How pandemics affect states’ affairs and international relations: The case of Covid-19

There are certain apparently insignificant episodes that contribute to making history what it is. As a matter of fact, small things may produce structural changes that larger events are not able to induce.

We enjoy apricots, for instance, but few of us link their flavor to the Crusaders marching through Armenia during the Middle Ages. Jacques Le Goff ironically affirmed (Le Goff, 1964: 98) that the apricot was the only fruit the West gained from the Crusades. ¹ Christian kingdoms invested a great deal in the conquest of Palestine, but the outcome was poor, and Le Goff's remark reminds us that the Crusades had a negative impact on the long-term development of Western civilization.

The opposite is also true. In ancient Rome, rat infestations, or their lack, were determined by the beech-marten's jaws, as this speedy, agile animal could kill them with a bite on the nape. Rome became aware of cats only in 31 BC, when Octavian Augustus conquered Egypt, where the cat had been respected as a sacred animal since very ancient times. The Roman legionaries brought cats back to Europe with them, but it took five centuries before the Romans appreciated how crucial cats were to fight the spread of rats. Cats were fully accepted on the continent towards the end of the 10th century, just in time to fight the terrible black rat disembarking in Europe as the bubonic plague's carrier. In those years the Crusaders imported from Soria, or Syria today, a cat breed now called Soriano in Italian (“tabby” in English). After these cats’ harsh battles with rats, they gained such respect and consideration that many considered their powers to come from Satan. Regardless, the humble cats contributed to a big event: stopping rats from contributing to kill millions of human beings!

The above examples are meant to illustrate that identifying factors that contributed to deep historical changes is a difficult exercise: large events may produce silly consequences in the long run, while small things may instead contribute to structural effects. The future is unpredictable, especially when it is determined more by humans and less by nature. As such, one of the main skills a social scientist dedicated to the study of international politics needs is the ability to identify authentic elements of change without becoming a victim of appearances, as well as a familiarity with frequent occurrences that point to the laws governing history and international affairs. They also need to be able to define what we call “deep” and “structural” change. Fernand Braudel helps:

Per me sovrastruttura è ciò che si svolge alla superficie, nella parte alta della storia; infrastruttura è ciò che si colloca nel più profondo (nella parte bassa, se si può dire) della storia. […] Poiché c’è uno spessore della storia con strati successivi, che non sono fatti della stessa sostanza. […] Soprattutto, conferisco alla posizione dei processi della storia un valore a seconda che siano in superficie o in profondità. […] La storia profonda, certo, non è immobile, ma si muove appena; ed il senso della sua pendenza, scarsamente indicato, non si indovinerà mai alla prima occhiata. (Braudel, 1984: 3)

This exercise represents a starting point for elaborating a befitting theory and producing a model that can anticipate the negative effects of pandemics on state and interstate systems.

States’ affairs, communities’ public health, and pandemics

A state is the system of institutions ruling a community during a particular historical period. It is part of the system of interstate relations that we are accustomed to calling the “international system.” Just as a state governs a community's functioning, so the international system deals with interstate and transnational relations.

If we assume that the states and the international community are capable of satisfying the prevailing values and the material needs of the populations they govern, we should consequently admit that their most stringent task is to guarantee the survival of state and interstate power, together with the survival of the respective populations. Basic factors such as strength and wealth contribute to keeping states alive and functioning. The state needs power to affirm itself in a competitive environment, and the international system needs power to discourage any subject from violating the existing international order. When the state and/or the interstate system are not able to resist and overcome structural and long-term challenges, they risk the existence of their respective systems: another power may intervene, or a kind of anarchy may prevail.

Various basic factors contribute to keeping states alive and functioning.

Strength: Armaments and a powerful system of defense, of which so-called hard power is made, appear at the top of the rankings of the factors on which a power builds itself. The state needs defense to prove itself in a hostile environment. The international system needs to have enough strength and power to discourage any subject from violating the existing international order.

Wealth: Economy and growth, together with other elements, as culture and traditions, constitute the so-called soft power of a state. States will flourish or fail based on trends involving hard and soft powers. The same applies to the international system.

Consensus and ruling: No political entity can exist without a long-term consensus. We must note, however, that in political science “consensus” does not coincide with our usual understanding of the term, i.e. a free and voluntary choice expressed in a democratic regime. Rather, the capacity to maintain law and order over a certain population in a certain territory is enough to register the existence of “consensus.”

Culture: Every political system is sustained by ideologies and values that work as pillars for consensus and subsistence. Culture is part of the soft power the state needs to guarantee its survival.

Public health and welfare: Public health is an essential issue for state and interstate systems. It affects their way of being and functioning and, in certain circumstances, their survival. As a matter of fact, public health is the precondition for bringing any state into existence and keeping it at work. The fact that our times are more complex and sophisticated than ever demands the political ideologies and ethics of contemporary states consider the mental and physical health of their populations more strategically than ever before in human history.

Taking these factors into account, two questions arise. Does a pandemic ² have the capability to affect one or more of the factors that guarantee the survival of state and interstate systems? And has Covid-19 pandemic generated structural long-term changes within states or the international system?

The public perception of moral and political healthcare, together with an appreciation of relative costs, is fundamental to the approach that nations have taken in relation to pandemics. The universal demand for receiving healthcare from states has certainly grown during the last several centuries. Before the Enlightenment, the organization of a public healthcare system, now considered a constitutional right in most countries, ³ was rarely perceived as a state's duty; often good Samaritans worked more and better than states to protect public health, and the elite preferred to keep waiting for such Samaritans instead of organizing medical support for the common people. So, churches and private charities voluntarily helped poor and sick people using their properties and donations from benefactors, while those who could afford to do so provided for themselves.

Let 's not forget that our ancestors were very religious and/or superstitious: the will of God and personal destiny and fortune mattered more than they presently do. One of the results was the acceptance of personal “providential” destiny, with no blame placed upon a higher authority, whether that be God or the Prince. The Enlightenment taught people that they had to search for rational solutions to the attacks that public health suffered, that they had to cope with these attacks, that science was possibly the answer, that no link existed between committing sins and getting sick, and that repenting did little to help one escape from illness.

In the late 19th century, the European states started approving legislation that marked the dawning of public healthcare systems, with the related expenditures becoming part of states’ budgets. The measures taken by the governments as a reaction to the Great Depression of the 1930s increased healthcare budgets. The same thing happened after the Second World War, thanks to the actions of Social Democratic parties in government and the influence of the November 1942 liberal-minded Lord Beveridge's report, published in the United Kingdom and immediately transformed by the Allied governments into a powerful tool of propaganda against Nazism (Troiani, 2005: lxxv). ⁴

Nowadays public healthcare accounts for an average of roughly 6 to 7 percent of state budgets. According to the World Health Organization (WHO), at the eve of the Covid-19 pandemic, the world health expenditure as a share of global GDP was about 10 percent, with about 3.5 percent coming from private sources and 6.5 percent from budgets (WHO, 2018). Given that statistics can be hard to trust, we ought to specify that global health investment and spending is quite varied: an average US citizen has a daily health expenditure larger than the yearly health expenditure of an average inhabitant of the Central African Republic, i.e. the per capita health spending in the USA is 387 times larger than in the Central African Republic.

Rising average life expectancies among nations is one of the results of building up a system of public healthcare. According to the United Nations (UN), an average person born in 1900 had a life expectancy of 31 years, while that number grew to 48 for individuals born in 1950 and 52.5 for those born in 1960. A person born in 2019 can expect to live 72.6 years. The key component of this shift has been the tremendous shrinking of the childhood mortality rate after the Second World War ⁵ (UN ECOSOC/UNESCWA/WHO, 2009). ⁶

As such, we can answer the questions raised above. Yes, the pandemic is capable of affecting state and interstate life. Whether its impact is superficial or deep, short term or long term, will depend on the specific circumstances it generates in a particular historical era. The pandemic may or may not generate structural long-term changes to the nature and behavior of states and the international system.

