by Phasawit Jutatungcharoen
On the day I went to get myself tested for COVID-19, I received conflicting texts from different people. My acquaintances in Geneva assured me it was a bad idea, which was reasonable within the guidelines of the canton. At the same time, I had messages from my parents and friends in Asia not only congratulating me on going, but saying that they felt assured that I went. It was an odd experience, receiving opposing views of the moral imperative of a responsible citizen in a pandemic.
When I had time to think about it, what interested me was the divide regarding what decisions were right to make, and the contexts behind their respective rationales. It got me thinking about my own decision, and why I did it despite knowing all the information circulating in Geneva. Why were my friends in Asia trying to convince me to get a mask despite me telling them none were available? Why were my parents resolute on getting me tested? (It turned out they were afraid that I couldn’t come home because the Thai government decreed you couldn’t return unless you had a certificate saying you were not infected within 72 hours).
While it is easy to attribute such clashing approaches to cultural differences, this article examines how the combination of mental shortcuts and the history of pandemics of the last century not only taught the East to prepare, but also taught the West not to.
Two Asian Stories: 2003 and 2015
In November 2002, a farmer in the province of Guangdong, China was being treated in a hospital, dying soon after. There was no clear diagnosis as the doctors had never seen such a viral illness, and assumed it was some sort of pneumonia. While doctors gradually realized they were dealing with something entirely new they were discouraging from reporting new cases, even to WHO.
The disease jumped to Hong Kong in February 2003, where a medical professor unwittingly infected others in his hotel before dying. An elderly woman from Hong Kong inadvertently spread it in Toronto that same month. An American businessman traveling from China fell ill and was kept in Hanoi. Italian doctor Carlo Urbani, who treated him, realized this disease was something new and contagious, he quickly notified the WHO while asking the Vietnam Health Ministry to isolate patients. He succumbed to the disease the next month.
SARS remains one of the most traumatic events in the history of Asia in the 21st century. China had over 5,000 cases and incurred at least 41% of total deaths. Hong Kong, the second worst hit, had only 50 deaths less than China, and therefore 163 times the death rate by population. Almost thirty countries experienced at least one case, with over 8,000 cases and a worldwide death rate of just under 10%. Lessons in transparency, preparedness, and global cooperation were learned, and the virus was contained in July 2003.
The legacy of SARS still looms large in many parts of Asia. The issue of information opacity in China was an issue that was at least acknowledged by the Chinese government, and public health emergency structures were taken more seriously. Political humor surrounding SARS also emerged within the country. While it is still debated whether transparency would be learned in the future, the Chinese Communist Party could not downplay further epidemics at this scale. Another nominally socialist country, Vietnam, would prepare itself on similar grounds.
In Taiwan, then director of the Centers for Disease Control, Su Ih-jen went to the US to study its health procedures before reforming the country’s public health system in early 2004. New staff were added, new facilities were built, and external medical centers were contracted to expand its capacity. Surgical masks were stockpiled, along with other basic items needed to deal with a future crisis. On a political level, a new management structure was overhauled for infectious disease specialists to be centralized around the Central Epidemic Command Center, where the expert panel could override political hurdles for rapid action.
Out of all other cities however, SARS seemed to have had the strongest socio-cultural impact on Hong Kong. As a period of massive anxiety in one of the densest places in the world, no one knew at the time how fast the virus could spread. Press conferences of the outbreak regarding deaths and new cases were released daily, a mark of transparency but also adding to the environment of fear. Mask wearing became commonplace for any sickness and building complexes would ensure that elevator buttons and surfaces were being constantly disinfected. With such a legacy, Hong Kong society saw a growing consensus for over-responding to be preferable to under-responding.
While 2003 was a devastating year for East and Southeast Asia, it would be a mistake not to mention the MERS outbreak in 2015 and its impact on South Korea as well. While SARS did not have a large effect on Korean society, MERS had made it the second worst country hit after Saudi Arabia. The South Korean government at the time refused to disclose to the public which hospitals were infected, the main sources of the virus at the time, only relenting about a week later. The findings from Korea revealed that many of the infected went from hospital to hospital to confirm their contraction of MERS, the reason of which may be familiar to a lot of us now: a lack of test kits.
Since then, the Korean government has made two new important moves. First, prioritizing the production of test kits in preparation for an epidemic became the go-to option, making sure that diagnosis runs as smoothly as possible. The second, a more controversial step – based on their previous lack of transparency, the government moved to become as transparent as possible, posting information about the precise movements of anonymous people testing positive, using phone records and credit card receipts. While contact tracing is seen as a necessity and the use of technology for it is growing, the question of forsaking privacy and risking confidentiality is still a concern for many.
While new innovations in Asia were made to prepare for such a similar event, it is also important to understand how such events were drilled into social consciousness. The impact on their respective societies had made them more sensitive to confronting epidemics more cautiously. Although each country’s public health emergency systems have been transformed in a way to better deal with such crises, the culture of mask-wearing in Asia, whether effective or not, is a good indicator for social preparedness. In these countries, not only were the mass majority of the population accepting of swift and harsh measures but were sometimes even demanding them.
