H E A LT H , M E D I C I N E , A N D S C I E N C E I N A S I A

Edited by Anoma P. van der Veere, Florian Schneider,and Catherine Yuk-ping Lo

Public Health in Asia during
the COVID-19 Pandemic
Global Health Governance,
Migrant Labour, and International
Health Crises

Public Health in Asia during the COVID-19 PandemicHealth, Medicine, and Science in Asia
Over the last few decades, the Asian health landscape has gone through profoundand dramatic changes. While access to healthcare shows severe inequalities fromone country to the other and within countries, the region as a whole has positioned
itself as a world player in the domain of health. Asia has become one of the primarydestinations for medical and wellness travelers, attracted by specialized hospitals
that follow international standards and provide first class treatments. The Asian
pharmaceutical sector is a global competitor and therapeutic innovation is fuelingnew domestic healthcare markets. Biotech and clinical research are often equivalent
to that seen in Europe and North America, while Asian traditional medicines
have become a central feature of most contemporary societies, with a significant
proportion of their industrial production aimed at export. New forms of therapeutic
practices, knowledge and objects have emerged from the encounter of Asian
medicine and biomedical science, giving way to braided concepts, products and tools,
new epistemologies and understandings of the body, or again, revised regulatory
schemes. Asian-born pandemics have contributed to redefine global healthprocedures, principles and meaning. The parallel evolution of these sectors coupledwith structural transformations and new health policies, technological advancement
and a low-cost workforce, have largely contributed to the renewal of Asian healthservices. This has not only modified national health policies and initiatives but also
contributed to transforming the image of Asia in the realm of science and medicine.
This book series seeks to bring attention to two decisive phenomena in these processes.
The first concerns the uneasy relationship between increasing social disparities, themarket and structural and technological developments in the field of health. The
second phenomenon deals with global issues and their scales, as macro dynamics,
transnationalism and local forms of globalization impact the production of health. This
dual approach, embedded into the politics of healing, such as modes of governance andregulation, will help to explore the local fabric and global aspirations of Asian health.
Studies from a variety of disciplines, from history to anthropology and the social studyof science provide the backbone of the series.
Series editor
Laurent Pordié, National Center for Scientific Research (CNRS), Paris
Editorial board
Sienna Craig, Dartmouth College
Wen-Hua Kuo, National Yang-Ming University, Taipei
Alex McKay, International Institute of Asian Studies, Leiden
Projit Bihari Mukharji, University of Pennsylvania
Volker Scheid, University of Westminster, London

Public Health in Asia during the
COVID-19 Pandemic
Global Health Governance, Migrant Labour,and International Health Crises

Edited by
Anoma P. van der Veere,
Florian Schneider, andCatherine Yuk-ping Lo

Amsterdam University Press

Cover image: with permission from Nick Potts
Cover design: Coördesign, Leiden
Lay-out: Crius Group, Hulshout
isbn
e-isbndoi
nur

978 94 6372 097 7
978 90 4855 524 6 (pdf)
10.5117/9789463720977
870© The authors / Amsterdam University Press B.V., Amsterdam 2022
All rights reserved. Without limiting the rights under copyright reserved above, no part ofthis book may be reproduced, stored in or introduced into a retrieval system, or transmitted,
in any form or by any means (electronic, mechanical, photocopying, recording or otherwise)
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Every effort has been made to obtain permission to use all copyrighted illustrations
reproduced in this book. Nonetheless, whosoever believes to have rights to this material isadvised to contact the publisher.

Table of Contents
Introduction: COVID-19 and Asia

Anoma Phichai VAN DER VEERE, Florian SCHNEIDER, andCatherine Yuk-ping LO

9PART I Health Policy in Asia and the Global
Community
1 Fighting for a Global Community in a Post-COVID World

31

2 Countering Emerging Infectious Diseases and COVID-19

45

3 The Outbreak of Infectious Diseaseand Trust in Government
in Asian Countries

63

Haruko SATOH

The Development of ASEAN’s Institutional Arrangements andInternational Cooperation
Kei KOGA

Yumi ISHIKAWA and Miki KOHARAPART II The Future of Global Health Governance inAsia
4 China and the World Health Organization

83

5 South Korea and the WHO during the COVID-19 Crisis

97

6 Escaping the ‘Realist Trap’111

Not an Easy Road for Either
Xue GONG and Xirui LI

Brendan HOWE

The ROC’s Participation in Global Health Governance Under the
One-China Principle
Catherine Yuk-ping LO

7 From Pneumonia to Pragmatism

The Role of the WHO in Japan During Public Health Emergencies
Anoma P. VAN DER VEERE

125

PART III Domestic Responses to COVID-19
in a Globalized Asia
8 The COVID-19 Pandemic

147

9 The Coordination of COVID-19 Responses in Malaysia

163

10 Analysis of South Korea’s Experience with the COVID-19
Pandemic and its Relations with the WHO177

11 State-Society Relations as Cooperative Partnership and the
COVID-19Response in Vietnam

197

Socio-Economic Issues, Health Care, Health Security and the Rapid
Response in Vietnam
Anh Tuyet NGUYEN

Efforts and Challenges
Nurliana KAMARUDDIN and Zokhri IDRIS

Eun Mee KIM and Jisun SONG

Mirjam LE and Franziska NICOLAISENPART IV The Global Economy and Transnational
Migrant Labour in Asia during COVID-19
12 The Coronavirus as the ‘Final Straw’ of the CCP’s Performative
Legitimacy? 217
A New Economic Model in the Post-COVID-19 Era
Catherine Yuk-ping LO

13 Health Governance during the COVID-19 Pandemic
Reflections on Taiwan’s Guest Worker Policy
Mei-Chun LIU

231

14 Public Health and Capitalism in Japan

247

15 Indonesia’s Response to Global Recommendations on Labour

259

The Impact of Labour Market Challenges and Welfare on Public
HealthSaori SHIBATA

Migration during a Pandemic: Muddling through Priorities andNeeds
Sylvia YAZID

List of Figures and Tables
FiguresFigure 3.1
Figure 3.2

Average level of trust in sample governments
71
Average level of trust in the SARS-affected (treatment) and non-affected (control) groups
72
Figure 4.1 Number of Statements Submitted to the WHA by
China, the EU, and the US85
Figure 4.2 WHO Assessed Contributions by Countries (Updated
until Q2 2020)
86
Figure 4.3 WHO Specified Voluntary Funding by Parties (Updated until Q2 2020)
87
Figure 4.4 WHO Projected Funding by Parties (Updated until Q22020)88
Figure 4.5 WHO Collaborating Centres in the US and China by
Subjects (Pending and Active)
89
Figure 8.1 The Number of Confirmed and Daily New Confirmed
149
COVID-19 Cases in Vietnam
Figure 10.1 South Korea’s ODA Trend for 2015-2021
182
TablesTable 3.1
Table 8.1
Table 9.1

Socio-Demographics, SARS Epidemiological Data,and the Responses of Governments and the WHO in
Target Regions
66
A summary timeline of nationally implemented
policies in Vietnam and the WHO’s recommendation151
and response plan
Daily reported cases from 25 September to 12 October 2020166

Table 10.1
Table 10.2
Table 10.3
Table 10.4

South Korea’s Contributions to the Global Health
Initiatives181
Global Solidarity Groups on COVID-19 Launched bySouth Korea
183
Editorials on the WHO in South Korean Media
185
Remarks from President Moon, Jae-in on the WHO
190

Introduction: COVID-19 and Asia
Anoma Phichai VAN DER VEERE, Florian SCHNEIDER, andCatherine Yuk-ping LO
Keywords: global health governance, labour migration, Asia, public health,
COVID-19, globalisation

In late 2019, the world watched closely as cases of an unknown virus causing
pneumonia started spreading through Wuhan province in the People’s
Republic of China (PRC). Gradually, more cases were being reported, and on
Saturday 11 January 2020 Chinese state media announced the first fatality(Qin and Hernández 2020). While the virus, now more commonly known
as COVID-19, spread across the globe with unprecedented ease, it would
take the World Health Organization (WHO) until 30 January to declare theoutbreak a public health emergency of international concern (PHEIC).1 Bythis time, there had been 7834 confirmed cases and 170 people had lost theirlives to the virus (WHO 2020a).
With the benefit of hindsight, we can now see that the virus has wreaked
havoc on the world. By 30 January 2021, a year after the PHEIC announcement, almost every country and region had been hit (WHO 2021a). Over 100
million people had been infected, resulting in more than two million deaths.
The interconnectedness of our modern transport systems carried people
from Wuhan to ports on every continent before any viable measures were
put in place, spreading the virus everywhere. As the outbreak developed, it
was those nations that are geographically close to China, in East Asia andSoutheast Asia, that especially struggled to cope with its scale. Different
1 A PHEIC is defined as ‘an extraordinary event which is determined to constitute a publichealth risk to other states through the international spread of disease and to potentially requirea coordinated international response’. This def inition implies a situation that: 1) is serious,
sudden, unusual or unexpected; 2) carries implications for public health beyond the affectedstate’s national border; and 3) may require immediate international action (WHO 2008, 19).

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_intro10 

Anoma Phichai VAN DER VEERE, Florian SCHNEIDER, and Catherine Yuk-ping LO

conditions have led to different results in these countries. South Korea andVietnam, for instance, had previously experienced the dangers of publichealth crises during the SARS epidemic in the early 2000s, and as a result
they were well-equipped to deal with the virus (see in this volume: Le &Nicolaisen, and Nguyen for Vietnam; Howe, and Kim & Song for South Korea).
Similarly, Taiwan (ROC) was able to quickly respond to the outbreak (seeLo, and Liu), despite its connections to the PRC. However, countries likeIndonesia and Japan were less prepared (see Yazid, Shibata, and Van der
Veere). Meanwhile, Malaysia was suffering an acrimonious political shiftthat resulted in a delayed response to the developing public health threat(see Kamaruddin & Idris).
These examples show that talking about Asia is challenging. It is the largest region on the planet, containing dozens of political systems, thousandsof languages and cultures, and billions of people. Moreover, as area studies
scholars have repeatedly pointed out, any attempt at defining it has political
implications, making it a difficult concept to work with (see for example
the contributions in Wesley-Smith and Goss 2010). Despite this theoreticalambiguity, however, the term ‘Asia’ has real-world uses. When we visit thewebsites of some of the world’s largest media outlets, news from the region
is frequently sorted under the banner ‘Asia’. Our understanding is therefore
partly formed by our consumption of the concept of ‘Asia’, ambiguous as it
may be.2 This ambiguity offers some disadvantages, especially in a scholarly
work such as this one. However, it offers one benefit. The main reason that wehave chosen to use Asia in the title of the book is because of the diversity of
the region. Leaning into the ambiguities that come with attempts to define
the region allows us to offer contrasting and comparative perspectives thatmight enable a better understanding of how dynamic a region like Asia is,and why public health crises such as the COVID-19 pandemic develop in
different ways even within such a region.
This book reflects this diversity by including chapters that respectively
focus on different countries, regions, governments, and institutions. It
offers local perspectives, local knowledge, and new information in anaccessible and informative way. One of the main motivations for creating
this volume has been to provide policy makers and health specialists witha better picture of the different strategies that have been employed in Asia
2 See for example BBC News, https://www.bbc.com/news/world/asia; or CNN, https://edition.
cnn.com/asia. Even media outlets based in Asian countries often default to the ‘Asia’ category,see for example Nikkei Asia, https://asia.nikkei.com/; and the South China Morning Post, https://www.scmp.com/news/asia.

