsequent cases appear to be linked to the outbreak in Saudi Arabia.[16] MERS is found in camels and bats. It is zoonotic and can be transmitted from animals to people; and from person to person via close contact. The most likely source of transmission is when the virus becomes airborne from severe coughing. 

Outbreaks of MERS (as of October 2018) occurred in the following Middle East countries: Saudi Arabia, United Arab Emirates (UAE), Kuwait, Qatar, Bahrain, Jordan, Iran, and Oman. 

Figure 2. MERS-CoV Cases

Source: U.N. Food and Agriculture Organization (FAO), MERS-CoV situation update, December 18, 2018, http://www.fao.org/ag/againfo/programmes/en/empres/mers/situation_update.html.

The two countries in the region with the largest outbreaks, Saudi Arabia and UAE, have had to address how to educate the public about the disease and how to best prevent increases in outbreaks. Studies of public awareness in the Middle East to MERS show that the vast majority of respondents are aware of the virus, but are not knowledgeable about transmission of the virus, nor do they understand best practices for prevention, and this coincides with relatively low vaccination rates (more generally) in the region for a number of common diseases.[17] Fatality rates of those infected are around 35-40%.[18]     

With the largest number of cases, Saudi Arabia’s disease response is vitally important. Yet, there are criticisms of Saudi authorities’ ability to implement effective policies for treating patients and educating the public to stem the spread of the disease. It would be understandable for an initial response to a new pathogen to be poor. Nevertheless, states need to be able to get up to speed quickly in identifying new diseases — providing the most effective treatments for patients, and critically, implementing preventive measures for most vulnerable groups of citizens to stem the outbreak. 

Initial studies show that Saudi Arabia’s initial response to MERS was poor and that it did not improve quickly enough in the first few years of the outbreak. It has been found that there was:

Ø poor communication among government agencies, hospitals, and labs;
Ø weak accountability;
Ø poor oversight of health care providers and government ministries;
Ø failure to learn from mistakes;
Ø under-reporting of cases, perhaps upwards of 20% of cases were not reported; and
Ø missing information in records from reported cases.[19]

These shortcomings demonstrate failures to build capacity in public health and health security.  This is somewhat surprising as Saudi Arabia scores well on its human development index ranking, placing the country in the top third of all countries for human well-being, including health indicators.[20] So, it may not be that the medical facilities don’t exist, or that they don’t have the ability to address the problems. Instead it may reflect poor incentives to respond robustly, and perhaps a reluctance to have outside monitoring and advice from international organizations such FAO and WHO, as well as to share information in an open and transparent manner with their own citizens. 

The United Arab Emirates ranks just above Saudi Arabia in their HDI, but with a much smaller population. There have been many fewer cases of MERS in the UAE. Nonetheless, the UAE has moved to implement more comprehensive measures to better track the initial source of the disease and to prevent further spread by sharing information and reaching out directly to those who came into contact with the person before symptoms developed:

Contacts of the confirmed patient have been identified and are being monitored for the appearance of symptoms for 14 days from the last exposure to the confirmed patient. The Communicable Disease Department in UAE is in coordination with the animal authorities to initiate camel testing at the patient’s farm in UAE.[21]

Although late developers, Gulf States have used oil wealth to build health care systems which, even 30 years ago, were able to offer access to medical care to almost all their citizens. However, like many state service and public goods, medical care is not necessarily offered to ‘guest’ workers in the region.[22] So, one problem in the Gulf region is the disparity in access to services. A second problem is a divide between public and private hospitals. Since there is a pay gap for doctors and staff in public hospitals, numerous problems have cropped up: demands for bribes, absenteeism (as better providers spend more time on private pursuits than in the public setting), and the creation of a dual-track economy in health care.[23] The health care sector in the Gulf also has a problem with high rates of turn over for medical personnel, and low levels of satisfaction and trust from citizens. Gulf states’ spending is still much lower than in OECD countries — an average of 7% as compared to 17% of GDP.[24]

Conclusion

At the core of a state’s ability to deal with a health emergency is how it manages transparency.  States must be willing to share information, both with their own citizens and with the global community. It is not surprising that many non-democratic states find that their first reaction is to withhold information and then to make it hard to share information within government agencies and between public and private sector actors. States in the Middle East and in Southeast Asia (except Indonesia) are not known for being robust democracies. So, there seems to be a preference for regimes to try to keep information from being widely disseminated about disease outbreaks, perhaps because of fear of popular opposition to ruling elites. And, without democratic accountability built in, there are few genuine electoral pressures to improve governance and public goods. Non-democratic regimes often find that there are greater incentives to maximizing the support of smaller groups of citizens (business elites, or party cronies for example) than in providing for improved governance structures that could better address health threats. It is unlikely that we have seen the end of the risk of a pandemic outbreak of H5N1 or MERS, and sadly, it is also unlikely that states are fully prepared for the next outbreak.