Historical plagues and pandemics with effects on state and interstate systems

The theory and the model here proposed have taken into consideration the following 10 pandemics:

The Pericles plague (432–430), perhaps typhus exanthematicus, originated in Asia. According to Diodorus Siculus, Athens lost one-third of its inhabitants, including Pericles and his family.

The lessons of pandemics in terms of state and interstate systems

Thucydides wrote that Sparta could win the war against Athens (431–404 BC) thanks to the so-called pandemic of Pericles. In his History of the Peloponnesian War, historians will note the effects on the war of the pandemic he described. The endless decline of Athens had begun, setting the conditions for the long-term transplant of Athenian civilization to Rome, with enormous consequences for Rome's culture and society. Horace commented (Horace: Epistles, Liber II, I, 157) “Graecia capta ferum victorem cepit,” adding that the agricultural Lazio region received the arts (“et artes intulit agresti Latio”) from the defeated Greece. ¹²

The power of Rome was strongly influenced by Greek philosophy, with Hellenism becoming an intimate part of Rome's history. Marcus Antonius's model of the “republic” came from Greek culture. The strategic orientations given to the empire by Adrian and Marcus Aurelius (who died of plague in Vindobona, presently Vienna, in 180) paid an important tribute to Greek culture. At a certain moment in its history, Rome proceeded to organize itself into two governing bodies: the Oriental in Nicomedia ¹³ and then the Constantinian dream that became reality on the shores of the Bosporus, with the enlargement and renewal of Byzantium, which started in 324. When Constantinople was inaugurated, in 330, there were two capitals governing, respectively the “pars orientalis” and the “pars occidentalis” of the historic heritage of Rome. In 395, at the death of Theodosius I, the Roman Oriental Empire took shape and quickly became “Byzantine.” At the same time, Rome and Western Empire approached their decline.

The Byzantine plague had enormous consequences and many historians will refer to it as the door to the Middle Ages. It certainly shook the economy and the demographic equilibrium of the Euro-Mediterranean region. The economic system was already suffering from the contextual effects of the decline of the Roman Empire and the division of the responsibilities involved in keeping the region in order between Milan and Constantinople. Thus, the repetitive waves of the plague met an already fraught situation produced by the divisive behavior of the rival leaders in both “partes” of the Roman empire. The consequences were tragic (Ward-Perkins, 2020: 162–163):

Lo smembramento dello Stato romano, e la fine di secoli di sicurezza furono i fattori fondamentali nella distruzione dell’economia evoluta dei tempi antichi; ma c’erano anche altri problemi, che svolgevano un ruolo secondario. Nel 541, ad esempio, la peste bubbonica raggiunse il Mediterraneo dall’Egitto, diffondendosi inesorabilmente in tutto l’antico mondo romano e ricomparendo in parecchie occasioni nei decenni successivi. […] Non v’è possibile dubbio che questo continuo ripercorrere del morbo non fosse solo una tragedia personale per gli individui, ma anche un grave colpo sul piano demografico per la popolazione dell’impero.

The Black Death has probably been the most studied plague in history. Its immense devastation influenced politics, economics, and the arts, especially literature and paintings. The expressions “Danza macabra” and “Il trionfo della morte,” which define an entire cycle of medieval paintings, were coined in that environment.

The heavy toll paid in terms of deaths and disabilities in the Euro-Mediterranean area erased the conditions for Mediterranean power and, together with the opening of the route to the Americas in the following century, set the stage for the decline of the Mediterranean-bordering nations and the rise of the Northern Atlantic nations. Ward-Perkins (2020: 163) argues that the shift happened due to the pandemic coinciding with the already ruined economic situation in the above-mentioned region, and to back his position he submits the resistance to the plague experienced by the United Kingdom:

Le cause di forza maggiore tendono ad agire in ogni periodo storico, ma i loro effetti sono in genere durevoli solo quando un’economia è già in difficoltà. Le economie stabili sono in grado di superare crisi intermittenti, anche su vastissima scala, perché queste raramente investono le strutture sottostanti alla società. Ad esempio, noi sappiamo che la Morte Nera uccise, nell’Inghilterra del XIV secolo, da un terzo a metà della popolazione totale, cifra straordinariamente alta. Ma non distrusse le strutture della vita inglese, e quindi non dissestò gravemente l’economia dell’Inghilterra tardo medioevale.

Many durable effects resulted from the continuous waves of the plague: the few survivors occupied the empty houses and abandoned lands of the richest families, moved from the country to towns, and obtained better salaries and working conditions. It was not a smooth and easy process, as is documented by the version of the “Statute of Labourers” discussed by the English Parliament at the royal ordinance of Edward III on June 18, 1349, before the enactment of the Statute in 1351. Here is an illuminating quotation from the Preamble (Constitution Society, n.d.):

Against the malice of servants who were idle and unwilling to serve after the pestilence without taking outrageous wages it was recently ordained by our lord the king, with the assent of the prelates, nobles and others of his council, that such servants, both men, and women, should be obliged to serve in return for the salaries and wages which were customary (in those places where they ought to serve) during the twentieth year of the present king's reign (1346–7) or five or six years previously. (University of Missouri-St. Louis)

The claims of the peasants and artisans forced the king and the dominating establishment to accept a number of new demands. The manorial system was under attack, and the Crown, together with the Lords and the Church, expressed a cruel opposition to the demands of reform, being not yet aware that the plague had changed the weight of the forces in play. In the end, in Britain as elsewhere, the general result was a significant shift in internal politics and international relations, giving more flexibility to medieval societies’ tradition of corporate, fixed social and political life.

The change had an especially important impact on religious behaviors and consequently the people's relations with the Church. The sense of escape from “submission” and the loss of trust in any authority interfered with the traditional relations of Christians with their pastors and the Pope.

With that in mind, it could be said that what we are accustomed to calling “modernity” started with the effects of the Black Death, whose minor waves spread in Europe through the 17th century and in the Near East until the middle of the 19th century. Let 's not be astonished by the length of the historical processes linked to the pandemics as we recall that the transition of the Western Roman Empire to feudalism required at least two centuries and two plagues.

The Black Death also documented an aspect of traditional state behavior that is not acknowledged as often as it deserves to be: the cruelty and lack of respect for the life of the enemy. In accordance with the chronicles, the worst pandemic in history came to the West from the steps of the Orient, when the Golden Horde, led by Ganī Bek, besieged the Genoese colony of Caffa. The besiegers knew they were infected when they catapulted the corpses of plague victims beyond the walls of the town. The political and sanitary effects of this first instance of voluntary biological warfare were soon carried to the Sicilian town of Messina, thus generating the roots of the horrifying pandemic called the Black Plague.

A century passed, and another instance of biological warfare had tremendous political effects in Central America. The Conquista set the contagious conditions for the destruction of the autochtonous traditional leading class of kings, monks, religious leaders, scientists, and intellectuals, thereby lowering the defenses of indigenous cultures against the invaders. A series of cyclical pandemics was generated. The biological fragility and the absence of antibodies meant the populations of the Central American nations suffered a true genocide, although that fate may have been unwanted by the conquerors. The Antilles’ Arawak people were destroyed by smallpox in 1518. Then it was Mexico's turn. Other local nations followed. It took a century before antibodies were active in the region and started saving the lives of the natives. A historian affirmed that 95 percent of the indigenous population present in Central and South America at Columbus's landing (between 40 and 100 million people) were killed by imported diseases during the first 130 years of European colonization. Recent, more accurate estimations reduce to 13 million the number of Central American inhabitants at the time of European discovery of the region (Cervera, 2015). ¹⁴

A century later, from 1616 to 1619, in the northeastern region of the same continent, in the southern part of a territory to be named New England, a plague, spread by the first wave of European colonists, wiped out a larger number of the indigenous people there. According to a study from Matthew Patrick Rowley, an Honorary Visiting Fellow at the University of Leicester, more than 90 percent of the local American Indians died during the four years before the landing of the Pilgrims in November 1620 (Rowley, 2020). This tragedy was interpreted by the settlers and the authorities in London as a privilege and a gift made to the faithful Britons by God himself, as confirmed by the following quotation, from the 1620 Charter of New England, given by King James I:

And also for that We have been further given certainly to knowe, that within these late Yeares there hath by God's Visitation reigned a wonderfull Plague, together with many horrible Slaugthers, and Murthers, committed amoungst the Sauages and brutish People there, heertofore inhabiting, in a Manner to the utter Destruction, Deuastacion, and Depopulacion of that whole Territorye, so that there is not left for many Leagues together in a Manner, any that doe claime or challenge any Kind of Interests therein, nor any other Superiour Lord or Souveraigne to make Claime “hereunto, whereby We in our Judgment are persuaded and satisfied that the appointed Time is come in which Almighty God in his great Goodness and Bountie towards Us and our People, hath thought fitt and determined, that those large and goodly Territoryes, deserted as it were by their naturall Inhabitants, should be possessed and enjoyed by such of our Subjects and People as heertofore have and hereafter shall by his Mercie and Favour, and by his Powerfull Arme, be directed and conducted thither. (Yale Law School, n.d.)