Introduc tion: COVID -19 and Asia

11

during the COVID-19 pandemic. It does this using thoroughly researched
and informed case-studies that are presented in an accessible format.
Although every country has its own context, and every institution operates
in its own place and time, hopefully this volume will deepen our sharedunderstanding of how interconnected people and institutions interact
during times of crisis.

The Importance of Understanding COVID-19 and Asia
In 2019, the Nuclear Threat Initiative and the Johns Hopkins Center for
Health Security published a report titled the ‘Global Health Security Index’(2019). In its conclusions, the report judged countries like the United States,
the United Kingdom, the Netherlands, and Brazil as being ‘Most Prepared’.
This was ostensibly for their ability to rapidly respond to the spread of an
epidemic. The only two Asian countries deemed ‘Most Prepared’ wereSouth Korea and Thailand. This was only a few months before the COVID-19
pandemic would devastate the global economy and throw international
mobility into disarray. The COVID-19 pandemic, which is currently far fromover, has already cost millions of lives and has shown that the list in thisreport was shockingly off the mark.
The supposed preparedness of different countries presented in thisreport is jarring considering the disorienting conditions into which theworld was plunged as the pandemic spread. The constantly changing
nature of the pandemic has left most observers guessing what was working
well, and what was not. This has led to a wave of erroneous, often hastily
constructed interpretations that have found their way into daily lived
experiences. Japan is an excellent case in point. The country’s government
was slow to act when it was forced to deal with a cruise ship full of infected
tourists in February and March 2020, early on in the pandemic. Throughits ineffective handling of the situation, the government inadvertently
created a cruise ship-sized COVID-19 petri-dish on the shore of Yokohama,near one of the world’s most densely populated metropolitan areas. It
was widely lambasted for this failure to act in the media and by othergovernments and institutions (Ratcliffe and Fonbuena 2020). Only twomonths later, however, with the number of infections stabilizing in the
country but exploding abroad, the Director-General of the WHO praised
Japan’s approach, hailing it as a great success (Kyodo News 2020). This cycleof ascribing either failure or success, depending on the circumstances ofthe moment, has continued ever since.

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Anoma Phichai VAN DER VEERE, Florian SCHNEIDER, and Catherine Yuk-ping LO

There has been a tendency in media reports to arrive at hasty conclusions
based on circumstantial evidence. This has in turn resulted in a high levelof mixed messaging. However, it would be irresponsible to lay the blame
solely with the media. Government officials, policy makers, and global actors
have taken part in the same game. As a consequence, such inaccuracies
have also found their way into official policymaking.
One example is an international comparative country review produced by
the Dutch Ministry of Labour, Welfare and Sports. This report was written
to inform the Dutch government about varying approaches to maintaining public health during the COVID-19 pandemic. The two health policy
specialists who authored the report found it helpful for their understandingof Asia to include South Korea as a case-study. They employed the Hofstede
model of national culture to frame their understanding of South Korea andindirectly the ‘Asian approach’. Despite the wide-spread criticisms of the
Hofstede model, it continues to be used as if it reliably represents factualand objective scientific analysis. It is beyond the scope of this volume todelve into the many problems with the model,3 but it is helpful to quotea particular section from the aforementioned report in order to illustrate
how this model is used to make problematic arguments about the successof the South Korean public health model:
A large difference becomes clear from the observation that South Koreansociety is a lot more collectivist. […]. 4 Moreover, as South Korean society
is primarily feminine this leads to most people realizing that everyone
is part of a group or that their role is to protect vulnerable people. […].
To conclude, South Koreans are less abundant than Dutch people. This
makes it easier for them to follow measures that restrict freedom for
longer periods of time (Hagenaars and Jeurissen 2020, 12).5
3 The Hofstede model is by and large a collection of statistical information based on fallacious
assumptions, yet it has remained popular as a measure for ‘national cultures’. We agree herewith Brendan McSweeney’s description of the model as methodologically flawed and ‘a restrictor
not an enhancer of understanding particularities’ (2002, 112). McSweeney also states that ‘theidentification claims are fundamentally flawed and the attribution of national level actions/institutions to national cultures is an easy but impoverishing move’.
4 The part left out of the quotation above reads: ‘And where the Netherlands is slightly risk
averse and pragmatic, South Korea is very risk averse and extremely pragmatic. Both of theseissues contribute to a culture that is able to change gears quickly and powerfully when necessary
in the face of an emerging infectious disease.’
5 Author translation. For readers wondering if a translation of the complete section will add
relevant context that will lead to the salvation of the report’s conclusions, I can assure you none
exists.

Introduc tion: COVID -19 and Asia

13

All of the above statements can be disproven point by point. More
importantly, the authors have chosen to eschew a thorough analysis
that critically analyses domestic measures in the context of a more successful approach. Instead, they present their findings in a way that serves
to justify their own set of (ineffective) public health measures – andeven the hesitancy to implement such measures – in the context of theNetherlands. The conclusion ignores any political factors that may havecaused Dutch people to be more hesitant towards public health measures.
It also does not address the possible causes of civil compliance among
South Koreans, such as previous experience with public health crises,
national interests, or the evolution of transnational political discourses
on public health. Instead, the population is deemed collectivist, feminine,and less abundant.
Interestingly, an early survey study showed that in countries including the Netherlands ‘public belief in the effectiveness and the actual
implementation of certain protective measures during the early phase of
the COVID-19 pandemic in March 2020 was high’ (Meier, et al. 2020). The
decline in social compliance of Dutch people in the later months of thepandemic can therefore be better attributed to a set of obviated domestic
circumstances that the authors of this report fail to address. Given thismissed opportunity, or possibly in spite of it, the authors attempt to
explain away public resistance in the Netherlands through naturalisticcomparisons with the South Korean population. Their report is an excellent example of how actors outside of Asia frequently misunderstand, oreven wilfully misrepresent, the politics and cultures of the region. Suchactors use the regrettably widespread public ignorance regarding Asia
to dismiss governance approaches that clash with entrenched habits
and ideologies.
Of course, not all policy-makers dismiss Asia as callously as the authors of
this Dutch policy report; many are aware that there are lessons to be learned.
There is then a serious need for informed case studies that highlight themost important issues in an accessible, concise manner. This book seeks to
do this. For example, it covers the South Korean case in two chapters. The
first of these details and contextualizes the South Korean government’s
national interests within a framework of global health governance (Howe).
The second chapter then explains how official and public sentiments haveaffected South Korea’s relations with the WHO (Kim & Song). These andother case studies in this volume offer a wealth of in-depth information
about how different governments, organizations, and political actors acrossthe Asian region have handled COVID-19.

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Anoma Phichai VAN DER VEERE, Florian SCHNEIDER, and Catherine Yuk-ping LO

Global Health Governance and Asia
Under the strain of our world’s ever increasing interconnectedness, the global
system of health governance currently in place has come under increasingpressure. As the largest health institution in the world, the WHO’s role inresponding to the COVID-19 pandemic has been widely criticized for being
slow and inefficient, and even for ostensibly appeasing China, where thevirus originated. While governments were scrambling to respond to theemerging threat of COVID-19, the pandemic became increasingly politicized.
Over the course of the pandemic, the line between public health concernsand political contestation has been blurred and the effects of already existing
international political tensions have been magnified. An example of thiswas China’s so-called ‘mask diplomacy’, where it sought to win the favourof other countries through the supply of masks and medical equipment(see Satoh). Another example is the high-profile political debates about theexact origins of the virus that have occurred in several different countries,
particularly in the US.
The health-politics nexus is further demonstrated in the case of the WHO’s
declaration of a PHEIC. The WHO has had the responsibility for determining
when an outbreak is a global public-health emergency since 2005. However,it has only done this five times prior to the COVID-19 pandemic: during theswine-flu pandemic in 2009; the Ebola outbreaks in West Africa in 2014 andin Congo in 2019; the emergence of polio in war zones in 2014; and the Zika
epidemic in 2016. The amount of time it has taken for the WHO to declare aparticular situation a PHEIC has nevertheless been a focal point of criticism.
For instance, during the 2009 H1N1 outbreak, it took the WHO 38 days todeclare a PHEIC after laboratories isolated H1N1 on 18 March 2009. In sharp
contrast to the speed of global action regarding H1N1, a PHEIC was notdeclared until 138 days after the first detected case of Ebola in West Africa
on 22 March 2014 (Hoffman and Silverberg 2018, 330).6
The reason why the WHO declares, or does not declare, a particularsituation as a PHEIC has been another point of criticism. Critics have argued
that the WHO’s decision is based on the economic conditions of the affected
countries. The Ebola outbreak in 2014 is a case in point. A leaked documentshows that the WHO intentionally delayed declaring a PHEIC for the sake of
avoiding catastrophic economic consequences for Guinea and other afflicted
6 The H1N1 outbreak began on 15 March 2009, was detected on 18 March 2009, and was declareda PHEIC on 25 April 2009. The West African Ebola outbreak began on 26 December 2013, wasdetected on 22 March 2014, and was declared a PHEIC on 8 August 2014.

Introduc tion: COVID -19 and Asia

15

countries (Boseley 2015). A study conducted by Hoffman and Silverberg (2018,331) indicates that the direct impact of infectious diseases on the US is also anecessary condition for a global health emergency pronouncement. A PHEIC
was declared ten days after the first US citizen was detected with the H1N1
infection. Meanwhile, Ebola was declared a PHEIC just six days after infected
health care providers arrived in the US for treatment on 2 August 2014.
When COVID-19 hit at the start of 2020, the WHO was blamed forserving the interests of the Chinese government. Social media users havemocked the WHO as ‘Winnie the Pooh Health Organization’, referencing
the common practice among Chinese Internet users of comparing Chinese
President Xi to Winnie the Pooh (McDonnell 2017). Others have referredto the WHO as CHO (Chinese Health Organization) to express their anger
about the way that the WHO is supposedly managing the pandemic in linewith Chinese interests (see Van der Veere). The US and countries in Europe
have condemned the WHO for being vulnerable to Chinese influence. Thissusceptibility is exemplified in the eyes of critics by the fact that Taiwan,
also called the Republic of China (ROC), has not been invited to attend theWorld Health Assembly (WHA), the highest decision-making body within
the WHO, since 2017 (see Lo).
In the process, the legitimacy of the WHO has gradually been eroded. Although we can attribute a certain degree of this erosion to global perceptionsof its response, we also need to understand the current state of the organization and the way it functions. Established in 1948 as a specialized agency of theUnited Nations (UN), the WHO is currently the most comprehensive global
health organization, tasked with preventing the global spread of diseases andpromoting better health around the world. The WHO has a decentralized
structure, operating from its Geneva headquarters and six regional offices.
The Secretariat, headed by the Director-General, is responsible for the dayto-day operations of the health agency in collaboration with the regionaland country offices. The Director-General is appointed by and responsible
to the World Health Assembly (WHA) that sets the agenda and approves thebudget of the WHO during the annual meeting held in Geneva, Switzerland.
The WHO’s budget operates on a two-year cycle, and in 2018-2019, it
received US$4.4 billion. To place this number in perspective, this is lessthan that of a typical major hospital system in the US (McKeever 2020).
The organization receives its funding from two main sources. The firstof these is assessed contributions, payable by its 194 Member States.7 The
7 The amount of the assessed contributions each Member State must pay is calculated relative
to the country’s wealth and population (See WHO 2021).

