With the coronavirus taking hold, conferences being cancelled (I’m looking at you ISA), and college campuses like Harvard shuttering or going online, the coronavirus outbreak has gone global and upended countries and markets around the world. The worst may be yet to come.

We will be posting some new guest posts, and we welcome additional submissions.

I’ll try to do a new post in the coming days, but here is my threaded Twitter rant on what the failures of early testing in the United States meant for the spread of the virus here.

A quick update to my series from last week. The coronavirus has not been contained to China, and there are now nearly 1000 cases in South Korea, 270 in Italy, and 60 in Iran.

Health experts and writers (see for example Ian MacKay, Devi Sridhar, James Hamblin, Helen Branswell, Michael Osterholm) now think it will eventually spread globally, meaning that containment strategies of travel restrictions will become increasingly ineffective.

We are now entering a phase of having to reduce the impact and harm associated with the spread of the virus, including taking precautions at the individual level to prevent infection like washing hands frequently and avoiding touching your mouth, eyes, and face.

(This is not the time for panic or overreactions, but I do think it is appropriate for us to be prepared for cases to come to countries that have not yet experienced an outbreak yet. Most cases are mild, but some are not).

I took a big bottle of hand sanitizer to the office and wrote our buildings manager about what plans they have in place to protect the workplace.

On the same day that the World Health Organization said that there were now only 889 new cases of the coronavirus in China (down from 1749 on Wednesday), there were also reports of new outbreaks in two Chinese prisons. We also witnessed the deaths of two people in Iran (apparently from COVID-19) and an outbreak in Korea–now up to more than 150 cases—fueled by a superspreader associated with a strange cult and no known connection to China.

I’ve been having quiet conversations with colleagues recently wondering when we would start to see more aggressive transmission outside of China. Between this, the weirdness in Iran, and the cruise ship, I suspect we’re starting to seee it. https://t.co/V3TmeU54d4

— Jeremy Konyndyk (@JeremyKonyndyk) February 21, 2020

In the U.S., there are both reports of several hundred people getting out of quarantine after 14 days with a clean bill of health as well as the amazing story that the State Department overruled the Centers for Disease Control in allowing fourteen people infected with the coronavirus to be on the same plane of evacuees from the Princess Cruises ship.

So, we might be cautiously optimistic that the worst is behind us, or maybe not. It’s looking like the disease will not be contained in China, with there being local transmission taking off in a few other countries.

The first post in this series provided background on the virus, the second examined the declaration of a global health emergency, the third explored international travel restrictions, and the fourth reflected on China’s internal policies. In this fifth and final post of the series, I write about what policies the international community and individual states need to implement to contain this outbreak and prevent the next one.

In the midst of the COVID-19 outbreak, the stories on China’s quarantine and population control measures seem downright crazy, with people needing hall passes to go out of their apartments, buildings turning away residents who had been out of town, periodic temperature checks on residents, drones being deployed to disinfect villages or to shame people to go indoors or put on a mask, and health workers deployed in train stations checking phone records of visitors to see where they have been.

Walking around without a protective face mask? Well, you can't avoid these sharp-tongued drones! Many village and cities in China are using drones equipped with speakers to patrol during the #coronavirus outbreak. pic.twitter.com/ILbLmlkL9R

— Global Times (@globaltimesnews) January 31, 2020

Over the weekend, the New York Times reported the extent of the measures China has imposed on its citizens to control the coronavirus outbreak, which encompass about half of China’s entire population, some 760 million people.

Are these draconian measures working? News out of China is confusing. The last few days have seen a decline in the number of new cases which raises hopes that the herculean efforts imposed by the Chinese government (implemented with zeal by local actors) are succeeding.

However, international observers, like Dr. Tony Fauci of the National Institutes of Health, warn that that it too early to conclude the worst is over: “I think we need a few more days to determine if that’s real or variability.” Others like mathematician John Allen Poulos have made similar points.

It is not clear when China’s workforce of some 700 million will get back to work after a three week hiatus and what that will do to infection numbers.

1. The Communist Party would like you to believe that they are getting the coronavirus outbreak under control. Yes, the no. of recoveries has exceeded deaths; the daily tally of new infections and deaths has declined steadily since Feb. 12. But it's too soon to conclude anything.

— Sui-Lee Wee 黄瑞黎 (@suilee) February 19, 2020

In my previous posts in this series, I laid out basic attributes of the virus, the declaration by the WHO of an international health emergency, and the role played by international travel restrictions. In this post, I want to review whether or not China’s efforts have made the situation better or worse.

My basic takeaway is that the same authoritarianism that gave China the ability to respond to the virus is the same one that allowed the outbreak to get as bad as it did in the first place.