In 1633, smallpox erupted and heavily impacted the native populations of New England, further increasing the negative effects of their presence on outbreaks in NA.

During the first half of the 16th century, in the opposite hemisphere, another pandemic, syphilis, was producing its own effects on certain states’ international affairs. The fact that the disease had come to Italy by way of French soldiers armed many Italian communities and their political leaders against the French Emperor, alienating the original consensus they had expressed for Charles VIII's Italian campaign. Syphilis influenced certain private behaviors of troops and conquerors, especially when it became known that Francis I, French Emperor from 1515 to 1547, died of the disease.

The Third Plague mostly spread within the British Empire, from the Himalayan boundaries of India to the immense territory where the Union Jack flew. From there it attacked the health of other nations. In China imperialist, colonialist interventionism along the southern coasts, together with the Opium War and the Boxer Rebellion, gave an important example of how pandemics may influence state and interstate political developments. In India the populace and the nationalistic press fought the repressive measures of social containment fixed by the British authorities, and in 1897 the Indian Civil Services officer in charge of the Special Plague Committee and his military escort were killed by a terrorist attack.

The developments of the new pandemic at the turn of the late 19th century and the early 20th century made manifest the conflict between science and politics. The plague coincided with numerous medical and scientific discoveries and the enhancement of biological laboratories. Because those new technologies were mostly in the hands of the youngest sectors of the medical establishment, the situation also produced a true generational conflict. There is an especially interesting aspect in that conflict, made evident by the following quotation (Echenberg, 2002: 434):

they (the youngest doctors, n.o.a) had both the capacity and the obligation to intervene globally to combat infectious diseases. On the other were municipal, state, national, and imperial decision makers who found themselves weighing medical risks against overriding political and sometimes even ideological imperatives.

In order to strengthen their standpoint, populist politicians agitated the discontented to turn against the doctors and scientists. In doing so, they reiterated a phenomenon described by Thucydides, wherein some infected Athenians came to distrust their doctors and returned to magicians and witches instead. An echo of this age-old conflict between the scientific community and state policy can be found in present times, as well, as in an editorial published on October 8, 2020 by the New England Journal of Medicine (2020):

This crisis has produced a test of leadership. […] Here in the United States, our leaders have failed that test. They have taken a crisis and turned it into a tragedy. The magnitude of this failure is astonishing. […] In general, not only have many democracies done better than the United States, but they have also outperformed us by orders of magnitude. […] And the Food and Drug Administration has been shamefully politicized, appearing to respond to pressure from the administration rather than scientific evidence. […] Instead of relying on expertise, the administration has turned to uninformed “opinion leaders” and charlatans who obscure the truth and facilitate the promulgation of outright lies.

At the end of the second decade of the 21st century, as at the beginning of the 20th, the scientific community requested that state and interstate political systems respect the contributions science makes to solving pandemics. It also demanded that the “truth” established by scientific research must be accepted as such, without any interference from the bickering and incompetence of states’ politics. The editorial is sharp on that matter:

But truth is neither liberal nor conservative. When it comes to the largest public health crisis of our time, our current political leaders have demonstrated that they are dangerously incompetent. We should not abet them enabling the deaths of thousands more Americans.

During the Third Plague's years, another element of internal and international states’ dynamics was the conflict between the different levels of power. That dynamic, too, has been reiterated in the behaviors of the authorities during the Covid-19 pandemic. At the beginning of the 19th century, the “new” approach to pandemics expressed by modernity affirmed that no pandemic could be overwhelmed by a parochial medical or governmental approach. When an epidemic becomes a pandemic, a “pan-” approach is needed, overruling the traditional local, regional, or national public health systems.

That position remained isolated, however, given that pandemics tend to fuel periods of conflict between the lower and higher levels of political organizations and among the different components of society. During the Third Plague, it has been pointed out, the British Empire suffered an increase of nationalism in its colonies, but it also had to cope with growing prejudices and anti-Asian mobs around the world that were replicating what the Middle Ages pandemic had spurred against the Jewish population. The two fires (1886 and 1900) in the Chinatown of Honolulu are good examples of the social hatred that pandemics may fuel. In Brazil, the pandemic coincided with the implementation of the national public health system, while in South Africa it coincided with the imposition of apartheid. According to Echenberg (2002: 434):

All things considered, the third pandemic was of considerable historical importance in its own right. As will be seen, its impact was a significant episode in the rise of nationalism in India, the Great Fire in Honolulu, the persistence of anti-Asian prejudice in the United States and Australia, the rise of apartheid in South Africa, and the growth of public health services in Brazil.

As far as political effects on state and interstate systems, the cholera outbreak in the 19th century provoked unrest and popular revolts in Europe and North America. That cholera pandemic is credited by historians with playing an important role in the disintegration of the European dynastic empires. The waves of the infection coincided with a series of institutional national building processes taking place in Greece in 1829; in Italy, Germany, Poland, and Belgium in 1848; and in Hungary in 1849.

The most evident interaction between states’ behavior and outbreaks has probably been provided by the Spanish flu. A 2018 study on this influenza by Daniel B Jernigan, the director of the Influenza Division at the US Centers for Disease Control and Prevention (CDC), illustrated that states were politically and technically responsible for generating the eruption of that pandemic. Taking into account the coincidence of the outbreak with the First World War's final phase, the agency enlists the following factors as the reasons why the pandemic developed. All of them are consequences of avoidable wrong behaviors on the part of the public administration:

A. Crowding of people as a super-spreading mechanism of disease transmission:

urban overcrowding was heightened by the accentuated industrialization needed to support national war machines;

It is well known that the results of the First World War had a negative influence on the development of European countries, with the rise of fascism and Nazism among the worst such effects. Widespread resentment and the socioeconomic crisis circulating through the old continent were only reinforced by the Spanish flu. The effects of the pandemic mixed with those of the Great War and produced rising discontent among the European population.

A model for state and interstate systems

The examination of historical pandemics has shown elements of both similitude and differentiation.

A sociological and politological exercise on Covid-19’s immediate effects

In July 2021, the vaccination campaigns were producing the expected results and the deadly curve of Covid-19 was not rising as fast as before, and even going down where large numbers of people had been vaccinated. This was an enormous achievement of the science and technology of our times. The economic effects of the outbreak were contained in 2020 and appeared less relevant in 2021. Global GDP contraction in 2020 was estimated at −3.5 percent. The global GDP growth was expected to be 9.5 percent that year, spreading hope and a sense of relief.