A Global Story: 2020
I was in Thailand when my family heard about the epidemic in China. We were quite worried as our country was a top destination for Chinese tourists. While SARS was not as devastating here, mask-wearing is still common and with my ethnic-Chinese background, even more so. While people were already wearing masks due to air pollution, it was jarring to see hand sanitizers and masks disappearing from store shelves. There was an environment of anxiety every time I used public transport to do research at the national archives for my thesis, with most people wearing masks around me. Going back to Geneva seemed like a good way to get away from it all at the time.
2020 has already been an odd year. A month before, my parents wanted me to cancel my flight transiting through Kuwait because of the US-Iran debacle, and thought flying through Beijing would be a good idea. Once I arrived in Geneva, there was a sense of comfort in the lack of pressure to wear masks and behave as if everything was fine. After all, no one was worried at the time, though I was still constantly washing my hands from my Thai experience. So, when social distancing and escalation towards partial lockdown was happening, a big part of me did not want to believe it, even though in hindsight it was rather inevitable for a place with large air traffic.
I say this because the issue made me think about the power of social influence and cognitive dissonance. When I was in Thailand, I made sure to be as secure as possible and stay vigilant, partly because everyone was doing it. In Geneva, I regularly used public transport and congregated normally, because everyone was doing it. But that isn’t the whole story either. In Asia, there is a common understanding for why everyone is doing what they are doing, that is, “doing the right thing” like wearing masks. However, in Europe earlier in the year, it wasn’t clear what we should do. We were still wondering how lethal COVID was and discussing what “the right thing” to do was. Was wearing masks effective? Should I cancel my plans? Is a lockdown necessary?
I had the honor of being part of the virtual meeting with IHEID’s Critical Theory Reading Group initiative where we discussed the issue of unknowing in public health, what governments need to do with limited information and their duty in what they must inform the public. This was a real concern especially when relying on information from the WHO, our relative national and local governments, not to mention those floating around social media. Yet it was also interesting to discuss how this was not a universal sentiment, especially in Asia where the government and people seem to be in relative consensus about what they know and what must be done from the beginning. The SARS epidemic taught China to react stronger, quarantining an entire province. Taiwan‘s response was well prepared on a supply and bureaucratic level, while South Korea’s investment on testing kit production paid off. Vietnam was one of the most proactive of the South-east Asian countries, managing to act swiftly despite having few resources. Hong Kong perhaps had a mixed approach, with their society mentally prepared but some being angry at their government for not issuing travel restrictions sooner.
When I talked with my friends in Asia regarding COVID in Europe, the reactions I received were that of shock and anger. It was genuinely shocking to many that Europe being far away and with records of good healthcare were struggling to deal with the epidemic. Anger was the most prominent, much of it coming from reading the news. Stories of people breaking quarantine, disregarding social distancing rules, refusing to wear masks and Asian people being harmed for doing so, were some of the common themes. The general impression that my friends had was that the West had been careless, ignorant, and dismissive of what was going on in Asia. When I told them that many countries here did not have the supply or capacity to follow Asian countries, the perception was that of irresponsibility. I was even derided for listening to the WHO as they were perceived to be less reliable than what Asian countries were already doing. Their recent turn regarding the wearing of masks only served to validate that impression.
Personally, the situation is far more complex than it seems. On the one hand, it is quite clear that many countries should have been more prepared far earlier to deal with the situation, and we should be angry about racist reactions against Asian people with regards to the virus. At the same time, was such a move that obvious at the time? The attitudes of Asian societies towards epidemics were perhaps more serious given their proximity and past events that are still ingrained into their respective social consciousness. Their respective states have also been institutionally prepared for another crisis, allowing the government the resources and will to do things that other countries could not, such as South Korea performing aggressive testing. While there are various factors regarding the diversion in preparation, the psychosocial aspect is the crux of this discussion.
The Availability Heuristic and Other Biases: Blessings and Curses
Just as Asian countries look to the recent epidemics that affect their societies, countries around the world are looking for something to compare. Various societies in Africa look to the Ebola epidemic for lessons to be learned as they prepare for the coronavirus. Medical studies began re-examining the Zika virus, some with regards to how people react to information or misinformation about it. Perhaps the most prominent one discussed in contemporary circles was the 1918 Flu Pandemic (the Spanish Flu). This sort of historical comparison hits deeply for someone studying International History, not to mention a one-off podcast on global health, forcing me to ask critical questions. The one question that comes to mind is:
Why the Spanish Flu?
Why be reminded of a pandemic that happened 100 years ago, when there was a pandemic that happened only 10 years ago, the 2009 H1N1 pandemic or the “Swine Flu”. This was perhaps more salient to me as someone who once contracted H1N1, but the crisis soon disappeared from public consciousness. While various diseases in the twenty-first century traumatized Asian societies into preparation, recency alone was not the only factor. Just as the Great Recession in 2008 reminded people of the Great Depression of 1929, the scale of the COVID-19 pandemic was large enough to be compared to the next largest pandemic in recent memory, which is to say, one that is more “available” in people’s mind.
