Professor Virasakdi Chongsuvivatwong, or "Ajarn Vii" as he is often referred, is the founder of the Epidemiology Unit and also an expert in infectious disease epidemiology and provider of insightful social commentaries during times of crisis. 

Over the past 2 months, Ajarn Vii has produced a series of reflective opinion essays (in Thai) on the evolving situation of the Covid-19 pandemic with a focus on the situation in Thailand, titled "Watching Covid-19 through the Eyes of an Epidemiologist". This article is the English translation of the Thai original.  

The following essay was written on:

13 May 2020

Security or Prosperity?

The original post in Thai can be found here

Something that is secure is hard to be damaged or lost because it has good foundation and protection.

In the past, we would hear the word "security" being used by the military, but now agencies like the National Security Council also has to manage Covid. Health security has become as prominent as military affairs. There are other aspects of security as well. Economic security starts to be compromised by Covid, while food security is relatively unaffected. The virus does not harm plants, animals and agriculture. We still can export food to feed the world. Environmental security has slightly improved because of reduced human activities. The food chain from watersheds, the mangroves and the oceans have had the time to recover.

Today, I want to talk about health security.

Health security is an issue of global importance. But there are two unique characteristics of health security that happen to collide during the Covid crisis.

For a long time, researchers in the USA, led by scientists at the National Institute of Health (NIH), have considered epidemics to be a global health security issue. The work of these researchers focuses on biomedical sciences in order to understand the body's systems and harmful pathogens. The aid that the US provides to other countries is almost exclusively in the area of infectious disease research and control. When Ebola spread in Africa, America led the world by deploying the public health workforce to control the disease. That was a heroic feat.

America's strength in bio-medicine, however, has existed alongside problems in equality under a health economic model where everyone is for their own. Former President Obama successfully deployed troops to prevent the outbreak of Ebola overseas, but efforts to increase the number of insured Americans were met with resistance.

Europe and Japan are less successful than America in biomedical sciences, but they have made greater advancements in public health. After countless terrible wars, countries in Europe joined hands after World War Two and eventually formed the European Union based on the principle of solidarity. Europe and Japan developed and advanced their health insurance systems and considered the health coverage system to be a part of health security. In the 1990s, Europe assisted the Thai Ministry of Public Health by providing numerous scholarships for doctors to study public health and health economics. These doctors (one of whom was Dr. Sanguan "Nguan" Nittayaramphong) returned home to reform the health coverage system and sold ideas to political parties to enact universal health coverage laws and established the National Health Security Office (NHSO). The name itself indicates that having health coverage is achieving health security.

Thailand's achievement in universal health coverage was world-renowned. It created the belief that health coverage would lead to household economic security, and the UN suggested inclusion of achieving worldwide universal health coverage by 2030 as one of the sustainable development goals (SDGs).

China, the world's second largest economy after America, is more interested in economic prosperity than the people's health security. In a way, China is similar to the US. China's health coverage system requires co-payment to hospitals when receiving service. Government hospitals belong to the state and are controlled by the Party, but hospitals need to find money to support themselves. Thai public hospitals, meanwhile, receive support in infrastructures and human resources from the Ministry of Public Health and payment for services from the NHSO.

I once followed a student who was conducting a study in a Chinese city with an outbreak of typhoid fever. Patients were required to make co-payment on all items from blood draw to blood culture and x-ray to rule out other diseases. The only item that was supported by the state was the antibiotics against typhoid. Typhoid fever is a virulent disease and so it created a health security problem for the entire city. Meanwhile, the residents of the study also lacked medical security. The poor had to ask the doctors to reduce the number of tests so that they would not have to spend as much money at the hospital. Instead of blood draw and culture to confirm typhoid infection, when the patient was not able to pay, the doctor had to treat by guesstimate and provided medication to the patient outright. The patient would return if there was no improvement.

This scenario happened over a decade ago. Right now China is more prosperous than Thailand. I have asked the new cohort of students to study whether patients with drug-resistant tuberculosis experience the same problems as the typhoid patients did in the past. It is regrettable that the situation was still the same in China. Nearly half of all TB patients stopped taking medication and did not return to the doctor because of lack of money. Those who stayed in treatment risked bankruptcy.

Prosperity, whether that of China or the USA, cannot resolve the problem of security from infection, as long as the two superpowers still do not regard health security as a public commodity that benefits society. Aside from making people impoverished by medical treatment, the lack of vision of health policy as a public commodity also enable the disease to spread in the entire society.

Ending with a remark on Covid. I have not heard news on whether China or the US has created a special health coverage system for this particular disease. My guess is that in China, if the tests were to be out-of-pocket, no one would have come because they were expensive. The state might have issued a special rule for the Covid test to be free. If the test found other diseases that were similar to Covid, such as the flu, I don't think that the test would be free.

In America, what kind of health security would I have if I was poor and a paperless immigrant. I would need to think over and over whether to go see a doctor if I was sick. If I went to see a doctor, would I get deported? In the US and the UK, black patients are clearly more likely to die from Covid than white patients. Race and genetics are unlikely causes of mortality from Covid. My guess is that these differences have something to do with health coverage.

A friend shared with me on the LINE messenger that luxury hotels in Bangkok are offering promotions for people to dine, and complementary room vouchers will be given. I told my friend that we have free accommodation with free food and Wi-Fi at the southern border. Just enter Thailand from Malaysia, and you can have these offers right away. You can't turn down the offer either. You need to / must stay there for 14 days.

So who pays for the quarantine accommodation of these Thai returnees? It's the health insurance system: the NHSO, the Social Security Office, and the Government Employees Insurance Scheme. Our provincial administration office also serves as the generous host to cover other unmet expenses.

Thai people are kind and generous. Everyone believes that paying hotels to quarantine potentially infected people is better than letting the infected pass through the border to infect others, including our healthcare workers, the 'warriors in white'.

China used to do this, too, during the beginning of the outbreak. But things have changed now. Chinese returnees are quarantined at hotels in the city where they land for 14 days, then move to their destination province and be quarantined for another 14 days. The returnees are required to pay for accommodation, food, and other expenses for the entire 28-days period. The Chinese must have thought that people who return from overseas should have enough money to afford these quarantine expenses. So overseas travelers must carry the burden of health security to keep others free from infection. It should be okay if these travelers were well-off.

My Thai readers must be feeling a lot more patriotic if they have read up to this point.

But don't forget: from now on, we only have more expenses. We don't know where to earn income. The government is taking out loans and is about to meet the limit of their financial security. 

We have this arrogance that we were able to pay off the debt to IMF incurred in 1997 within the span of a few years. Everything was ready for us then. There were few competitions. We have no idea who long we are going to be in the Covid debt trap.

Our sufficiency economy principle should be able to keep us afloat and keep Thailand from the breaking point. But it may not be easy to pay off our debts. Countries in Southern Europe have been on the verge of bankruptcy many times because of public debt, and had to take financial aid from other countries to pay their public servants. If we cannot control our spending while we are still poor, we may be in that situation one day.

Comprehensive security must be based on caution. 

Composed by Prof. Virasakdi Chongsuvivatwong, MD, PhD. Epidemiology Unit, Faculty of Medicine, Prince of Songkla University.