At the same time, negative developments were noted:

SARS-CoV-2 was developing variants capable of resisting the vaccines currently in use. On July 15, 2021, the statement on the eighth meeting of the International Health Regulations (2005) Emergency Committee regarding the coronavirus disease (Covid-19) pandemic affirmed:The Committee noted that, despite national, regional, and global efforts, the pandemic is nowhere near finished. The pandemic continues to evolve with four variants of concern dominating global epidemiology. The Committee recognized the strong likelihood for the emergence and global spread of new and possibly more dangerous variants of concern that may be even more challenging to control. (WHO, 2021)

In that very period, the statistical information on the pandemic considerations, in sociological and political terms. The following tables organize three groups of data dating back to the end of June 2021: a balance of the pandemic in terms of its extent and casualties, a representation of how the vaccination campaign was performing, and forecasts on the expected developments of the situation.

The balance of the pandemic appears in Table 1, which includes the most significant countries in terms of cases and deaths, both in absolute numbers and per million. Numbers in bold are the highest number in the column, while italics indicate the lowest.

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Table 1.

Covid-19 dashboard as of June 30, 2021.

Country	Total cases	Cases / million people	Recoveries	Deaths	Vaccine doses	Deaths/million people	Active	Vaccine doses / million people
USA	34,580,198	103,862	29,072,881	621,161	328,809,470	1866	4,886,156	980,000
Brazil	18,687,469	87,296	16,989,351	522,068	102,780,096	2439	1,176,050	480,000
India	30,514,190	21,896	29,610,909	401,218	335,671,794	288	502,063	240,000
Mexico	2,531,229	9760	2,007,339	233,425	46,451,716	5558	290,465	362,621
UK	4,855,169	71,145	4,329,769	128,189	78,254,768	1878	397,211	1,150,000
Italy	4,262,511	70,603	4,089,298	127,637	52,682,992	2114	45,576	870,000
France	5,580,648	88,365	5,626,675	111,135	54,483,343	1699	42,838	800,000
Peru	1,867,442	61,631	-	192,902	7,594,782	5770	39,156	230,000
Spain	3,833,869	81,968	150,376	80,911	42,792,983	1730	146,168	910,000
Iran	3,241,037	38,100	2,914,830	84,627	5,717,914	995	241,580	60,000
Colombia	4,297,302	83,564	3,993,651	107,723	18,578,199	2095	195,928	360,000
Russia	5,561,360	38,260	5,053,417	137,262	41,821,794	940	395,120	280,000
Belgium	1,086,508	93,342	1,036,831	25,185	11,060,661	2164	24,492	950,000
Germany	3,737,826	44,470	3,627,800	91,576	75,781,404	1090	18,450	900,000
Canada	1,416,317	37,200	1,383,644	26,338	38,417,799	692	6335	1,010,000
China	91,833	64	86,766	4636	1,283,175,000	3	431	890,000
Israel	842,371	90,325	833,727	6429	10,799,605	689	2215	1,240,000
World	183,958,871	23,384	168,367,730	3,982,217	2,950,104,812	506	11,608,924	374,854

Source: Author's processing from Covid Visualizer and WHO official websites. Accessed on July 2, 2021. Reviewed in January 2025.

The United States led the column in four negative outcomes: total cases, cases per million, deaths, and active confirmed cases. In respect to the global data (found in the last row of Table 1), the above four numbers suggest the following: at the beginning of July 2021, the United States incurred 18.8 percent of worldwide cases, had about 3.69 times more deaths per million people, and was home to 42.1 percent of the infected population.

China received a bold number in one column (the highest absolute number of vaccines) and italics in six: the minimum number of cases (91,833), cases per million people (64), recoveries (86,766 equivalent to 94.5 percent of Chinese cases; [the same value for the United States was 84 percent, which was lower than Italy (96%), Israel (99%), Brazil (90.1%), and Canada (97.7%)], deaths (4636), and active cases (431).

Here the regional and global data permit an easy blueprint to understand how situations evolved during the more virulent period of the outbreak. Table 2 indicates that, in terms of cases and deaths, the pandemic particularly affected the European and Northern American regions. Though they contain less than a quarter of the world's population, at the date the two regions experienced 72 percent of global cases and 78 percent of deaths. The fact that the percentage of deaths was higher than that of infected individuals was an additional element of concern for Americans and Europeans.

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Table 2.

Covid-19 by region: Confirmed cases from June 2020 to June 2021, deaths in June 2021.

Region	30 June 2020	30 September 2020	30 June 2021
Americas
cases confirmed	4,749,9272,817,212 (1 June 2020)	15,942,421	74,700,288
Deaths			1,920,764
Europe
cases confirmed	2,659,7532,142,547 (1 June 2020)	5,410,422	54,283,978
Deaths			1,184,608
South-East Asia
cases confirmed	684,192272,512 (1 June 2020)	6,522,394	35,757,910
Deaths			506,006
Eastern Mediterranean
cases confirmed	997,534520,137 (1 June 2020)	2,335,565	11,412,816
Deaths			217,064
Africa
cases confirmed	258,752104,242 (1 June 2020)	1,186,895	4,202,610
Deaths			101,741
Western Pacific
cases confirmed	218,315183,198 (1 June 2020)	621,666	3,601,269
Deaths			52,034
T O T A Lcases confirmeddeaths	9,568,4736,039,848 (1 June 2020)	32,019,363	178,779,3473,982,217

Source: Author's processing from the official WHO website. Accessed in June and September 2020 and July 2021. Reviewed in January 2025.

It also has to be noted that the pandemic surged once more in the late spring and early summer of 2020, with effects that lasted for a long period. In Table 2, the relationship between the numbers on June 1 and the numbers on June 30 in the second column highlights that total confirmed cases of Covid-19 increased by a third in the month of June 2020.

A number of political effects from the virus

At the beginning of the third quarter of 2021, the pandemic had killed more than 4 million people worldwide and affected about 200 million people, i.e. 23.5 of every thousand people on the planet.

Compared to the most virulent pandemics experienced in the post-war period, Covid-19 showed a higher lethality, notwithstanding the relevant scientific and technological progress. The Asian flu (subtype H2N2) was active between 1957 and 1958, and its death toll is generally considered to have been 2 million (though estimations go up to 4 million). In 1968 the Hong Kong flu (subtype H3N2) claimed another 2 million lives (with estimations calculated between 1 and 4 million). That said, with respect to the 1950s and 1960s, the global population had increased (it was about 3 billion in 1957, and slightly more than 3.5 billion in 1968), and this shift has to be taken into account when comparisons with the past are proposed.

Communication flows and people's movements offer the first of such factors worthy of attention. Immediately after the outbreak, governments and other authorities in many countries set limits to domestic and international circulation for established periods and continuously checked and reviewed these limits. The total figures of contagion and deaths suggest that communications ought to be governed, that more limits to movement ought to be imposed.

The countries where limitations to the movement of people, social distancing, and strict travel restrictions were enforced appeared affected less by the virus in terms of stress to their health systems, suffering, and deaths. Those countries included (through July 12, 2021) Iceland, New Zealand, Palau, Singapore, Australia, and China. With the exception of Iceland, all of these were located in the Pacific Ocean: Palau, an island of 18,000 people, recorded zero cases.

A higher number of positive cases and deaths can be linked to the opposite rules and behaviors, particularly when it comes to Europe and the Americas. A significant example was given by people's participation in two coincident football championships on two continents: the UEFA European Football championship (June 11 to July 11, 2021), and Copa América (June 13 to July 11, 2021). The matches took place in the presence of the public, and authorities did not restrict mass celebrations of victories in Italy and Argentina.

In this regard, the spread of the pandemic in Sardinia between summer 2020 and summer 2021 appears to be of great interest. In 2020, at the beginning of the tourist season, the island was practically Covid-19-free. At the end of that season, it was instead highly contaminated and itself an agent of contamination to the territories where summer visitors and tourists were returning. Only an intense vaccination campaign during spring 2021 made it possible, after an entire year of increasing total cases, active cases, and deaths, for Sardinia to hope to be, once again, Covid-19-free. Table 3 illustrates the contagion curve in Sardinia from June 2020 to June 2021.

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Table 3.

Covid-19 in Sardinia: Total cases, deaths, and active cases, June 2020–2021.