Students of basic psychology or avid readers of “Thinking Fast and Slow” would be familiar with the term availability heuristic. Psychologists Tversky and Kahneman define it as a mental shortcut, in which immediate examples that could be recalled are used as models for evaluating a certain topic or decision. I see that such a phenomenon could be extrapolated to a larger society. In the event of an epidemic, people in Hong Kong would often recall the SARS epidemic in 2003 and make decisions based on it. Even on a policy level, South Korean policymakers would easily recall and make their decisions regarding test kits based on the MERS epidemic in 2015. What event would people in Europe or America recall upon hearing of an epidemic in China? Even if they recalled SARS, that pandemic barely made a dent in the West. In a way, most of the things that immediately came to mind were either faraway epidemics that never made an impact, or nothing at all.
However, other important factors played into the lack of preparedness in the West. Major 20th century influenza pandemics emerged like the 1957-1958 influenza (Asian Flu) and the 1968 flu pandemic (Hong Kong flu) that each killed at least 1 million people worldwide, yet their impact was forgotten even at the time. With the Second World War in recent memory, the mortality rate of the 60s and the rapid improvement of modern medicine, those numbers were seen as acceptable at the time. In contrast to COVID-19, governments around the world saw no need to issue restrictions on public life and economic activity, allowing the disease to run rampant until a vaccine was found shortly after. Global events like the Vietnam War and the civil rights movement also led to public pressure being placed on other matters. Dr Anne-Marie Moulin of the French National Science Research Center (CNRS) stated how pandemics had faded from the Western public consciousness, creating a “zero-risk” mentality, superseded by more psychologically salient risks like terrorism. Such an attitude may have persisted in the East if not for the major impact that SARS and MERS had on public life in Asian countries.
While the availability heuristic reveals how biases can help or hinder preparedness to pandemics, it also reveals its downsides. Reports of racism and prejudice against Asian people or those who wear masks, while should not be tolerated, must also be understood. I will not pretend to know what these people are thinking, but mental biases like the availability heuristic is a good framework. COVID-19 is a pandemic, yet it is hard to separate it from its origins in China. Chinese and Chinese-ethnic people have been subjected to prejudice as it was easy to associate it to the virus. While the WHO has refrained from naming the virus after geographical locations, names like “Wuhan coronavirus” or more controversially the “Chinese virus” further entrenches the connection while distracting us from where the virus is now.
The availability heuristic is only one bias among many. Thomas Davenport wrote an article called “How to Make Better Decisions About Coronavirus” regarding how cognitive biases influenced the way societies and political leaders make decisions. The “status quo bias” or believing that business-as-usual is already the optimal route seems to explain why a lot of us were reluctant to change our plans and policies, resulting in a crucial delay of action. The “normalcy bias”, or the belief that everything would continue to go as they always have seemed even closer, perhaps leading most of us into a false sense of security despite numerous cases warning us to take the situation seriously. The article goes into many more interesting ones and you may peruse it to your leisure.
Final Thoughts: Lessons in Irrationality
This article began as a follow up to my previous article, “COVID-19 Testing: What to Expect in Geneva?” It was succinct, simple, and under 400 words as I was asked. However, it really wasn’t the helpful sort of article that I would have wanted to write, being too anecdotal. There are probably other accessible sources that were better, and I was essentially telling people, “If you’re going to get tested now, they’ll probably send you home”. This article, though long overdue, was closer to what I wanted to write about regarding this whole situation, and perhaps time allowed me to think more clearly about how to write it.
I lost my grandfather a couple weeks after my hospital visit. We were mentally prepared for it. He had been weak for quite some time, and in our hearts, we were ready to let him go. The funeral was the most difficult part. My family was in Thailand, our extended family was in the US, and the only people in Hong Kong with my grandfather was my grandmother and her domestic helper. There were back and forth discussions about cremating the body, but we also wanted to freeze the body so we could gather for a real funeral. Surely, we could wait for the summer when everything blows over. Of course, the inevitable had to happen. My family gathered and attended the funeral, watching a pre-recorded truncated version on Google Drive.
With time to think back, I’m slowly processing the contention that I had been dealing with. My friends and family in Asia understood how crucial time was in dealing with the virus, learning from previous experiences to be alert and act swiftly. Their criticisms of the West for their delayed responses and indecision seem increasingly validated everyday as we begin to see the true damage. However, we must also understand that the imbalance of historical experiences had led to a difference in social consciousness, or rather a social unconsciousness to pandemics. The societal impact up until recently had been so low that there was no reason for the West to wake up.
The frequently misattributed quote “Never let a crisis go to waste” is perhaps my cynical hope for the world forward. A new social consciousness and prepared mentality is emerging, and time will only tell how long it would remain. It may be hard for me to ask my fellow friends in Asia or of Asian descent, who hear so much of Western prejudice, to nevertheless empathize with them. We were all still living in the carefree days of pre-2020, irrationally clinging on to it in the hopes of keeping what we could before the true impact had really been felt. In a different time, in different shoes, we might find ourselves doing the same thing.
Featured photo by MirceaIancu on Pixabay
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