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Anoma Phichai VAN DER VEERE, Florian SCHNEIDER, and Catherine Yuk-ping LO

second source is voluntary contributions made by Member States (in addition to their assessed contributions), by other UN organizations, as well
as by intergovernmental organizations, philanthropic foundations, andthe private sector.
The size of assessed contributions, which are a key source of WHO financing, declined following the 2008/09 global financial crisis. To date, about
80% of the WHO’s funding comes from voluntary contributions (WHO2021a). It is important to note that 96.1% of all voluntary donations shouldbe spent either according to the contributors’ priorities, or are tied to specificprogramme areas and/or geographical locations and must be spent withina specified timeframe (WHO 2021a).8 In other words, the WHO only has
full discretion over approximately 3.9% of all voluntary contributions. This
therefore means that the WHO has limited financial autonomy to initiate
new programmes for advancing overall global health.
The WHO seemed set to encounter a budget crisis at the start of the
COVID-19 pandemic. As the biggest single donor, accounting for 15% of theWHO’s biennial budget in 2018-2019 (McKeever 2020), the US suspended
its funding in April 2020. Under the administration of former US president
Donald Trump, the US withdrew from the WHO in July 2020, accusing
the organization of being too slow to respond to the outbreak in China
and being too deferential to the Chinese government (Alpert 2020). The
Biden administration has since halted the US withdrawal from the WHO.
However, it is widely believed that funding for the WHO still needs to be
diversified to pre-empt future budget crises triggered by the withdrawalof key contributors. The availability of sufficient funding is crucial for the
WHO to facilitate timely responses in emergency situations, including global
infectious disease outbreaks.
In addition to budgetary constraints, the WHO functions under a specific
set of rules: the International Health Regulations (IHR). This is a legalbinding global agreement for addressing the risks of the international spreadof infectious diseases and is also geared to avoiding unnecessary interferencewith international travel and trade (WHO 2008). The first version of thelegal framework, the International Sanitary Regulations (ISR), was issued
in 1951, and there have been a number of revisions since then. Following theeradication of smallpox in 1980, the WHO revised the IHR in 1981 to focus
8 The voluntary contributions are further categorized based on the degree of flexibility
the WHO has in deciding how to spend these funds. These are fully flexible core voluntary
contributions (3.9%), partially flexible thematic and strategic engagement funds (6%), andnon-flexible specified voluntary contributions (90.1%; WHO 2021).

Introduc tion: COVID -19 and Asia

17

solely on three diseases: cholera, yellow fever, and plague. After the outbreakof Severe Acute Respiratory Syndrome (SARS) in 2003, the organization again
revised the IHR in 2005, with these revisions entering into effect in 2007.
This current version of the IHR, also referred to as IHR (2005), has amuch broader scope of application than earlier versions, covering ‘all events
potentially constituting a public health emergency of international concern(PHEIC)’ (WHO 2008, 19). The current IHR took into account the reluctanceof the Chinese government to share information during the early stagesof the outbreak of SARS in 2013. As a result, the current IHR was revised
to guarantee that event-related information provided by the country thatis notifying the organization about a disease outbreak is not shared withother countries before the WHO has announced that there is a PHEIC. Thismechanism aims to ‘protect affected countries from any unjustified overreaction by other countries’ (WHO 2008, 19). Following an official PHEIC
announcement, the WHO is allowed to share information concerning an
outbreak with member states.
In addition to enabling information sharing, the declaration of an outbreakas a PHEIC also allows the WHO to activate its funding channels to grapple
with global health emergencies in a short period of time. The first WHO
funding channel is the Contingency Fund for Emergencies (CFE). Establishedin 2015, the CFE aims to remedy the WHO’s chronic budget deficit and theoverdependence on voluntary contributions, allowing the organization
the flexibility to scale up operations during disease outbreaks and healthemergencies. Funding from this mechanism can be released in less than 24hours and utilized for financing immediate response activities. One monthafter declaring COVID-19 a PHEIC, the CFE had provided US$8.9 million for
COVID-19 when no other funding was available (WHO 2021b). The WHOthen called for US$675 million in the Strategic Preparedness and Response
Plan (SPRP), another WHO funding channel, after the PHEIC declaration
was made (WHO 2020a). The WHO has reached the target, having received
US$677 million from its member states by 1 April 2020 (WHO 2020a). The
COVID-19 Solidarity Response Fund is the third funding channel throughwhich individuals, philanthropists, and businesses are able to contributeto WHO-led efforts in responding to public health crises. This Solidarity
Response Fund received more than US$108 million in donations from over
203,000 individuals and organizations in the first two weeks after the WHO
officially declared COVID-19 to be a PHEIC (WHO 2020b).
While this PHEIC-induced global financial mobilization has been quite
successful in the case of COVID-19, overall compliance of member stateswith the IHR has been questionable. For example, the IHR (2005) requires

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Anoma Phichai VAN DER VEERE, Florian SCHNEIDER, and Catherine Yuk-ping LO

member states to strengthen or re-establish the public health infrastructuresdesigned to facilitate early recognition of, and rapid response to, emerging
diseases. As part of their commitment to the IHR, participating countries
agreed to comply with these rules by 2012. However, only about one-thirdof participating countries (64 countries) reported fully achieving the corecapacities by 2014 (Gostin and Katz 2016, 276).9 Based on these figures, it
is not surprising to see that many countries were not ready to deal with
COVID-19. It remains to be seen whether countries’ approaches to compliance with the IHR have changed as a result of the pandemic.
Apart from the limitations of voluntary compliance with the IHR, we haveseen an erosion of member states’ trust in the WHO. As globalization has
pushed the integration of national economies to the point of interdependence, transportation systems have developed along the same lines. Thismeans that a country cannot physically isolate itself from the rest of theworld without inflicting economic damage on itself. As the pandemic hit,an urgent concern for national governments was therefore controlling thein- and outflow of people, especially tourists and migrants. When COVID-19
was declared a PHEIC, the WHO simultaneously advised states to keep
borders open on the basis of the IHR. However, almost every country ignored
the WHO’s advice, and many countries even closed their borders to all
nations (Mallapaty 2020), leading to an unprecedented crisis for migrant
workers in a number of Asian countries (See Part IV of this book).
In this sense, the complete lockdown of Wuhan in China set an example(see Lo). However, other countries and regions also took measures that
affected how human beings could move across space. Foreign workers werebarred from entering or leaving Japan, often stranding them abroad awayfrom their jobs, homes, and families. Meanwhile Taiwan’s exclusionary
guest worker policy made it practically impossible to include all migrants
in public health strategies dealing with the pandemic (see Liu). In the caseof Indonesia, a country that sends more workers abroad than it receives, awave of returning migrant workers exerted sudden pressure on the country’s
healthcare system (see Yazid). The mobility of foreign workers is intricately

9 According to the IHR (2005), member states of the WHO are required to submit a selfevaluation of their core capacities for emergency preparedness and responses. The designatedthirteen core capacities include: (1) Legislation and financing; (2) IHR Coordination and National
Focal Point Functions; (3) Zoonotic events and the Human-Animal Health Interface; (4) Foodsafety; (5) Laboratory; (6) Surveillance; (7) Human resources; (8) National Health Emergency
Framework; (9) Health Service Provision; (10) Risk communication; (11) Points of entry; (12)Chemical events; and (13) Radiation emergencies.

Introduc tion: COVID -19 and Asia

19

linked with global health governance and any strategy to contain a pandemic
has to account for the inherently transnational nature of public health crises.
As the case-studies in this volume also show, these developments canhave devastating long-term effects for the future of global health governance.
This is especially as public trust in governments during health crises has
previously proven to be reliant on cooperation with the WHO (see Ishikawa& Kohara). To regain public trust, some WHO member states called for amore in-depth investigation into the origin of the virus during the WHO’s
annual decision-making meeting, the World Health Assembly (WHA) in
May 2021. This was after an international mission to China earlier the same
year proved inconclusive (Larson 2021).
The WHO’s investigation and report have also faced criticism for failingto include all essential data, as well as for not fully evaluating theories that
COVID-19 was the result of a leak from a laboratory located in the Wuhan area
(Miller, Nebehay, and Farge 2021). Critics allege that the WHO has been too
deferential to China in its handling of the COVID-19 pandemic and its sharingof data concerning viral origins. They argue that a drastic reform of the WHO
is needed to avoid future COVID-like crises. Among the recommendations forthe organization’s reform are measures to boost the WHO’s independence, togive it the power to investigate serious health threats in countries concerned,
and to allow it to sound the alarm about risks without waiting for the green
light from the countries that have notified it about disease outbreaks (Larson
2021). In the absence of a meaningful reform, it cannot be assumed that the
WHO will have an appropriate response to future global health crises. Neither
can it be assumed that national governments will listen to the WHO’s advice.

Overview of the Volume
This volume is organized around four themes: health policy in Asia and theglobal community; the future of global health governance in Asia; domestic
responses to COVID-19 in a globalized Asia; and migrant workers and theglobal economy during COVID-19.
Part I of the book is devoted to an assessment of health policy in Asia andthe interactions between the agencies at national, regional, and global levels
in times of infectious disease outbreaks. Satoh, for example, highlights theinherent deficiency of the UN system, showing that differences between
political values among member states and the principle of upholding statesovereignty make joint actions difficult. This has been demonstrated during the COVID-19 pandemic. The WHO has been unable to make China

20 

Anoma Phichai VAN DER VEERE, Florian SCHNEIDER, and Catherine Yuk-ping LO

accountable for their poor track record of transparency, issuing guidelinesthat member states can easily ignore. Moreover, the WHO has been vulnerable to great power competition between the US and China, undermining
coordinated disease responses at both regional and global levels. Satohargues that US action (or inaction) has been by far the most consequential
in undermining the confidence of the global community towards the WHO.
In contrast, Koga argues that the Association of Southeast Asian Nations(ASEAN), the key regional organization in Asia, has made a successful effort
to build its own capacity to tackle emerging infectious diseases (EIDs).
Koga demonstrates how ASEAN’s mechanisms to tackle EIDs were beendeveloped prior to the COVID-19 outbreak. ASEAN’s health governanceefforts were initiated during the Cold War against the backdrop of great
power rivalry, long before the COVID-19 outbreak took place. An accelerationof the institutionalization of health cooperation among ASEAN member
states then occurred after the SARS outbreak in 2003.
Criticism of the functioning of the WHO has been prolific. However,while critiques of the WHO and the UN system are valid, Ishikawa & Kohara
show that the WHO has nevertheless played a positive role in countries
encountering infectious disease outbreaks. In their chapter they offer astatistical investigation into public levels of trust in selected Asian countries
before and after the 2003 SARS outbreak. They demonstrate that public trustin government dropped in the countries that were seriously affected by SARS.
However, they further show that the deterioration in trust was alleviatedin countries hosting a WHO collaborating centre in a domestic research
institute. This suggests that such collaboration with the WHO can mitigate
declining public trust in national governments during public health crises.
Part II of the book, taking into account the function of the WHO in
coordinating disease responses in Asia, attempts to envision the role ofthe institution in global health governance in the future. Gong & Li, forexample, assess Chinese influence on the WHO and the role of China inglobal health governance. They argue that Chinese leadership potential
has been constrained by several factors. Among these factors, two of themost important are the relatively low contributions that China makes tothe funding of the WHO when compared to traditional donors as well as
China’s illiberal and fragmented domestic governance structure. As such,it is misleading to assume that China will have sufficient resources to lead
global health governance, despite the declining role of the US.
Looking at the attitudes towards the WHO of Asia’s other leading power,
Van der Veere shows that Japan viewed the WHO as a neutral and scientificsource of information during the outbreaks of SARS, Middle East Respiratory