2020–2021	Cases	Deaths	Active
July 1 2020	1366	133	11
August 1	1410	134	39
August 15	1489	134	101
August 31	2193	134	789
September 15	2964	140	1457
September 30	3900	154	2061
October 15	5603	169	3024
October 30	9106	214	5821
November 15	15,183	322	10,220
November 30	21,475	444	13,528
December 15	26,737	600	15,384
December 31	31,113	747	16,453
February 15 2021	40,263	1072	13,495
March 15	42,553	1197	12,835
April 15	50,524	1302	17,642
May 15	56,099	1433	14,459
June 15	57,061	1484	11,867
June 30	57,236	1491	2322

Source: Author's processing from https://statistichecoronavirus.it/coronavirus-italia/coronavirus-sardegna/. Accessed 11 July 2021.

The case of Sardinia, along with other similar cases, taught us how far the effects of a lack of hygienic and sanitary restraints may go and how the absence of social solidarity and discipline in certain segments of the population may produce contagion and deaths for all.

In this respect, the behavior of those who refused vaccines and/or social distancing merits attention. These people considered the rules the pandemic imposed upon our societies a limit to their individual freedom and acted accordingly.

Russia may be taken as an example of how such behavior caused the pandemic curve to grow. The country was at the same time one of the best performing in terms of vaccine production and one of the worst in distributing the vaccine and inoculating its populace with it. The Sputnik V vaccine was the world's first registered combination vector vaccine for the prevention of Covid-19, appearing in August 2020; one year later, however, Russia had a very low percentage of vaccinated people and was thus manifesting a new rising wave of confirmed cases and deaths. Apparently, the Russian people distrusted the vaccine or governmental pressure to be inoculated, or perhaps both, given the strict link between the vaccine and the government. As of July 15, 2021, only 15 percent of the population had been fully vaccinated.

With a population of about 144 million, at the end of June Russia had injected 41,821,794 vaccine doses (see Table 1), fewer than Germany (83,320,000 inhabitants), France (67,060,000), the United Kingdom (66,750,000), Italy (60,360,000), and Spain (46,990,000). Only 13 percent of Russians had completed the vaccination process by that point. According to a Levada Center poll conducted in April 2021, an astonishing 62 percent of the population declared that they would refuse the vaccine, and 56 percent claimed not to be afraid of being infected by the virus. In May, Vladimir Putin recommended the vaccine to the population with his delicate, persuasive style: “It is just as reliable as Kalashnikov assault rifles” (Mirovalev, 2021). But he wasn’t convincing. As a result, though the Covid-19 situation had been stable in the spring, on July 11 official Russian sources announced 25,033 new cases in a day (25,082 on July 10 and 25,766 the day before) and 749 deaths. On June 4, the last day before the surge in infections, new cases reached only 8947 (Moscow Times, 2021). One of the paradoxes in the Russian situation was that the country had been one of the best performing in exporting its Sputnik vaccine, wrongly calculating its own vaccine needs.

Accordingly, certain responsibilities fall on governments and the international organizations they set up. Certain governments were strict in applying the rules of social distancing and other recommendations coming from the WHO, while others were lax and even militantly against these regulations. Governmental policies affected public health and consequently had political consequences. Many have affirmed that Trump's removal from the White House in 2021 was an effect of the President's mismanagement of Covid-19. ¹⁸

Former President Donald Trump has blamed his election loss on baseless claims of voter fraud, but a report by a Republican pollster found that he mostly lost due to his handling of the coronavirus pandemic. The December 2020 report by Trump campaign pollster Tony Fabrizi studied voters in 10 states and found that they ranked the Covid-19 pandemic as the top issue. President Joe Biden won those votes by a roughly 3-to-1 margin, while most voters disapproved of Trump's response to the pandemic. The report was distributed to Trump's advisers ahead of Biden's inauguration on Jan. 20, Politico reported. (Lin, 2021)

In Europe, Covid-19 strengthened the EU institutions that were de facto coordinating the actions member states had taken to combat the virus, including the vaccination campaign. The EU's handling of the coronavirus response was not completely positive, though. In particular, an important lag in providing expected vaccine doses to member countries occurred, in contrast with the actions of the United States and the United Kingdom. Paul Krugman analyzed the reasons for this partial failure of the EU in March 2021:

Britain and the U.S. have administered around three times as many doses as France or Germany. And the EU countries are still lagging, administering vaccines less than half as rapidly as we are. Europe's vaccination debacle will almost surely end up causing thousands of unnecessary deaths. And the thing is, the continent's policy bungles don’t look like isolated instances, a few bad decisions made by a few bad leaders. Instead, the failures seem to reflect fundamental flaws in the continent's institutions and attitudes—including the same bureaucratic and intellectual rigidity that made the eurocrisis a decade ago far worse than its should have been. (Krugman, 2021)

However, for the first time in its history, the EU was able to cope autonomously (through a decision of the European Council on July 21, 2020) with the economic and financial crisis that erupted as a result of the pandemic. The EU did so by inflating the European economic system with a €750 billion “Next Generation EU” package that utilized the EU's own bonds. The package included a €672.5 billion “Recovery and Resilience Facility,” which consisted of loans of €360 billion and grants of €312.5 billion.

A Pew Research Center survey from June 2021, utilizing polls from 17 advanced economies, described how perception of the EU had changed during the Covid-19 pandemic. Eight among the polled nations are EU members. These eight expressed a median 65 percent “favorable view of the EU”: the highest score came from Sweden (74%) and the lowest from Greece (49%). The most interesting “favorable view” from non-EU members came from South Korea (78%) and Canada (73%), while the US score was 62 percent.

A median 56 percent said that the EU “has done a good job dealing with the coronavirus outbreak”: the highest score was Sweden (70%), the lowest Germany (43%). Pew commented that “the sense that the EU has handled the pandemic well is related to positive assessment of the EU in every public surveyed.” In France, 83 percent of those who viewed the EU's handling of the outbreak positively also had a favorable view of the EU.

The Pew data allow us to understand how opinions of the EU shifted during the pandemic. Table 4 shows the progress of favorable views from 2019 to 2021 (Fetterolf and Kent, 2021). Only two out of seven EU member countries expressed a less favorable view of the EU in 2021 with respect to 2019, the last year before Covid-19 began to spread.

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Table 4.

Favorable views of the EU 2019–2021 (% of the population).

Countries	2019	2020	2021	2021 on 2020 Diff. + -
Italy	58	58	67	9
Sweden	72	66	74	8
Spain	66	68	72	4
Netherlands	66	66	70	4
France	51	61	61	–
Belgium	–	63	57	−6
Germany	69	73	63	−10
Canada	69	71	73	2
United States	–	60	62	2
United Kingdom	54	60	53	−7

Source: Author's processing from Fetterolf and Kent, Pew Research Center, June 2021.

In many EU countries, a harsh debate erupted as to whether the measures taken by governments to combat the insurgence of the pandemic were violating individual constitutional rights such as freedom of movement. A similar debate arose when the vaccination campaign took place: the question touched on the right of doctors and hospital personnel to refuse vaccination. On July 14, 2021, the Spanish Constitutional Court ruled 6 to 5 that the rigorous home confinement included in a national state of emergency to lower the first wave of Covid-19 infections in 2020 was unconstitutional. The court's decision was provided in response to a petition filed by far-right party Vox and defined the measures as too taxing, as having demanded the suspension, rather than the limitation, of civil liberties.

