Intended for healthcare professionals


Covid-19: how a virus is turning the world upside down

BMJ 2020; 369 doi: (Published 03 April 2020) Cite this as: BMJ 2020;369:m1336

Read our latest coverage of the coronavirus outbreak

  1. Ilona Kickbusch, director1,
  2. Gabriel M Leung, dean of medicine2,
  3. Zulfiqar A Bhutta, co-director3,
  4. Malebona Precious Matsoso, director of health regulatory science platform4,
  5. Chikwe Ihekweazu, director general5,
  6. Kamran Abbasi, executive editor6
  1. 1Global Health Programme, Graduate Institute of International and Development Studies, Geneva, Switzerland
  2. 2Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
  3. 3Centre for Global Child Health, Hospital for Sick Children, Toronto, Canada
  4. 4Wits Health Consortium, University of Witwatersrand, Johannesburg, South Africa
  5. 5Nigeria Centre for Disease Control, Abuja, Nigeria
  6. 6The BMJ, London, UK
  1. Correspondence to: I Kickbusch kickbusch{at}

We may emerge from this with a healthier respect for our common humanity

The covid-19 pandemic is the biggest threat in living memory to health and wellbeing, social welfare, and the global economy. In a world shaped by neoliberalism the economy has always come first, but many leaders of rich countries are now explicitly prioritising people’s health over the economy. On 26 March, G20 leaders held an extraordinary summit on health, focusing on covid-19. In the face of the severe economic impact of necessary public health actions, financial rules that were considered sacrosanct are being bent with startling speed and force.

Germany’s chancellor, Angela Merkel, promised, “We will do what is necessary.” Germany has enough financial reserves and emergency instruments to release additional funds and maintain economic life.1 France is engaged in an economic and financial war, according to its finance minister: “This war will be long, it will be violent, and we must mobilise all our national, European, and G7 forces.”2 President Cyril Ramaphosa of South Africa believes that, “What we are witnessing is social solidarity in action, a defining feature of our nationhood.”3

Health before wealth

The global economy is braced for at least $2.7tn (£2tn; €2.5tn) in lost output, equivalent to the annual gross domestic product of the United Kingdom.4 Projections indicate that many economies will be crippled and unable to recover quickly, especially in the global South.5 The Organisation for Economic Cooperation and Development, created to implement the Marshall plan after the second world war, is calling for a global new deal.6 If economies and social order collapse in South Asia, Africa, or Latin America, no border, wall, or boundary will be enough to contain the consequences. At its emergency summit, the G20 committed “to do whatever it takes to overcome the pandemic,” including injecting over $5tn into the global economy.7

In contrast to the financial crisis of 2008, when the focus was on saving banks and capitalism, political declarations and economic programmes now also seek to protect the most vulnerable people, nationally and globally. Hundreds of billions of dollars are available in the global North to finance rescue measures such as tax cuts, extended unemployment benefits, mortgage holidays, and liquidity for small and medium sized businesses.

Even countries that were initially willing to allow some older people to die, such as the UK and US, are bowing to pressure to follow a similar playbook.8 The US congress has agreed to a bipartisan $2.2tn covid-19 rescue bill, and despite substantial corporate handouts there is tacit agreement across the political divide to include direct payments to the most disadvantaged citizens.9

The World Bank announced up to $12bn of immediate support for country responses to covid-19.10 The International Monetary Fund belatedly said it might relax structural adjustment measures to allow countries to invest in prevention and treatment of covid-19.11 The European Union is fighting over a common Eurozone debt instrument called “corona bonds” to bolster economies.12 More urgent and decisive initiative is required from the World Bank and IMF, such as writing off debt; this may follow the G20 statement, which calls for an action plan to safeguard the global economy in response to covid-19.

For ordinary citizens, coming through experiences of austerity and seeing national infrastructure and public services starved of investment, the sums of money that are suddenly available are bewildering. Politicians who came to power with plans to weaken government, dismantle the nanny state, and privatise government functions are now discussing how to nationalise major strategic sectors.13 The strong state is back, but there is no way to predict which political agenda, left or right, or which type of leader this development will support in the end.

Guided by Asia and Africa

The G20 made it clear that the repercussions of this pandemic can only be resolved through global cooperation. But many countries that once claimed leadership in global health have offered little. Indeed, in their hubris, they have taken too long to learn from Asia to save themselves. Now, every country is asked: why are you not applying successful measures from South Korea, China, Hong Kong, Taiwan, or Singapore? The public health lockdown, initially heavily criticised as typical of China’s authoritarianism, has in one form or another become an international norm.