Introduc tion: COVID -19 and Asia

21

Syndrome (MERS), and COVID-19. It has often used specific information fromthe WHO to justify domestic policy goals. However, trust in the organization
among policymakers has faltered due to its connection with China. Van der
Veere argues that the importance of the WHO in Japan has declined and willcontinue to do so as long as the organization’s neutrality is in doubt, and aslong as its guidelines and advice conflict with the country’s domestic agenda.
In contrast with the Japanese case, Howe shows that the Republic of Korea(ROK) has seized the opportunity provided by COVID-19 to present itself asa health leader on the world stage. It has positioned itself as an exemplary
member state to the WHO over the course of the COVID-19 pandemic. The
ROK has not only followed and promoted WHO guidelines, but has also
been at the forefront of developing measures to combat COVID-19. Howefurther argues that South Korea, as a middle power, is likely to continue its
support of the WHO and increase its contribution as a global player in thefield of health governance.
While South Korea has increasingly contributed to global health governance, it has frequently been argued that the role of Taiwan in global healthgovernance has remained minimal because of its ambiguous international
status and the increasing pressure exerted on it by the People’s Republic ofChina (PRC). Offering a contrasting argument, Lo instead posits that the defacto status of Taiwan may allow it to escape the so-called ‘realist trap’ thatstate actors often encounter in global health governance. This trap describes
the way that states seeking to engage in international cooperation face
problems such as freeriding or failure to comply with existing norms andregulations. In escaping this trap, Lo argues that Taiwan has the potential
to participate in global health governance in a meaningful way.
Part III of the book consists of a number of contributions examining
domestic responses to COVID-19 in Asia. These case studies explore thevarious factors that have contributed to, or impeded, an effective response
to COVID-19, and their effects on the local population. For example, Nguyenshows that Vietnamese measures to respond to COVID-19 were taken aheadof recommendations made by the WHO in the early stages of the global
outbreak. The chapter also shows how the early responses and strict policies
adopted in Vietnam have limited the spread of COVID-19 in the country. Yet,despite Vietnam’s relative success during 2020, Nguyen also demonstrates thesocio-economic impacts that COVID-19 has had on healthcare in Vietnam,
calling for the provision of social support to those who are most vulnerable
during public health crises.
The chapter by Le & Nicolaisen describes further underlying factors thathave led to the success of the Vietnamese response to COVID-19, namely the22 

Anoma Phichai VAN DER VEERE, Florian SCHNEIDER, and Catherine Yuk-ping LO

timeliness in implementation of policies, the country’s prior experiences
in infectious disease crises, the transparency in communication, and theactive social mobilization. Drawing on the extensive research of Vietnam
they have conducted in the past, Le & Nicolaisen argue that the politicallegitimacy gained by the Vietnamese government could diminish once thepandemic is over. They suggest that this could occur if there is a reversal oftransparent communication or a continuation of economic uncertainties
during the post-COVID-19 era.
While fast action helped contain the spread of COVID-19 in Vietnam, intheir chapter Kamaruddin & Idris demonstrate that there are more factors
than rapid responses in play. They show that the Malaysian government wasin the middle of political unrest when COVID-19 struck and had to scramble
to respond appropriately. Accordingly, Kamaruddin & Idris highlight how
a professional and well-established civil service system can also be key toshaping a country’s pandemic response, even in times of political crises.
However, countries’ actions in response to COVID-19 have not only been
domestically focused. Kim & Song show how, in its response to COVID-19,
the South Korean government quickly embraced multilateralism. It provided
financial resources to key global health initiatives for fair and equal access to
COVID-19 vaccines, established global platforms for dialogue, and enhanced
its participation in global health institutions. They further demonstrate
how the South Korean government has displayed consistent support for the
WHO despite swaying public sentiments in South Korea toward the WHO’s
management of the situation, and a wavering public position towards China.
Part IV, the final section of the book, takes a closer look at the effects of
COVID-19 on workers in different Asian nations, in particular non-regular
workers and migrant workers. It examines the socio-economic impactsof COVID-19 related measures in societies in Asia. To start this section,
Lo discusses the economic and political repercussions on the Chinese
economy of the COVID-related Non-Pharmaceutical Interventions (NPIs).
Considering the ongoing Sino-US trade disputes and the rising suspicionof China and Chinese firms in the US and Europe, this chapter asks towhat extent the Chinese Communist Party (CCP) will be able to save its
performative legitimacy through the new economic strategy dubbed the‘dual circulation strategy’. It looks at the implications of Chinese economic
reforms in the post-COVID-19 era.
With economic reforms likely to follow after the COVID-19 pandemic indifferent countries, changes to the mobility and health conditions of migrant
workers need to be understood. A chapter by Liu presents Taiwan’s successful
experience in dealing with the COVID-19 pandemic during 2020. It also shows,Introduc tion: COVID -19 and Asia

23

however, how the pandemic has exposed the vulnerability of migrant workers
in Taiwan, who often lack healthcare access and financial support. Presenting
these problems faced by migrant workers in Taiwan, Liu calls for changes
to the ‘divide and exclude’ guest worker policy that leaves migrant workers
facing dire working conditions and unable to access basic health services.
Low-wage and migrant workers seem to be among the most vulnerable
groups during public health crises, when existing inequalities are magnified.
In a chapter looking at Japan, for example, Shibata shows how the problems
faced by Japanese workers during the COVID-19 pandemic can be best
understood when seen through the lens of the country’s on-going neoliberal
reforms and when changes in Japan’s labour market and public health system
are taken into consideration. Shibata argues that the problems that Japanese
workers face in the labour market and the welfare system have created anumber of obstacles to the successful management of the pandemic and thenecessary public health interventions. The chapter concludes that the WHO
needs to consider the impacts of nation-specific, socio-economic institutions on public health to improve the formulation of its recommendations
regarding how to respond to global health crises such as COVID-19.
While Japan is a country that receives migrant workers, Indonesian workers mostly migrate to other countries. The chapter by Yazid describes how
Indonesia has responded to the COVID-19 outbreak, which has seen a waveof returnees arriving in the country. Yazid shows that Indonesia’s responses
are essentially in line with the recommendations of the International Labour
Organization (ILO). However, like the arguments made by Shibata about theWHO, Yazid argues that global institutions, in particular the ILO, shouldtake into account the specific characteristics and needs of each country
when formulating a global response.
The COVID-19 pandemic has made it clear that public health crises arecomplex and dynamic processes. As the case-studies in this volume show,
we need to thoroughly understand how certain actions result in particularconsequences. Even if a response is quick and effective, as in the cases ofVietnam and Taiwan (ROC), there are still segments of the populationthat can suffer under the new measures put in place. Socio-economicallyvulnerable groups, such as low-income informal workers, or immigrant
workers, are especially prone to marginalization. The success of a response
to a sudden public health crisis is therefore not only determined by the
number of infections, but by the long-term effects on the public.
Moreover, the politicization of public health has impeded the implementation of a unified global response. This extends from the great power politics
between China and the US to the prioritization of a domestic agenda in the24 

Anoma Phichai VAN DER VEERE, Florian SCHNEIDER, and Catherine Yuk-ping LO

case of Japan. Across Asia we see that public opinion has a lasting effect on
how effective governments can be in responding to new crises. Public trustis quickly eroded and there are only a few means by which governments
can try to re-establish a higher level of legitimacy. Domestically, they might
do this through transparent communication, rapid and strict responses,
media effects, or scientific cooperation with the WHO.
At the same time, however, we have to realize that public health andpublic trust are transnational. They cross borders, and this is where thepolitics between nation-states once again come to the fore. Over the course of
the COVID-19 pandemic, this has forced multilateral and global institutions
like ASEAN, the WHO, and the ILO to play a game of catch up, some more
successfully than others. It is therefore paramount for policy makers, healthspecialists, and the public to realize that health governance is not simply amatter of scientific facts, but a goal that keeps changing, requiring policy
makers and citizens alike to adjust to dynamic circumstances.
If this volume can offer one takeaway, it would be this: Asia is diverse,
and this diversity has practical, real-world consequences. Understanding
the way that Asian countries and regions have variously responded to the
COVID-19 pandemic goes beyond the binaries of ‘success’ and ‘failure’,‘national’ and ‘global’. The diverse responses showcase a mixture of causes
and consequences that continuously come together or fall apart. We do
not know when the next global health crisis will strike, but we know thatthe complexities of our interconnected world make such a crisis almost
inevitable. This makes it essential to look at Asia, to learn lessons where
they are available, and to ensure our societies are better prepared and more
resilient the next time around.

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—. 2020a. ‘WHO Director-General’s Opening Remarks at the Mission Briefing
on COVID-19.’ 2 April. Accessed 17 June 2021. https://www.who.int/directorgeneral/speeches/detail/who-director-general-s-opening-remarks-at-themission-briefing-on-covid-19---2-april-2020.
—. 2020b. ‘WHO Director-General’s Opening Remarks at the Media Briefing on
COVID-19.’ 27 March. Accessed 17 June 2021. https://www.who.int/dg/speeches/
detail/who-director-general-s-opening-remarks-at-the-media-brief ing-oncovid-19---27-march-2020.
—. 2021a. ‘How WHO is Funded.’ Accessed 17 June 2021. https://www.who.int/
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pdf?sfvrsn=18b1db33_1.