Thanks to its management of the Covid-19 crisis, the Chinese system raised its internal and external standards. The Chinese public had badly reacted to the Communist Party's handling of the first episode of Sars in 2002 and 2003. Protests and incidents involving Chinese citizens and local authorities revealed the people's dissatisfaction regarding how the administration dealt with the syndrome, including the lack of information that characterized the first phase of the infection. Yanzhong Huang recalls what was at the stake in those days:

In November 2002, a form of atypical pneumonia called severe acute respiratory syndrome (SARS) began spreading rapidly around the world, prompting the World Health Organization (WHO) to declare the ailment “a worldwide health threat.” At the epicenter of the outbreak was China, where the outbreak of SARS infected more than 5300 people and killed 349 nationwide. […] The SARS epidemic was not simply a public health problem. Indeed, it caused the most severe socio-political crisis for the Chinese leadership since the 1989 Tiananmen crackdown. Outbreak of the disease fueled fears among economists that China's economy was headed for a serious downturn. A fatal period of hesitation regarding information-sharing and action spawned anxiety, panic, and rumor-mongering across the country and undermined the government's efforts to create a milder image of itself in the international arena. […] In the weeks that followed, the Chinese government launched a crusade against SARS, effectively bringing the disease under control in late June and eliminating all known cases by mid-August. (Huang, 2004)

Nothing comparable happened when SARS resurfaced in the last two months of 2019 and the beginning of 2020. Over the previous 15-year period, China had built up true sanitary diplomacy, taking advantage of the WHO to promote a system of global sanitary relations, spreading from China primarily to developing countries. Until 2011, China had been one of the major recipients of international aid. Conversely, from 2013 on, it became one of the major donors, and it specialized in sanitary aid: Africa and Latin America were the privileged regions of that policy. Between 2015 and 2017 the transformation was completed, as China was guaranteed a special position in the WHO, widely interpreted as the nation's door to access a credible authority: the UN system.

When Sars-CoV-2 appeared in Wuhan, Xi Jinping's response took advantage of the instruments underlying his power: both doctrine and technology. Unlike in 2002, the Communist Party overcame the challenge. Chinese civil society followed its strict directives, and the spread of the virus was promptly contained. Recalling how Covid-19 spread through China will make the Party's effectiveness evident.

Given the testimony of Wuhan ophthalmologist Li Wenliang, ¹⁹ we know for certain that Sars-CoV-2 was in Wuhan at the end of December 2019. Beijing was informed of the outbreak on December 27. The WHO was notified on December 31. On January 7 the virus was identified, and it was sequenced on January 12. On January 20, the Chinese government confirmed person-to-person transmission of the new coronavirus to the WHO. Three days later, a first group of 400 people was isolated. On February 4 the upward curve of the contagion in China came to a first, decisive halt. By the middle of April, the infection had been contained, as the figures in Table 5 document.

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Table 5.

China, Covid-19 dashboard 2020–2021.

2020	Cases	Deaths	Day cases	Active
04/13	82,160	3341	108	1156
04/16	82,692	4632	351	116
04/18	82,719	4632	27	1058
06/26	83,562	4634	13	389
11/14	85,307	4634	10	168
2021
06/30	91,833	4636	-	431

Source: Processing of the author from Covid Visualizer, Johns Hopkins University, WHO.

At the same time, the behaviors of both Chinese culture at large and the communist internal power system were locked, as in 2002, in secrecy and a lack of transparency. ²⁰ Moreover, the local party in Wuhan appeared not to trust the central power in Beijing or it feared not being trusted by it, which would have the same effect. The outcome was an unforgivable delay characterizing the first weeks of the Covid-19 pandemic in China. Chinese scientists sequenced Sars-CoV-2 on January 12, but they officially informed the WHO only on January 20 and isolated the first 400 people only on January 23.

It is interesting to look (see Table 6) at a comparison of the situation in a number of countries, based on the date on which the first case of infection was detected, total cases, and deaths on April 11, 2020, immediately before the events described in Table 5 began to take place in China.

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Table 6.

Selected countries, Covid-19: Evolution from first case to April 11, 2020 at 8:30 p.m. EDT

Countries	1st case	April 11, 2020
		Cases	Deaths
China	31 December, 2019	83,014	3343
USA	23 January, 2020	526,396	20,463
France	24 January, 2020	130,727	13,851
Germany	27 January, 2020	124,908	2736
Netherlands	27 January, 2020	24,571	2653
Italy	31 January, 2020	152,271	19,468
United Kingdom	31 January, 2020	79,874	9892
Spain	1 February, 2020	163,027	16,606
Belgium	4 February, 2020	28,018	3346
Iran	19 February, 2020	70,029	4357

Source: Processing of the author from Covid Visualizer.

In fact, comparing the situation as it appeared in key countries on various dates gives further evidence of the different results that different national strategies produced (see Table 7).

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Table 7.

Covid-19 dashboard 2020–2021, selected countries.

	13 April, 2020	16 April, 2020	18 April, 2020	26 June, 2020	14 November, 2020	30 June, 2021
USA
Cases	577,332	674,829	736,790	2,511,784	11,124,894	34,580,198
Deaths	23,077	34,475	38,920	126,911	250,445	621,161
Day cases	17,032	26,826	27,055	7196	60,432	18,442
Active	520,348	583,098	630,432	1,332,344	4,072,126	4,886,156
Canada
Cases	25,548	29,925	34,813	102,622	290,353	1,416,317
Deaths	767	1191	1583	8504	10,873	26,338
Day cases	1165	1546	1430	441	3035	931
Active	17,122	19,063	21,423	28,693	48,830	6335
Italy
Cases	159,516	168,941	175,925	239,961	1,144,552	4,262,511
Deaths	20,416	22,170	23,227	34,708	44,683	127,637
Day cases	3153	3786	3491	255	37,255	677
Active	103,616	106,607	107,771	17,638	688,435	45,576
Germany
Cases	127,916	135,663	144,387	194,013	781,423	3,737,826
Deaths	3022	3867	4547	9012	12,561	91,576
Day cases	1260	910	663	228	6601	3852
Active	60,594	54,796	51,840	7901	275,662	24,492
UK
Cases	88,261	103,093	120,067	307,980	1,344,356	4,855,169
Deaths	11,329	13,729	16,060	43,230	51,766	128,189
Day cases	4342	4617	5850	1205	26,860	20,223
Active	76,948	89,020	103,663	263,970	1,291,810	397,211
India
Dases	9635	12,759	17,615	506,972	8,810,400	30,514,190
Deaths	383	423	566	15,662	129,618	401,218
Day cases	430	389	1250	15,802	37,157	45,951
Active	8208	10,882	14,290	196,322	480,838	502,063

Source: Processing of the author from Covid Visualizer and the WHO.

With the limit underlined in note 18, upon observation, China appeared to be the best performer of the group, especially when one takes into the account the fact that it was probably the first country to suffer the outbreak and that the health system in the agricultural Chinese provinces is rather backward.

Moreover, through a technique of international relations that Joseph Nye (2018) would classify under the formula of “sharp power,” ²¹ China was able to exploit certain circumstances to raise its credit in the international arena, particularly in a number of developing countries where Chinese sanitary diplomacy had been active for years. It moved important quantities of materials and equipment and sent ²² its vaccines to countries ²³ unable to cope with the prices requested by producers using more advanced techniques such as mRNA. Even though sources (Doucleff, 2022) affirmed that the vaccine was less effective (50.4% according to a Brazilian report, 67% according to a Chilean report, and 79 percent according to Chinese sources) than the others, it did not need excessively low temperatures to be preserved and it was easier to transport and inoculate. Local production plants were easy to set up.

In the middle of July 2021, the trend of indicators related to Covid-19 was increasing in Africa. Every three weeks, the number of cases was doubling. As a consequence, the numbers of new deaths, cumulative deaths, recoveries, and active cases were also growing. The onset of the third wave began on May 3; it was more aggressive than those before it, pushing African active cases, at least for the time being, up to about 450,000, according to the WHO. July 2021 appeared to be the most aggressive month of Covid-19 in Africa, as the peak of the second wave, which occurred at the start of 2021, was largely exceeded by the new figures in July. Africa contributed more than any other region to the increasing number of new global cases and deaths, and new African deaths were increasing beyond expectations (WHO Africa, 2021).

Governmental decisions and measures influenced the growth of the pandemic in a number of African countries. A weak reaction to public health rules and the restarting of social interaction, together with the rise of the Delta variants in 14 countries, motivated the upsurge of infection. A lack of vaccines and minimal vaccination rates are also at the root of the problem. By the middle of July, only about 2 percent of the African population had been fully vaccinated.