If you’ve been following the coronavirus outbreak, you’ve probably heard about the Princess Cruises ship, quarantined in Japan with thousands of passengers on board. It sounds like the veritable cruise ship from hell. Of the 1219 passengers screened for the virus, some 355 passengers tested positive for COVID-19, including some 44 Americans. The Americans were finally being evacuated today after having been quarantined on the ship since February 5th.

The horror of confining thousands to a boat underscores the incredible measures governments have undertaken to try to contain the virus. The Princess Cruises ship harkens back to the original meaning of the word quarantine as Howard Markel reminds us:

Quarantine laws — from the Italian “quaranta giorni,” meaning 40 days— were first developed in Venice in 1370, to keep the bubonic plague at bay by banning any ships and goods for the time it seemed to take most epidemics to burn themselves out.

Howard Markel, New YorK Times

But, were these extreme measures justified? This is the third in the series on the coronavirus COVID-19. In my first post, I provided some background on the nature of the virus, from what we know. In the second, I reflected on the belated declaration of the Public Health Emergency of International Concern by the World Health Organization in late January 2020.

In this post, I want to reflect on both the international restrictions on travel to and from China. In the next post, I’ll reflect on China’s internal response.

In my first post on the coronavirus outbreak, I reviewed the nature of the disease. Here, I want to ask and answer the first of four questions I posed about whether a global public health emergency should have been declared earlier. In the next post, I’ll tackle the appropriateness of China’s quarantine measures, the adequacy of its overall response, and what should be done going forward.

The response to the COVID-19 coronavirus has been draconian. With the lunar year vacation looming at the end of January, China shut down travel out of the city of Wuhan on January 23rd (and severely restricted entry as well), soon extending to the wider province of Hubei, with a population of 58 million people.

Commerce and public outings in much of the rest of the China have also dropped markedly with cities like Shanghai looking like ghost towns after the government extending the lunar holiday and people stayed away from malls and other public places.

Meanwhile, the World Health Organization finally declared the COVID-19 outbreak to be a Public Health Emergency of International Concern (PHEIC) on January 30, 2020 after having deferred making such a declaration the week before.

In making the declaration, WHO Director-General Tedros Adhanom Ghebreyesus praised the Chinese response and argued against travel and trade restrictions with China, raising concerns he was being overly deferential to the Chinese government.

In many ways, #China is actually setting a new standard for outbreak response. Our greatest concern is the potential for the virus to spread to countries with weaker health systems, and which are ill-prepared to deal with it. #2019nCoVhttps://t.co/GdUQZGvzkd

— Tedros Adhanom Ghebreyesus (@DrTedros) January 30, 2020

In response, the United States elevated its travel advisory warning citizens not to travel there and said it would deny entry to foreign nationals who recently visited China. On January 31, three American air carriers — American, Delta, and United suspended all flights to China temporarily, with some airlines cancelling all flights to China and Hong Kong through the end of April.

Should a PHEIC been declared earlier? Has it had an impact?

Even if you don’t study global health, you’ve probably been following the coronavirus outbreak in China with a mix of dread and fascination. Li Wenliang, the whistleblower Chinese doctor, who himself succumbed to the virus riveted the world. His death was mourned in China, even as the government initially censored conversations about his passing.

The Chinese government’s problematic response has created one of the most significant political challenges the Xi Jinping government has faced. Today, the heads of the Communist party in Hubei province and the city of Wuhan, the epicenter for the virus, were both fired.

This episode reminds us that global health is high politics. The stakes of a global outbreak for international relations, the global economy, and trade are enormous, independent of the impact on human lives. The nearly 1500 who have already died is a major tragedy, and we do not know if things are finally getting better.

This week, just as some analysts thought new cases had peaked, the Chinese government widened the definition to include suspected cases, since the diagnostic techniques for verifying infections have often produced false negatives, showing no infection even when people are symptomatic and ultimately do have the virus.

#HubeiProvince reports 4,823 new cases, 116 new dead. Global total now at 65,236 and 1,487 dead, based in #China media stats. #coronavirus

— Eunice Yoon (@onlyyoontv) February 13, 2020

I’ve been hoping to have a roundtable on the topic on the Duck from global health experts, but many of the top folks I reached out to are just overwhelmed. If you are interested, do send me a note, as we would love to hear from you.

Here are the questions I posed, which I’m going to try and answer in a series of posts. This first post is mostly background on what I’ve learned about the coronavirus, but I ultimately hope to answer the following questions:

1. What do you make of the WHO’s decision to declare a Public Health Emergency of International Concern (PHEIC)? Too late? Impact? 
2. What do you make of various quarantine measures and airline flight cancellations to China?
3. What’s your take on the adequacy of the Chinese response?
4. What’s needed at this point to prevent this outbreak from becoming worse on the global level?