About the Authors
Anoma Phichai VAN DER VEERE is a Researcher of Modern Asia within
the Leiden Asia Centre at Leiden University, and a Research Fellow at the
IAFOR Research Center at the Osaka School of International Public Policy.
He is currently based at Osaka University, Japan, and has published onhealth and labour policy, sports, technology, and human rights in Asia
and Europe. His latest publications include: ‘Japan’s Fragmented Response:Technology, Governance, and COVID-19’ (Leiden Asia Centre, 2020), ‘The
Tokyo Paralympic Superhero: Manga and Narratives of Disability in Japan’(Asia Pacific Journal: Japan Focus, 2020), and ‘The Technological Utopia:

Introduc tion: COVID -19 and Asia

27

Mimamori Care and Family Separation in Japan’ (AsiaScape: Digital Asia,
2019). He is currently the principal investigator in the Road to Tokyo 2020
project about local policymaking in disability sports in Tokyo in the run-up
to the 2020 Olympic and Paralympic Games, and the ‘Understanding theLimitations and Future of Transnational Migrant Labor and Global Health
Governance in Asia’ project, both funded by the Leiden Asia Centre.
Catherine Yuk-ping LO is an Assistant Professor at University College Maastricht, Maastricht University. She specializes in international relations andglobal health. Her current research interests include HIV/AIDS in China
and India, infectious disease responses in Northeast and Southeast Asianstates, antimicrobial resistance (AMR) challenges in the Global South andNorth, and also global health diplomacy. She is the author of HIV/AIDS in
China and India: Governing Health Security (Palgrave Macmillan, 2015). Herbook won the 2017 International Studies Association (ISA) Global Health
Section Book Prize. Her works appear in such journals as the Australian
Journal of International Affairs, Health and Policy Planning, Globalizationand Health, and the Journal of Global Security Studies.
Florian SCHNEIDER, PhD, Sheffield University, is Senior University Lecturer
in the Politics of Modern China at the Leiden University Institute for Area
Studies. He is managing editor of Asiascape: Digital Asia, director of the
Leiden Asia Centre, and the author of three books: Staging China: The Politics
of Mass Spectacle (Leiden University Press, 2019, recipient of the ICAS Book
Prize 2021 Accolades), China’s Digital Nationalism (Oxford University Press,
2018), and Visual Political Communication in Popular Chinese Television Series(Brill, 2013, recipient of the 2014 EastAsiaNet book prize). In 2017, he wasawarded the Leiden University teaching prize for his innovative work as an
educator. His research interests include questions of governance, politicalcommunication, and digital media in China, as well as international relationsin the East-Asian region.

PART I
Health Policy in Asia and the Global Community

1Fighting for a Global Community in a
Post-COVID World
Haruko SATOH

Abstract
This chapter argues that the COVID-19 pandemic has exposed the weaknesses of the UN system. This system becomes ineffective when the UnitedStates fails to lead during global health crises. At the regional level, the
COVID-19 responses in Asian countries have shown that China cannot
garner enough trust to replace the US as a leading power to maintainregional order. China was not transparent enough in handling the newvirus at the start of 2020. Besides, Beijing’s intimidation tactics towards,
among others, Hong Kong, Taiwan, and Australia, continued unabatedduring the first year of the COVID-19 pandemic. These incidents highlightthe importance of the US presence in the region. The chapter concludes
that restoring trust in the US as the beacon of democracy and openness
is crucial.
Keywords: international community, United Nations (UN), public health,
US-China rivalry, COVID-19, international order

The COVID-19 pandemic has been a profound reminder that international
cooperation in the United Nations (UN) system cannot be taken for granted,
even in the face of a global health crisis where millions of lives may be at risk.
The World Health Organization (WHO) saw its ‘directing and coordinating
authority’ to lead the world out of the pandemic hampered from the outset
as it became embroiled in a blame game between the United States andChina. The US not only forfeited its leadership role but also became part ofthe problem as then president Donald Trump refused to publicly aknowledge
the gravity of the new virus (Woodward 2020; Forgey and Choi 2020).

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_ch01

32 Haruko SATOH

China tried to compensate for its initial missteps in handling the outbreakby engaging in ‘mask and test kits diplomacy’ (and later ‘vaccine diplomacy’)toward affected countries. However, these Chinese diplomatic actions met
with a mixed reception, particularly in Asia where many are concerned
about China’s expansionist intent (Chellaney 2020). While the WHO was
vilified for failing to rise above this rivalry between major powers, thecontext in which this occurred is equally, if not more, problematic. The
growing US-China rivalry has far-reaching implications for restoring global
trust in the UN system of international cooperation.
This chapter takes a broader view of the COVID-19 pandemic. It sees thisas a crisis to the system of global governance in relation to the future of
the liberal international order, with a focus on the the Asia-Pacific region.
The responses of Asian states to COVID-19 have varied, ranging fromhighly organized approaches to muddling through. Asian states werearguably more concerned by the abrupt changes to economic conditions,such as border closures and restricted mobility, than by the debates that
divided societies in Europe and North America over effective measures forcontrolling the spread, such as wearing face masks and lockdowns.1
Most Asian states had experienced pandemics before, which meant
they were better prepared to manage the crisis in terms of institutional
capacities, having already developed aspects of the healthcare systemneeded to respond to pandemics and information technology that allowed
them to carry out ‘track and trace’ of patients (Fitzgerald and Wong
2020; Pardo et al. 2020). Moreover, for most governments in Asia, hard
lockdowns tended to be a reluctantly pursued ‘last resort’ option. This
debunks the notion that Asian governments tend to be more authoritarianand that Asian societies are more compliant and group-oriented (Nikkei
Asia 2020).
However, it should be noted that Asia is seeing arguably more profoundpolitical changes than other regions of the world. The region is also beset byuncertainty over a US-China rivalry, which is affecting the regional order. In
this way, Asia could be seen as a microcosm of what could happen globallywith regards to America’s diminished standing in the world and its ability
to maintain the liberal international order in the face of China’s apparent
revisionist intentions. By focusing on the Asia-Pacific region, this chapter
argues that US actions (or inactions) have been most consequential during
1 Mask-wearing was not a hugely contested issue as East Asians are accustomed to wearing
face masks during the flu and hay fever seasons, and also to protect against harmful airborne
particulates (PM 2.5) produced by industrial activities and heavy urban traffic.

Fighting for a Global Communit y in a Post- COVID World

33

this pandemic in undermining the global community’s confidence in theUN system as represented by the WHO.

Global Community Matters
It has been three decades since the Berlin Wall collapsed in 1989, and since
the end of the ideological conflict between the ‘free world of the West’ andthe communist bloc, respectively led by the two superpowers, the US andthe Soviet Union. In 1991, the first Gulf War then brought together the former
enemies to agree at the UN Security Council that Iraq needed to be drivenout of Kuwait. This moment sparked the hope that the UN might finallybe on the track to function as originally intended, as a world government
and a ‘peace factory’ (Solana 2020).
Although declarations made at the time of a ‘new world order’ and the‘end of history’ (Fukuyama 1989; 1992) were evidently premature, the UN
neverthless gained renewed relevance at this time. It was called upon to takecharge of a significant portion of problems and challenges of the post-Cold
War world. One indicator of this growth in UN activities can be seen in rise in
the number of UN Security Council resolutions that have been passed since1990. Until then, there had been less than 700 resolutions (the resolution thatsanctioned the use of force against Iraq was number 678). However, in thethree decades since 1990 there have been nearly 2000 additional resolutions(UN 2021). Also, importantly, at this time the notion of the ‘global’ took holdof people’s imagination and became part of the lexicon of diplomacy andinternational politics (Iriye 2002, 159).
The post-Cold War era was characterized by the emergence of a worldof borderless, near-global connectivity. The globalization of capitalism
brought an unprecedented level of economic development and growth
to vast parts of the world. Rapid advances in information technology,
especially the advent of the Internet, hastened the pace of this globalization. This in turn increased the level of interdependence between nations
and economies at the level of everyday life, creating a realm where therole of states receded to the background. This also meant that the notion of security broadened in tandem with global social and economictransformation. An entirely new category of non-traditional security(NTS) issues, such as climate change, pollution, international terrorism,
mass migration, and infectious diseases were identif ied as threats tointernational peace and security. In short, it was a world where ‘my concern
is your concern, too’.

34 

Haruko SATOH

Yet, the UN system and the global community it represents are inherently
fraught with political tension. The differences in the political systems
and value systems of the UN member states, combined with the principleof upholding state sovereignty, make joint action difficult (Satoh 2021).
Although the UN has a general charter that espouses certain ‘universal
values’, it does not make state membership conditional based on sharedvalues in the way the European Union (EU) does. The UN’s paradoxical
set-up of respecting the sovereignty of member states while at the same time
asking for the transference of sovereign rights requires intense negotiations
for consensus-building among member states. At worst, the UN system risks
becoming a ‘spoils system that puts too many people in important positions
for reasons other than competence, lack of accountability, and hypocrisy’(Haass 2020). An example of this might be the way that countries that ignore
human rights sit on a UN body meant to uphold them.
In this sense, the problems that the WHO initially encountered in handling the outbreak of COVID-19 were neither unforeseen nor new. First,
China’s track record for transparency and openness was questionable even
before the pandemic (Stanway 2020; Perper 2020). Second, the WHO has
no enforcement power and can only issue guidelines for the member states
to voluntarily follow. Third, great power rivalry obstructing international
cooperation in the UN system is, as explained above, endemic, if not thenorm. Last, but not least, intensifying China-US rivalry over trade, geopolitical influence, and concerns about the fate of the rule-based, international
order was already foreshadowing difficult times ahead for the UN andmultilateralism in general (Satoh 2021).
The Trump Problem
What the global community did not foresee this time, however, was theextraordinarily uncooperative behaviour of the ‘America First’ president
Donald Trump and his administration in handling the pandemic. After hetook office in 2017, and through until his defeat in the 2020 presidential
election, Trump wantonly undermined the liberal international order ofalliances and international institutions of American design, showing a
disdain for multilateralism. However, very few (if any) could have predictedthat under Trump the US would become one of the countries worst hit by
the pandemic, counting over 300,000 deaths by the end of 2020. That 2020
was an election year did not help, as Trump appeared more concerned withwinning a second term in the November elections than saving lives (Shear
2020). He knowingly ignored the science, tweeted misinformation, andFighting for a Global Communit y in a Post- COVID World

35

turned (non-)mask wearing into a political statement. At the same time,
he blamed others, including his chief public health advisor Anthony Fauci,
the former president Barack Obama, and above all China and the WHO,for the consequences of the political and public health mayhem that his
administration’s inaction was causing (Forgey and Choi 2020; Woodward2020).
China’s missteps and the WHO’s alleged complicity in downplaying thedanger of the new virus rightfully drew international criticism. However,
Trump made no attempt to salvage the WHO’s reputation, even though the
US was its largest donor. Instead, he chose to punish the WHO by first freezing funding and then withdrawing the US from the organization altogether.
In this way, Trump essentially reduced the pandemic and the WHO to mere
props to enhance his popularity as a MAGA (Make America Great Again)
leader who is ‘tough on China’.
Under Trump’s successor, Joe Biden, the US has now rejoined the WHO, aswell as the Paris climate accord which the US officially left in November 2020
(BBC 2020; Biden 2020). These are important steps for the US to recover lostinternational ground. However, the Trump administration had also chiselledaway at America’s democracy, which is arguably a deeper concern to theglobal community esconsed in the US-led liberal international order. For
allies and many parts of the world that looked to the US as the beacon of
democracy, faith in liberal values, such as in the freedom, human rights,
and transparency undergirding this international order, was badly shaken(Kaufman 2017; Stokes 2018).
While the US has never been a natural multilateral player, the effectiveness of international organizations, such as the WHO, in providing global
public goods has depended greatly on America’s willingness and ability to
do the same. That is why Trump’s excessive unilateralism and attack on
democracy are tantamount to a crisis in the entire international system.
The Impact on the Asia-Pacific
The Asia-Pacific region is the main arena where China is challenging the USled post-1945 order. This order is frequently described as a hub-and-spokes (SanFrancisco) system of bilateral alliances (with Japan, South Korea, Australia,
the Philippines, and Thailand). The COVID-19 pandemic hit at the time when
China was increasingly becoming assertive, while the US commitment toAsia-Pacific regional security was waning under the Trump presidency.
In recent years, the Asia-Pacific region had seen various examples ofChina’s ‘wolf warrior’ diplomacy and muscle flexing, including the maritime36 