These conditions inevitably produced consequences within the African political sphere. Overly repressive measures imposed by some governments in reaction to 2020's first wave caused social discontent and protests, endangering the future of a number of leaders. Besides the short-term impacts in various African nations, the pandemic's effects stimulated long-term socioeconomic and political challenges that were potentially dangerous for a continent characterized by conflicts and vulnerability.

The discourse on these national and regional situations provides the opportunity to say some more words on the WHO, the international organization dedicated to universal health. Contrary to previous surges of infections, the WHO documented limitations and incorrect behaviors. This is not up for discussion, whereas the reasons behind these wrongdoings must be explored, to ensure these mistakes are not replicated in the future.

A book on the WHO and Covid-19, published during the Covid-19 pandemic (Dentico and Missoni, 2021: 74) stated:

any judgment on its [the WHO's] behavior, has once more to take into the account first of all the conditioning historically imposed on the institution by those member states now pillorying it. We urgently need a universal sanitary diplomacy, one that is strong, capable, and autonomous, acting exclusively in the interest of global health and consequently denying any state from derailing the WHO from its statutory duties. Member states must establish and pay for the necessary financial tools, and the WHO must set up a system of adequate resources of its own. An interstate organization like the WHO, which is supposed to take care of the supreme good of mankind, also operates thanks to the support of private foundations and donors: the off-balance sheet and purpose funds cover more than 80% of its total expenditures. It is likely that these donors influence the policies of the international organization; it is certain that their representatives obtain seats in leading bodies of the WHO to orientate and influence its research and programs and establish its priorities.

No power should be able to blackmail the WHO, reducing its capability to cope promptly with the challenges of any disease. Yet, the United States challenged the autonomy of the WHO in 1985, when President Reagan suspended the nation's annual payment to the organization, and in 2020 and 2025 when President Trump decided to withdraw from the international organization altogether. President Trump's Executive Order of January 20, 2025, withdrawing the United States from the WHO (White House, 2025), ²⁴ looks totally inconsistent with the need to fight lethal viruses.

Macabre dance is forever part of humankind, and the powers dance it

The historical series of pandemics we dealt with highlighted that the period separating resurgences shortened each time. Eight centuries passed between the start of the Byzantine plague and the Black Death, and six between the end of the first and the eruption of the second. The Second and the Third Plague were four and a half centuries apart. About half a century after that came the start of the Spanish flu. The three most recent outbreaks – Asian flu (1957–1960), Hong Kong flu (1968), and Covid-19 (2019 on) – had intervals of decades.

A study (Eichel, 1922) found that, commencing with the influenza pandemic of 1510, spreading from the Southern Mediterranean to the Middle East and then to Europe, influenza epidemics and pandemics have occurred, on average, once every 19.8 years.

In the near future, additional acceleration of pandemic events and shorter intervals between their succession appear likely. This stance is confirming the analysis offered by French historian Emmanuel Le Roy Ladurie in relation to the “microbial unification of the world” (Le Roy Ladurie, 1973) taking place during the second Christian millennium. The globe, he wrote, has been set together by economy, trade, human exchanges, and the formation of urban civilization: human development is marked by exchanges and conviviality that favor the circulation of diseases, thus unifying the globe through microbes, viruses, vibrios, and bacteria.

The above process accelerated during the second part of the 19th century. Governments and capitalism stimulated the quantitative and qualitative circulation of the factors that produce the aforementioned “microbial unification.” In the last 70 years, for example, communication technologies’ development and spread, together with impressive and unprecedented industrial and economic growth, led the world to experience such a large number of unparalleled epidemiological changes that they eventually contributed to defining the contemporary era.

At the same time, the progress of medicine and science, together with increased global hygiene, universal sanitation, and the generalization of public health systems and healthcare, has radically diminished humanity's death toll in the face of deadly infections. That is evident in absolute numbers, when comparing the post-Second World War pandemics’ victims and those before. It is even more evident in relative terms. In 1918 the population was about 2 billion. The Spanish flu took between 20 million and 40 million, or 1 percent and 2 percent of the population respectively. Given the present global population of 7.7 billion, corresponding absolute numbers would be a terrifying 77 and 154 million, but Covid-19 was far from producing such figures.

On January 5, 2025, the WHO Covid-19 dashboard documented the following totals (WHO, 2025):

Cases 777,310,393

Vaccines (from the date of first Covid-19 vaccine product introduction, 22 July 2020):

Doses administered 13.64 bn

Virologists and epidemiologists have informed us that two structural elements came together to make Sars coronaviruses active in this specific era of human evolution: the general conditions of the global environment, particularly in terms of climate warming and aggression towards biodiversity, and the changing rules regarding proximity to and promiscuity between the human species and certain animals in the openly communicating global world. Climate change is also said to influence these plagues.

More than 10 years ago, David Quammen anticipated these events in his book Spillover (Quammen, 2012); those who read it were not surprised by what happened with Covid-19. A pathogen from one species moving into another is a normal process in nature. The question is whether the human element negatively influences that process, or even causes it, rerouting nature towards a process that wouldn’t have happened without human interference. Close contact between humans and animals, excess in production and consumption of meat from animals, and the intense growth of the global population are examples of factors leading to pandemics identified by the Quammen theory. In Quammen, if nothing fundamental changes with regard to human behaviors, the Next Big One is inevitable.

A radical change is needed in the way we conduct ourselves in the global community. At the same time we are aware of the impossibility of producing that fundamental change through the present fragmented international system. The states are not ready for the abandonment of the diplomacy rooted in their nationalistic arrogance, a prerequisite for opening themselves to cooperation and recognition of the common interest of each and all countries to a positive survival.

Life endurance and health should be the priority for any government and for the strategic goals of international relations. People-centered investment policies should prevent the loss of adults who are the engine of the economy, whether they are disabled prematurely by non-infectious diseases or promptly die from infectious diseases. Governments must adopt cost-effective policies for using healthcare resources, aiming to keep budget deficits under control, even though the high costs of prevention should be preferred to the higher costs of any mass infection.

The states already have at their disposal the instruments to carry out the needed policies: the WHO and the World Trade Organization. However, the states, namely the United States, provoked a lasting diminishing effectiveness of international health organizations, making them suffer from structural and financial constraints and a lack of qualified personnel for decades. One researcher (Kamradt-Scott, 2012) documented that in 1997, when the Hong Kong H5N1 outbreak occurred, the influenza division at the WHO had only one full-time staff member.

After decades of deliberately reducing the ability of both of these international organizations to cope with the challenges of the moment, the global powers should start cooperating to reinforce them, in terms of budget, competence, independence, and autonomy. This is precisely what world powers have disliked doing to date, and the actions of the present US administration are adding additional strength to this policy. It is worth recalling that the WHO was established in 1946 by nations wishing to avoid suffering from another pandemic like the Spanish flu that arose at the end of the First World War. In fact, one of the first tasks assigned to the Interim Commission of the WHO was a project to monitor and study the Spanish flu virus, the influenza virus A subtype H1N1.

In terms of preserving humanity from the effects of the present and future pandemics, immediate provisions have to be adopted to guarantee that the WHO can effectively coordinate and guide global sanitary affairs. Its choices and priorities have to be determined on a scientific and sanitary basis, independently from the influence of member states, especially those with more financial and political power. Coordination between the WHO and member states has to be enforced and ensured, and no room for propaganda or status building may be allowed among the various powers that participate in the international organization.

On average, nations spend 6.5 percent of their budget on healthcare. In coordinating their efforts with the WHO and assigning to the WHO whatever functions are more logically managed on a common basis, states will save national public money and rationalize global healthcare. In particular, the poorest countries’ health would benefit greatly from such an operational strategy. Let 's also keep in mind that, with the global population aging and the people affected by the pandemic in society increasing, health costs will increase exponentially, which will make it increasingly difficult to cope with health crises on a purely national basis.