 Containment or suppression is a de facto strategy, whether by choice or necessity, based on the success of countries that rapidly “controlled’ the outbreak. However, the degree of political repression in some national strategies is still blurred. Hungary, for example, has passed legislation that will allow the government to indefinitely extend its state of emergency.14 In several countries, armies ensure compliance with lockdowns. Draconian methods, partly based on digital surveillance, that can work for the public good in terms of health create major challenges for Western democracies that profess to uphold individual freedoms.15 They will also completely change the trading systems in Africa and circulation of goods in the informal business sector.16

Physical distancing and lockdowns mean very different things in societies with and without support systems and social safety nets. Strategies to strengthen these may flounder if communities are not engaged. A failure to win over religious and community leaders in South Asia and Africa, for example, will fuel resistance to public health measures. African countries with recent experience of Ebola will probably better understand the value of community involvement than the global North.

Learning from others and from Asia and Africa is becoming essential. Citizens and experts outside the corridors of power are holding governments to account by comparing their response to that of other countries, to the relative success of South Korea or the relative failure of Italy. Everyone is a lay epidemiologist, poring over graphs and analyses produced by experts, institutions, and charlatans. Media coverage is extensive, and social media is buzzing with debate, creativity, facts, and fiction. Health literacy is critical as an “infodemic” is competing with the real pandemic. Leaders of public health institutions, virologists, and modellers have rarely been so visible and held so much responsibility.

Paradoxically, at the crest of an isolationist wave, international solidarity and strengthening multilateral institutions have never seemed more vital. Building on its successful handling of the 2018-19 Ebola outbreak, the World Health Organization has improved its performance. It is highly visible, with its director general at the forefront, leading calls for solidarity between people and nations, launching global initiatives, and fundraising.17

But WHO’s mandate is still too weak and its funding gravely inadequate. It faces problems in some of its regional and country offices, which find it difficult to challenge governments on lack of transparency or inaction and struggle to influence policy. Disappointingly, the UN Security Council has yet to recognise the threat covid-19 poses to international peace and security because of a geopolitical fight over what to call the virus.18

International solidarity

In the face of these difficulties, will international solidarity win out? It is, after all, a loathed concept for many countries that have refused more funding for WHO, or those that persist with economic and other sanctions. The US perversely imposed additional sanctions on Iran, denying access to diagnostic kits and protective equipment.19 One outcome of this is the effect on bordering countries: an estimated 80% of cases of covid-19 seeded to Afghanistan and Pakistan originated from people returning from Iran who were not tested or quarantined.20

International solidarity is also soft power, a diplomatic code for gaining geopolitical sway and influence. While the US is fully focused inward and its president blames the “Chinese virus,” China is positioning itself as a global health benefactor and showering aid to cope with the pandemic. President Xi described China’s mass deployment of medical aid to Europe as an effort to establish a “health silk road,” stretching the concept of its belt and road initiative.21

The last time the world found courage for true solidarity was after a devastating war in 1945. The enemy now is common but invisible. Viruses such as SARS-CoV-2 do not recognise nationalities, borders, or political leanings, but they do lend themselves to being politicised. As both our health and our economies are threatened, is there a lesson in all of this for those who vehemently oppose globalisation and promote nationalism? Can the world accept that global risks require solutions that engage countries and people as equal partners?

In global health it took the experience of the SARS crisis for countries to accept the International Health Regulations as a “cosmopolitan moment.”22 Cosmopolitan moments are points in time at which the global community comes together and creates new institutions and mechanisms that it has not otherwise been willing to introduce. The covid-19 pandemic, once it has passed, might force us to turn our united and undivided attention as a global community to jointly address global health, climate change, and the widespread egregious disparities that leave our existence at risk.

Covid-19 has taught us that health is the basis of wealth, that global health is no longer defined by Western nations and must also be guided by Africa and Asia, and that international solidarity is an essential response and a superior approach to isolationism. We may emerge from this with a healthier respect for the environment and our common humanity. All citizens, governments, businesses, and organisations must heed these lessons. Covid-19 is the virus that is turning the world upside down. It will destroy the world as we know it; in the process we may learn to hold it together.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and have none to declare.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

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