Haruko SATOH

territorial disputes in the South and East China Seas, Beijing’s attempts
to quash demonstrations in Hong Kong, increasing bullying of Taiwan(including its exclusion from the WHO; Chen and Cohen 2020), and therecent intimidation of Australia after it asked China to account for theorigins of the coronavirus.
Yet, with Trump behaving more as a ‘kindred spirit of the neo-authoritarians’ (Wright 2018) than as a leader of democracies, China’s challenge
to the status quo was alarming not only to US allies in Europe, but also
to democratic allies in Asia, such as Japan, South Korea, and Australia.
These allies in Asia all have a higher stake in maintaining the ruled-based,international order in the region. In this regard, the COVID-19 pandemic’s
impact on the Asia-Pacific regional order offers insights into why restoring
trust in the UN system is contingent upon how the US recovers from theinternational impact of Trumpism.
Regionalism in the sense of community development is a work-in-progressin the Asia-Pacific region. The region does not have a values-based, overarching organization like the EU or a security architecture like the North
Atlantic Treaty Organization (NATO). There are democracies as well as
communist or military-led authoritarian regimes. The principle of noninterference prevails across the region, such that many consider it as ‘themost Westphalian region’ (Howe 2020). While security has long relied on
the hub-and-spokes system, the spoke states are not necessarily friendly
toward each other, as seen in the case of Japan and South Korea. As thechief architect of the regional order, commitment from the US is therefore
crucial to the system’s cohesion and survival (Richey 2019).
On the other hand, there is another layer of the region’s relations that has
primarily been economically driven, where Northeast and Southeast Asia
are highly economically interdependent and interwoven as a production
network (Kimura and Obashi 2011). The Asia Pacific Economic Cooperation(APEC), a regional forum that was established in 1989, is representative of
how the region often prioritises economic development and interdependence
over issues such as democracy and human rights. Therein lies the paradox
where China, Japan, and South Korea can be politically antagonistic toward
each other, and yet still maintain closely knit economic ties with each other,and also with Southeast Asia.
In this complicated landscape, regional political dialogue and mechanisms for cooperation have evolved around the Association of Southeast
Asian Nations (ASEAN). The institution’s role has been indispensable infacilitating multilateral dialogues, such as the ASEAN Regional Forum (ARF),
the various ASEAN plus formulas and the East Asia Summit that involve

Fighting for a Global Communit y in a Post- COVID World

37

all stakeholders, including China, the US and Russia (see the contribution
by Koga about ASEAN in this volume).
However, despite these regional forms of cooperation, there continues tobe great importance attached to US presence – as a democracy and providerof public goods, such as safety of navigation – as the regional order evolves.
Yet, during the Trump presidency the US failed on both fronts: as the beaconof democracy and the guarantor of stability for the region.
Trump’s ‘tough on China’ agenda was welcomed in some security circles
in Japan or Australia. However, this agenda did not translate into a stronger
hub-and-spokes system or enhanced multilateral dialogue. Instead, thealliance politics and multilateralism in Asia faced difficulties with Trump’stransactional style of ‘America First’ diplomacy, in a similar way to NATO.
That said, we need to note here that the attempts by Trump’s predecessors,
George W. Bush and Barack Obama, to engage with China also had theirstrengths and weaknesses. These two former presidents presided over the
US’ China policy during nearly two decades in which China was rapidlytransforming. They were responding to a rising country whose economic
importance became undisputed. However, the ramifications of a rising
China for regional security order were not then clear, nor did they occupy
the same central position in in US policy toward Asia as they have since.
Whatever one might think of these two former presidents’ policies toward
China, however, neither of them allowed the hub-and-spokes system tofragment by ignoring multilateral frameworks in the way that Trump did. For
example, a fallout between Japan and South Korea, the two most important
US security allies in Asia, took place in the ‘shadow’ of Trump’s theatrical,
but ineffective, dealings with the North Korean dictator Kim Jong-un.
The Japan-South Korea relationship is now at its lowest point since thenormalization of relations between the two countries in 1965 (Satoh 2020).
During his time as president, Trump only attended two APEC meetings (2017in Da Nang, Vietnam and 2020 in Kuala Lumpur, Malaysia, the latter held
virtually), and he attended none of the East Asian Summits. His withdrawalof the US from the Trans-Pacific Partnership in his first year in office wasan ominous sign for a region where managing economic relations is an
integral part of regional stability.

The Trust Deficit
As has been mentioned earlier in this chapter, the COVID-19 pandemic hit
at a time of growing regional uncertainty about the extent to which the US38 

Haruko SATOH

would intervene in China’s attempts to challenge established norms. At a
global level, trust in the US became a rare commodity as its ability to leaddiminished. The regional response to the pandemic revealed a complex
interplay of ‘untrusting’ relations between the US, China, and the regional
states. This occurred as part of an on-going order transition from one basedon the hub-and-spokes system to one where China may become dominant.
The question boiled down to trust, and who to trust, with trust remaining
in short supply.
People in different parts of Asia, such as in Vietnam, Singapore, and Hong
Kong, had not forgotten China’s mishandling of the 2002-3 Severe AcuteRespiratory Syndrome (SARS) pandemic. At that time, China reportedly
hid the outbreak in Guangdong from the WHO for several months (Martin
2020; Perper 2020). Therefore, when COVID-19 outbreaks occurred, China’s
apparent attempts to once again obfuscate the origins of a new coronavirus,
including its unwillingness to allow WHO inspections (Euronews 2021),
deepened the region’s inherent mistrust towards it. After this, it appearedthat no amount of ‘mask diplomacy’ was going to win China trust fromregional states (Kausikan 2020).
However, the humanitarian and political disasters caused by the WhiteHouse’s misinformation about the virus were arguably a deeper concern topeople in Asia, and the region’s faith in the US took a nose-dive. If China’s
problem was suppressing inconvenient facts, America’s problem was thatit had no use for truths, let alone facts.
The attitudes of ASEAN states toward China and the US are, in this case,
illuminating as they are informed by their past colonial experiences andthe Cold War bipolar system. These experiences have left ASEAN stateswith a strong desire to maintain autonomy and to avoid entanglement ingreat power rivalry. The current regional organization was formed, after
all, during the ideological divide between the US and the Soviet Union.
ASEAN countries remain wary of taking sides, nowadays between the US
and China. Maintaining manoeuverability by hedging is their key strategy.
They are cautious toward both China and the US, although the sense of threatand suspicion toward China is traditionally greater. A Singaporean thinktank’s survey (mainly of government officials, academics and researchers inthink tanks, and businessmen) proves these points vividly: while a majority(52.2%) acknowledge China to be the greatest political and strategic powerin Southeast Asia, 53.5% also see it as a threat (corresponding percentages
for the US are 28.7% and 21.8%, respectively). Regarding what choices
ASEAN should make based on US-China rivalry, 48% chose to ‘enhance
ASEAN resilience and unity’, while 31.1% chose ‘not siding with China orFighting for a Global Communit y in a Post- COVID World

39

US’. This may reflect some wishful thinking, as well as ASEAN’s penchantfor hedging (ISEAS 2020).
Indeed, ASEAN’s preference for avoiding entanglements in great power
rivalry makes multilateralism and rule-based international order important.
This preference also makes other multilateral players, such as Japan and theEU, attractive in the eyes of ASEAN states. While China and the US, the two
great powers that can act unilaterally, are regarded with caution, these othermultilateral players are viewed more favourably. In the same survey, over 60%
expressed little or no confidence in China to ‘do the right thing to contribute to
global peace, security, prosperity and governance’. For the US, this percentage
is just under 50%. By comparison, Japan and the EU respectively receive a
61.2% and 38.7% confidence rating. Japan is considered a threat by only 5.0%
of respondents, while the EU is considered a threat by just 3.5%.
At the same time, only 10.5% of respondents saw China as a ‘responsible
stakeholder that respects and champions international law’. This is compared
to 15.4% for the US, 51% for Japan, and 68% for the EU (ISEAS 2020, 16-18).
That ASEAN does not trust either China or the US to ‘do the right thing’should be food for thought for the Biden administration as it plans for the
US to make its comeback as a global leader.
However, future US engagement in Asia needs to be more mindful of thecomplex structure of the political economy in the region. As mentioned
earlier, in Asia taking sides or ‘decoupling’ from China is not an option. Thisapplies to the two main hub-and-spokes allies, Japan and South Korea. We
might also note that democracy as a preferred political system has come tomatter more than before in Asia, especially at the grassroots level. This isin reaction to what has been described as China’s ‘salami-slicing strategy’.
It has been suggested that China uses this strategy to slowly undermine
the integrity of countries and organizations. To this end, it has been argued
that China uses a combination of diplomatic and economic tools (such as
the creation of debt traps), soft and hard power, and technology to makeinroads into countries and organizations (Chellaney 2013).
China’s encroachment and the COVID-19 pandemic have highlighted theimportance of the political side of the liberal international order. Issues oftransparency and accountability have become more important as states
have sought to ensure accurate information and trust-based international
cooperation to combat COVID-19. Most Asian states, including China, hadtaken advantage of the liberal economic order for their development. Someof these states have been ambivalent, if not hostile, toward embracing
democracy because they saw it as a Western imposition. However, thissituation may be changing. The presence of the US as an ‘Asian power’ in40 

Haruko SATOH

this context would be important. However, this makes the damage done
to US credibility by the Trump presidency all the more of a grave concern,
both to the region as well as to states around the world.

Coda
It might be worth noting that the pandemic has not necessarily strengthened
China’s position in the region, although it has emerged as the only country
to register economic growth in 2020. If anything, it has demonstrated that
China is no more qualified to be a global leader than the US was under
Trump. This is largely because China’s expansionist actions continued
unabated throughout the year when regional states and regions were all
struggling to handle the COVID-19 outbreak. Its actions in Hong Kong werearguably most noticeable, with the imposition of its new national security
law in June 2020 (Maizland and Albert 2020). That said, there is growing
recognition that the question of how democratic governance can take firmer
root in Asian countries is tied to the future form and shape of regional order.
Recognition of the need to protect or fight for democracy as a politicalsystem, and to keep the liberal international order, has only a limited placein the political evolution of the Indo-Pacific. The goal for many Asian states
is not necessarily to become liberal democracies in the model of Europe
and North America. Rather, Asia’s path to democracy is being shaped outof a social and political struggle that involves pushing back postcolonial
legacies, the strong role of the military, a resistance to the imposition of‘universal’ values, and a guarded stance against China.

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About the Author
Haruko SATOH is co-director of the IAFOR Research Centre at the Osaka
School of International Public Policy, Osaka University, a member of IAFOR’s
Academic Governing Board, and Chair of the Politics, Law & International
Relations section of the International Academic Advisory Board. She is amember of the International Advisory Board at the Leiden Asia Centre
at Leiden University. She is a Specially Appointed Professor at the Osaka
School of International Public Policy (OSIPP), where she teaches about
topics including Japan’s relations with Asia and identity in international
relations. She was previously part of the MEXT Reinventing Japan projecton ‘Peace and Human Security in Asia (PAHSA)’ with six Southeast Asianand four Japanese universities.