The same applies to the policies needed to protect the environment and make more just our present social relations. As the UN affirmed, pandemics are one of the effects of environmental policies not taking into account the principles of sustainability and human development. Interstate cooperation should thus be inspired by the above principles, aiming to prevent the outbreak of infections and their subsequent development into pandemics.

In order to limit the risks, a new political behavior has to be developed, favoring the spread of a liberal open culture, including respect for nature, hygiene, and sociable interactions among nations, especially in fast-developing countries in Asia and Africa. Air pollution and greenhouse gas emissions should be reduced, especially in rapidly urbanizing low- and middle-income areas and countries, targeting carbon neutrality. Technologies may help to develop this model, especially in relation to transportation and urban planning, knowing that the priorities, for the time being, remain the care of the environment and reversing global warming. None of these are unconnected to the pandemics; on the contrary, tarnished environments and global warming contribute to setting the conditions for viruses and bacteria to become more aggressive.

Another factor to remember is the sanitary disequilibrium between rich and poor countries; in terms of global public health, producing a certain level of equity would be in the general interest of humanity, including in wealthier nations. We certainly need to invent a global sanitary system, but, alas, the current fossilized system of relations between states cannot foresee such an outcome.

The above model of state and interstate actions is the opposite of what the global powers, with the only partial exception of the EU, did and intend to do in the near future. There is no other choice but the immediate substitution of those policies if we wish to avoid the risk that the “microbial unification of the world” backfires on humankind, producing further pandemics with dreadful results. We cannot exclude the possibility that other catastrophic pandemics will attack humankind in the near future, disrupting nations or their governments, contributing to or even promoting extensive political crisis. After all, our list of historical pandemics showed that eight out of 10 pandemics caused state and interstate crises. We need an international crisis management effort to instigate a global response to a situation that risks endangering the world's future for decades.

In a discussion paper (WHO, 2009) on noncommunicable diseases (NCDs), the WHO analyzed thoughtfully the mistakes that governments and nations continue to share in fighting NCDs. Even though NCDs are external to the family of contagious diseases that generate pandemics, they nevertheless undermine the capability of patients to cope with pandemics. The document revealed that no specific investment in prevention and control of NCDs had been promoted, notwithstanding the fact that 60 percent of all deaths in the world (a yearly 38 million) were due to the four main NCDs (cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases) and 80 percent of these deaths happened in poor and middle-income countries. The projections of the document are of absolute relevance for any interstate fight against the risks of pandemics:

In the next two decades, low-income countries of today will be overwhelmed by strokes and heart attacks in middle-aged adults. In Africa, for example, 44% of people are below the age of 15 years. As these children and young people grow into adults in a few short years, they will carry with them the risks accumulated from a youth spent in increasingly unhealthy cities, adopting risky behaviours, and burdened by the metabolic legacy of under-nutrition in their childhood. In their middle age, they will become a sick generation, with early onset of diabetes, stroke, heart disease, cancer, and chronic respiratory disease. Their health systems will buckle and face bankruptcy. And the losses of human life will be more tragic because many of them are today preventable. The developed world, unless it responds to the epidemic of NCDs today, risks failing a considerable proportion of its intended beneficiaries. The world has undergone a health transition, and health systems and development agencies must quickly catch up. The epidemic of NCD is the product of failed development: of unhealthy urbanisation, of poor trade choices, of health systems that lock out those most in need of care. A fundamental economic and development choice is thus facing the world today.

With the above, the paper provided the sanitary policies needed for any government whose aim is to avoid enabling a pandemic to find the best conditions for becoming more aggressive. The document highlighted the diseases to be tackled and the associated costs to families, which are often so high that they ruin familial budgets:

The costs of NCD create a poverty trap: Studies by WHO in forty-two countries (including two in the WHO Eastern Mediterranean Region) have shown that 2%–3% of households face catastrophic health care expenditures and that 1%–2% are pushed into poverty when they become sick. For those in near-poverty, the catastrophic cost of NCD care leads households to impoverishment. Work in progress in South Asia suggests that for households with a male member with cardiovascular disease, approximately 25% experienced catastrophic spending on health (defined as spending 30% or more of annual household spending, less survival income for all household members); and one-tenth of the households that were above the poverty line at the beginning of the year slipped below. Using eight cross-sectional panel data from 1997 to 2004 from the Russian Federation Living Standards Measurement Study, NCDs were found to be significantly associated with higher levels of household healthcare expenditure in Russia and further analysis is indicating that this situation is worse in poorer households. In the design of Seguro Popular, the Popular Health Insurance scheme in Mexico, a burden of disease analysis found an “advanced transition” to NCDs in the poorer segments of the population and an “unmet demand [for NCD care which] has been serviced by the mostly unregulated private sector, with more than half of total spending on health paid out of pocket”. […] The NCD epidemic slows economic growth: There are many ways in which NCDs create a drag on economic growth, where deaths are more usually premature than in high-income countries. NCDs reduce incentives for savings (in the expectation of a shorter life). They reduce social capital (the death of a teacher or skilled labourer eliminates the investment in the development of their skills and forgoes the benefit of their future work to society). Carers of chronically ill patients lose the opportunity to earn wages. A number of efforts have been made to correlate the burden of NCD with the drag on growth rates with consistent results; applying these models to current realities, the most recent estimate suggests that a region such as Latin America will see an annual slowdown of around 2% from the projected rise in NCD until 2030.

The paper strategically comments on the effects on human health and disease trends of environmental mismanagement and increased global warming. Let 's note the specific link between these issues and respiratory disease, which, from the beginning, has been a preexisting matter in the medical treatment of Covid-19:

Another direct connection between NCD and sustainable development lies in the overlap between climate change and the burden of respiratory disease. Incomplete household combustion of coal and biomass in developing countries causes 1.5 million NCD deaths per year among women and children, mostly from respiratory diseases. This combustion is also a significant contributor to the global emissions of black carbon, which is the second most important greenhouse pollutant after carbon dioxide. Improved stoves are highly cost effective for both reducing greenhouse gas emissions and improving health. Transport and urban planning contribute significantly to the NCD burden – each year there are 800,000 deaths from outdoor air pollution and 1.9 million deaths from physical inactivity. Transport already contributes 13% of global greenhouse gas emissions and is expected to double between 1990 and 2020.

In the Book of Numbers, 11, the Bible narrates that, during the Exodus from Egypt, the Lord, tired of listening to Israelis lamenting that they were eating only manna, lacking the rich food they had had in Egypt, sent large numbers of quails to feed them. The vindictive God of the Bible gave them so many quails, indeed, that the birds became a plague, as many Israelis were poisoned by an excess of meat, given that ornithology teaches us that quails eat poisoned berries so as to become immune to any self-poisoning effect. The place where the victims have supposedly been buried is called Kibroth Hattaavah, or “graves of craving.” The episode highlights how bacteria and viruses are ambiguous and undetectable outside of medical laboratories.

When Moses intercedes with the Lord to feed his fellow Israelis meat, he is not acting as a good leader. In providing manna to his privileged nations, God chose the appropriate food for that circumstance, so, in interfering with God's menu, Moses obtains an immediate temporary success but sets the conditions for a killing plague. The tragic story of Numbers says that governments and their international gatherings may either protect their people or instead contribute to their infection. In certain situations, the Biblical text teaches us, the tougher states are, the better they meet the interests of their populations. The pandemic is probably one of those situations.

In the desert, during the Exodus, the Israelis had no public sanitary system to assist them with the conundrum in which they found themselves after greed led many of them to eat too much. The situation isolated the poisoned Israelis from others. In applying the Numbers episode to state and interstate systems, it is likely that public health inequalities, together with the lack of resources many countries will soon encounter, will make the pandemic a contributor to a wider divide between rich and poor at national and international levels. Poor people and poor nations will suffer more and may risk exploitation and hoaxes.

In the post-Covid-19 future, we may have to pretend that the quails falling from states to businesses and families, and from rich to poor nations, are not poisonous.