2

Countering Emerging Infectious
Diseases and COVID-19
The Development of ASEAN’s Institutional Arrangements
and International Cooperation
Kei KOGA

Abstract
This chapter argues that ASEAN’s mechanisms to tackle emerging infectious diseases (EIDs) have been developing gradually since the declaration
made at the ASEAN Health Ministers Meeting (AHMM) in 1980. While the2003 SARS crisis significantly enhanced ASEAN’s cooperation to counter
EIDs, ASEAN had already laid a foundation for such cooperation before
2003. This chapter shows that ASEAN has tended to focus on the regionalrather than global level due to a lack of financial and technical resourcesand ASEAN’s long-standing institutional norms. The recent intensificationof great power rivalries, particularly between the United States and China,
means that relying on external actors for medical support would entrap
ASEAN in great power politics. As such, ASEAN needs to make efforts tobuild its capacity to respond to EIDs.
Keywords: emerging infectious diseases (EIDs), ASEAN, regional cooperation, SARS, COVID-19, institutional norms

1

Introduction

The Association of Southeast Asian Nations (ASEAN) was established in 1967
as a multi-purpose regional institution that facilitates social, economic, andpolitical cooperation in Southeast Asia. Despite the severe regional strategic
environment during the Cold War era, when great powers competed with

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_ch02

46 Kei KOGA

each other for influence in the region, ASEAN was able to maintain its
relative autonomy and promote economic development by strengthening
intra-ASEAN cooperation in a comprehensive manner (Acharya 2014, 43-78;
Koga 2017, 28-76; Emmers 2018, 349-370).
ASEAN’s areas of cooperation include health cooperation. This is because ASEAN has a ‘comprehensive’ concept of security, which not only
focuses on the military but also the economic and social aspects of security.
The approach aims to support ASEAN member nations’ socio-economic
development to increase their domestic regime security, which can also
contribute to regional security through the enhancement of national stability(Emmers 2009, 161-163). However, health governance mechanisms havebeen underdeveloped in ASEAN. Given its limited resources, ASEAN has
consistently needed to prioritize some issues over others. Health was not
top of the organization’s agenda in its nascent days. During the Cold War
era, ASEAN made little effort to advance health-related cooperation or tocreate a mechanism that could manage regional health issues.
This trend somewhat reversed in the post-Cold War era, particularly after
the start of the new millennium. The end of the strategic rivalry between two
global superpowers generated globalization, which facilitated the economic
and social interconnectedness and increased the salience of transnational
security issues. These trends contributed to a shift towards ASEAN placing
greater attention on health cooperation. Further, the emergence of severe
acute respiratory syndrome (SARS) in Southeast Asia in 2003, which had
a serious negative socio-economic impact on different ASEAN member
nations, facilitated regional health cooperation. During the 2003 SARS
outbreak, national governments in the region, the World Health Organization(WHO), and epistemic communities securitized health issues and facilitatedthe creation of regional cooperation programs (Caballero-Anthony 2018, 6166). However, the development of ASEAN’s health governance mechanisms
did not occur overnight. Instead, it was a gradual process through which
ASEAN created its own mechanisms, enhanced its communication links
with international organizations, and facilitated regional cooperation.
This chapter argues that ASEAN’s emerging infectious disease (EID)
mechanisms have been developing gradually since the declaration madeby the ASEAN Health Ministers Meeting (AHMM) in 1980. While the SARS
outbreak significantly enhanced ASEAN’s cooperation to counter EIDs,
ASEAN had laid a foundation for such cooperation before this, and it continued to develop the cooperation afterwards. ASEAN created institutional
linkages with the WHO in 1997. It also institutionalized regional cooperation
mechanisms after the 2009 H1N1 outbreak.

Countering Emerging Infec tious Diseases and COVID -19

47

Furthermore, ASEAN has tended to focus more on cooperation at theregional rather than global level. This is due in part to a lack of financial andtechnical resources and ASEAN’s long-standing institutional norms, such as
the non-interference principle. Regional states are more familiar with these
institutional principles and norms – the so-called ‘ASEAN Way’ – and havesignificant interests in its aims of increasing regional economic and security
stability. The recent intensification of great power rivalries, particularly
between the United States and China, means that relying on external actors
for medical support would entrap ASEAN in great power politics. As such,
ASEAN needs to make efforts to build its own capacity to respond to EIDs.
This chapter is divided into three sections. The first section outlines
the three phases seen in the development of ASEAN’s health governance,
which were caused by three pandemic shocks, namely SARS in 2003, H1N1
in 2009, and COVID-19 in 2020. The second section examines ASEAN’s
global, regional, and national level cooperative frameworks, highlighting
the salience of regional frameworks. The third section discusses the future
implications of ASEAN’s management of COVID-19, analysing the extent
to which it can facilitate regional cooperation amid the ongoing strategic
confrontation between the US and China.

2

The Development of ASEAN’s Health Governance

ASEAN’s health governance efforts were initiated during the Cold War. In
fact, since the organization first made a declaration about health governance at the second AHMM in 1980, ASEAN has gradually consolidated its
health-related institutions (ASEAN 1980a). One of the main aims of ASEAN
when it was established was to further socio-cultural development in the
ASEAN region. It was believed that this kind of domestic development would
contribute to the enhancement of ‘self-reliance and self-determination’(ASEAN 1980b). Functional cooperation, such as exchanges of ‘information,
experience, and expertise’ and ‘identification of specific regional projects,’
was thus endorsed as a first step of institutional development on health(ASEAN 1980b).
In the 1990s, ASEAN also strengthened its ties with global health institutions. Most notably, ASEAN signed a Memorandum of Understanding (MOU)
with the World Health Organization (WHO) in 1997 (ASEAN, 1997). Oneof the most important reasons for concluding such an MOU was because
the member states included in the different WHO regional offices do notcorrespond with the member states of ASEAN. Specifically, the WHO’s

48 Kei KOGA

Regional Office for South East Asia (SEARO) includes Indonesia, Myanmar,
and Thailand. However, seven other ASEAN member states belong insteadto the WHO’s Regional Office for the Western Pacific (WPRO). Because
these different geographical demarcations would create redundancy andinefficiency, the memorandum signed by ASEAN and the WHO was an
attempt to ensure policy coordination among these groupings.
Admittedly, ASEAN’s institutional consolidation did not go smoothly.
After the second ASEAN Health Ministers Meeting was held in 1980, it thentook sixteen years to hold the next three ministerial meetings. The third
meeting was held in 1984, the fourth in 1991, and the fifth in 2000 (ASEAN
1991). This demonstrates the relatively low priority placed on health by
ASEAN. However, this trend changed in March 2003, when SARS spreadin Southeast Asia, disrupting economies and societies in the region. Since
then, the development of ASEAN’s health governance has moved forwards
in three phases; these were prompted by the outbreaks of SARS in 2003,
H5N1 in 2005, H1N1 in 2009, MERS in 2012, and COVID-19 in 2020.
First Phase: Ad hoc Responses
The first phase started in 2003, when SARS emerged in Southeast Asia. Its
economic impact was significant, albeit short-term. For example, the numberof tourists and visitors to Malaysia, Thailand, and Singapore dropped byapproximately 30% between March and May 2003. This affected various
business sectors in the countries and cost around US$40 billion (Barua
2020; Caballero-Anthony 2020, 222). In response to this, ASEAN began toseriously discuss its coordinated responses to the pandemic. However, at
this time ASEAN lacked financial resources, expertise in countering EIDs,
and medical infrastructure to implement measures that could cover all ofSoutheast Asia. As a result, ASEAN began to coordinate its policies andoperations with external actors.
ASEAN explored utilizing two institutional frameworks: the ASEAN
Plus Three (including ASEAN members, namely Brunei, Cambodia,
Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, Vietnam,
Thailand, with China, Japan, and South Korea) and the ASEAN-China
framework. Given the geographical proximity and deepening economic
interconnectedness of states in these two cooperation frameworks, theirinterests were relatively congruent. The ASEAN Plus Three (APT) framework
was a particularly useful tool for ASEAN to receive external assistancebecause the framework included the regional economic powers of Japanand China. Indeed, in April 2003, soon after the SARS outbreak, this group

Countering Emerging Infec tious Diseases and COVID -19

49

held a special meeting. The states involved issued a joint statement callingfor a coordinated work plan, namely the ASEAN Disease Surveillance Net
and the ASEAN Epidemiologic Network (ASEAN 2003a). In 2004, the group
created the APT Emerging Infectious Diseases (EID) programme to discuss
effective surveillance capacity as well as early warning and rapid response
mechanisms (ASEAN 2006). ASEAN and China also held a meeting andissued the Joint Statement of the Special ASEAN-China Leaders Meeting on
SARS. Both actions aimed to coordinate measures taken to counter SARS
by exchanging information, creating a ‘hotline’ network, and facilitating
research collaboration (ASEAN 2003b). However, the two initiatives were
not entirely successful. Their shortcomings stemmed from a lack of generalinstitutional mechanisms. The cooperation of the APT and ASEAN-China
frameworks only facilitated ad hoc responses to SARS. These mechanisms
did not create longer-term institutions to tackle EIDs.
The trend for limited cooperation on tackling infectious diseases persisted
in East Asia (geographically covering both Northeast Asia and Southeast
Asia) because not all regional states were equally negatively impacted by
SARS. Admittedly, EIDs were seen as a regional issue to some degree. For
example, participants in the East Asia Summit (EAS) in 2005, including
three APT members, Australia, India, and New Zealand, expressed theirconcerns about the emergence and the spread of the H5N1 virus, also called
Avian Flu (ASEAN 2005). As a result, the summit created five priority areas
for regional cooperation which included avian flu. However, EIDs were also
considered sub-regional specific issues. It was not until the sixth East Asia
Summit in 2011 that the scope of EID management was broadened. This
modified the objective to ‘enlarge cooperation in the fight against avian flu
to encompass broader global health issues and pandemic diseases’ (ASEAN
2011). In this sense, ASEAN-led organizations were not compelled to createa general framework to tackle infectious diseases in the first phase.
Second Phase: Institutionalization
The second phase began around the year 2009, as the frequency of infectious
diseases affecting the region was gradually increasing. After experiencing
SARS in 2003, and then H5N1 in 2005, Southeast Asian states faced a novel
influenza H1N1, also called Swine Flu, in 2009 (CDC 2009). In 2013, theMiddle East Respiratory Syndrome (MERS) coronavirus emerged. Then in2015, South Korea faced a MERS outbreak which also created fear acrossthe region (CDC 2015; WHO 2015). The series of pandemics in Asia propelled
ASEAN to establish general mechanisms to counter EIDs within ASEAN-led

50 Kei KOGA

institutions. The aim was that these mechanisms would allow ASEAN to
rapidly respond to such events by monitoring and analysing situations.
Since APT had past experiences in dealing with regional infectious diseases,
it became the basic platform used to facilitate the establishment of suchfunctional cooperation.
In fact, APT created more functional mechanisms in addition to its
previous effort to implement an EID programme. In 2010, it created theASEAN Plus Three Partnership Laboratories (APL) to carry out laboratory
surveillance and regional networking (ASEAN 2010b). This was supportedby the National Institute of Infectious Diseases of Japan (NIID). In 2012,
APT health ministers decided to focus on ‘Communicable and Emerging
Infectious Disease, Pandemic Preparedness and Response’ and produced
the ASEAN Strategic Framework on Health Development from 2010 to 2015
(ASEAN 2012b). At the same time, the APT also established the ‘ASEAN+3
Field Epidemiology Training Network’ (FETN; ASEAN 2012a). The ASEAN
Emergency Centre (EOC) Network for public health emergencies, which
aimed to promote information-sharing among the Public Health Emergency
Operations Centres (PHEOCs) of the ASEAN member states, was also established in 2016 (Disease Control Division, Ministry of Health Malaysia 2016).
Alongside these APT functional mechanisms, the ASEAN Secretariat
and the WHO signed a Memorandum of Understanding to form a strategic
partnership in 2010 (ASEAN 2010a). ASEAN and the WHO, however, needed
to resolve a perception gap about disease control. ASEAN suggested that the
WHO’s pandemic alert levels did not necessarily match the reality in the
ASEAN region and needed to be updated (ASEAN 2010a). This shows that
information dissemination and sharing were not only the responsibility of
global institutions but also that of regional institutions and states (as well
as non-state actors). Strategic partnership status would be able to facilitate
these activities by more concretely institutionalizing the inter-organizational
interactions.
Third Phase: Activation
The third phase in the development of ASEAN’s health governance began in
December 2019, when the world saw the first cases of COVID-19 appearing
in China. This phase presents more continuity with the second phase thanchange. However, COVID-19 is the first case where it has been necessary
to activate the mechanisms to handle EIDs that ASEAN had established,
to assess their utility and to improve them. Indeed, in its response to the
COVID-19 crisis, ASEAN has both utilized existing health governanceCountering Emerging Infec tious Diseases and COVID -19

51

mechanisms and created new ones. Admittedly, they did not necessarily
function smoothly. During the initial phase, ASEAN was uncertain about
how to collectively respond to the virus. In January 2020, China’s government
said that there was ‘no clear evidence of human-to-human transmission’ of
COVID-19. The WHO cautiously stated the necessity for additional investigation (WHO 2020). Because of such ambiguous information as well associo-economic differences among the ASEAN member states, these states
responded differently to the COVID-19 outbreak. Until 30 January, when the
WHO declared COVID-19 to be a ‘Public Health Emergency of International
Concern (PHEIC)’, ASEAN did not take serious political and social measures
to respond to the virus. This slow response from ASEAN has been criticizedby some scholars and policy-makers (e.g. Djalante et al. 2020).
However, several mechanisms had been activated to f ight against
COVID-19. For example, on 24 January, the ASEAN EOC Network and
the ASEAN Biodiaspora Virtual Center (ABVC) launched its ‘Risk Assessment for International Dissemination of 2019-nCoV across ASEAN’ (ABVC2020). This report provided information about the situation regarding thecoronavirus in Southeast Asia. It warned about a possibility of humanto-human transmission spreading all over Southeast Asia because of theextensive travel between China and the region (ABVC 2020). Furthermore,
the ASEAN EOC Network and ASEAN+3 FETN were actively utilized
to share local situational updates (ASEAN 2020a). The ASEAN Defense
Ministers’ Meeting (ADMM) also agreed to use military resources for
information-sharing and best practice sharing through the ASEAN Centreof Military Medicine and the Network of ASEAN Chemical, Biological andRadiological Defense Experts (ASEAN 2020b). After the WHO announcement declared COVID-19 a Public Health Emergency of International
Concern, ASEAN also held COVID-19-related meetings on a regular basis.
Meetings were held at least four times in February, with China, Japan, andSouth Korea also participating.
After the WHO declared COVID-19 a ‘pandemic’ on 11 March, ASEAN
diplomatic efforts intensified. This resulted in ASEAN and APT summits
as well as a number of foreign ministers’ meetings with external states
and actors, including the United States and European Union. Because
the negative impacts of COVID-19 on member states were cross-sectoral,
ASEAN organized a broad range of ministerial meetings in areas such as
economics, agriculture, and transportation, allowing the different member
nations to coordinate their policies on COVID-19 (ASEAN 2020c). A special
APT Summit was held on 14 April and decided to establish the COVID-19
ASEAN Response Fund for public health emergencies (ASEAN 2020d). Since52 Kei KOGA

April 2020, ASEAN has worked with member states and external actors
to gain technical assistance, such as medical equipment and media andinformation literacy.
Because of the tremendous impact of the ongoing COVID-19 pandemic, it
has been difficult for ASEAN to further consolidate its general cooperation
mechanisms for combating EIDs. However, in April 2020 Vietnam, which was
the chair of ASEAN in 2020, proposed that ASEAN create its own standard
operating procedure. As a result, in November 2020, ASEAN formulated its‘Strategic Framework for Public Health Emergency’ (ASEAN 2020b; ASEAN
2020e; Koga 2020, 141-143). This framework sets up comprehensive guidelines
for the responses to EIDs of member states. Essentially, the 2020 guidelines
aim to further enhance regional cooperation and policy coordination. Given
ASEAN’s continuous emphasis on the importance of the WHO’s International
Health Regulations (IHR), ASEAN has incorporated these principles in orderto maintain coherence with existing international laws (WHO 2005; ASEAN
2020e, 3). This has created a more structured coordination mechanism
between national and regional levels, incorporating the existing frameworks
in the field of disaster management and humanitarian assistance. In thisstrategic framework ASEAN proposed the creation of the ASEAN Centre for
Public Health Emergencies and Emerging Diseases (ACPHEED) to coordinate
member states’ responses, which was formally established in November 2020
with the financial and human resource support of the Japanese government(ASEAN 2020e; ASEAN 2020f).
As such, ASEAN has steadily developed its institutional mechanisms forpursuing effective and efficient measures to tackle emerging infectious
diseases. It has especially made efforts to develop these mechanisms at
those times when it has faced external shocks – SARS in 2003, H5N1 in 2005,
H1N1 in 2009, MERS in 2012, and COVID-19 in 2020.

3

ASEAN’s Cooperation to Counter EIDs: Regional Focus

ASEAN’s health governance mechanisms function at global, regional, andnational levels. At the global level, ASEAN has institutional ties with otherinternational organizations, particularly the WHO. The WHO’s expertise,
information dissemination, and guidelines help ASEAN formulate its own
countermeasures in response to EIDs. Despite the US criticism of the WHO,
where it accused the organization of being politically too close to China
and of having delayed its response to COVID-19, ASEAN has closely worked
with the WHO. However, the WHO’s advice and protocols, when adopted

Countering Emerging Infec tious Diseases and COVID -19

53

by ASEAN, have often remained as ‘guidelines’ that do not obligate states tofollow them. This is because ASEAN recognizes the existing capability gaps
among member states which limit their ability to implement these protocols(Tan 2020). The WHO’s International Health Regulations (IHR) are legallybinding agreements, created in 2005, that aim ‘to prevent, protect against,
control and provide a public health response to the international spreadof disease in ways that are commensurate with and restricted to publichealth risks, and which avoid unnecessary interference with internationaltraffic and trade’ (WHO 2005; WHO n.d. (a)). The capacity to implement
these nevertheless depends on each state’s financial, technical, and political resources, and some states require external assistance to build theircapacities.
At the same time, ASEAN’s institutional principles, or the so-called‘ASEAN Way’, often prevent the organization from taking enforceable
measures at the national level. The ASEAN Way consists of several norms,
such as the non-interference principle, a consensus-based decision-making
process, and non-use of force. More importantly, the great emphasis onprotecting state sovereignty makes ASEAN generally reluctant to pressure
member states to change their behaviour in the domestic realm. Becauseof this, persuasion is often employed (Acharaya 2014; Koga 2018, 50-51; Tan
2013, 237-240). This modus operandi partly explains the incongruence in the
responses to EIDs that is seen among the ASEAN member states.
To overcome these difficulties, ASEAN has nurtured institutional arrangements that draw external assistance and has simultaneously createdinter-state coordination mechanisms. More specifically, ASEAN has focusedon the enhancement of regional cooperation, which revolves around ASEAN
itself and APT. This is well illustrated by several of the existing mechanismsthat have been established to counter EIDs. These include the ASEAN+3
FETN, the ASEAN EOC Network, and the ABVC. The ASEAN+3 FETN was
established in 2011 for facilitating capacity building programmes, narrowing
the gap in the capabilities of ASEAN member states to manage EIDs, andpromoting networks of experts in the region (ASEAN+3 FETN 2012a). The
financial resources are voluntarily contributed by the member states, but
as the mechanism is under the APT framework, China, Japan, and South
Korea are the main contributors (ASEAN+3 FETN 2012b).
The ASEAN EOC Network is not under the APT framework, but is locatedwithin ASEAN’s own mechanism. This network ‘serves as the central locationin monitoring disasters and coordinating ASEAN’s collective response todisasters’ (AHA Centre n.d.). Each member state’s Public Health Emergency
Operations Centre (PHEOC) can exchange information with others through54 Kei KOGA

this communication channel (Disease Control Division, Ministry of Health
Malaysia 2017). In response to COVID-19, daily communication among themember states has been conducted through WhatsApp, a commercial text
messaging mobile application. This has meant that member states can
exchange information in a timely fashion and allowed the communication channel to compile contact information about health centres in eachmember state (ASEAN 2021). This mechanism is financially supported by
an external state, the Canadian government, which offered US$11.6 million
in 2013 for its initial establishment (Disease Control Division, Ministry of
Health Malaysia 2016).
The ABVC is responsible for conducting big data analysis and data visualization. It is also responsible for disseminating information about the ongoinghealth situation to the member states and the international community.
The idea to establish this centre was adopted in 2019, but the centre became
visible in 2020 when it functioned to raise member states’ awareness about
COVID-19, particularly through its risk assessment reports. The centre has
two computer programmes – the Explorer Tool and the Insights Tool. The
former tool aims to track trends of infectious diseases, to find out about local
transmissions, and to enable users to communicate with each other (ASEANn.d.). The latter tool helps health centres in the analysis of the threat posed bydifferent EIDs, sorting out the most significant events that would pose healthrisks at the national and regional levels (ASEAN n.d.). This centre was alsofinancially supported by the Canadian government in 2019 (ASEAN 2019).
The characteristics of ASEAN’s health governance mechanisms are
therefore mainly shaped by ASEAN’s institutional principles, norms, andrules. These mechanisms are made to be compatible with the ASEAN
Way and with the idea of receiving external assistance to build member
states’ capacity. Because today EIDs have become one of ASEAN’s and theworld’s top non-traditional security issues, ASEAN has been able to build
its own mechanisms with external assistance. There are also other ASEAN
mechanisms, such as the ASEAN Risk Assessment and Risk Communication
Centre (ARARC) and Regional Public Health Laboratories Network (RPHL).
These mechanisms facilitate laboratory readiness and the combating of fakenews. They are supported by external actors, such as the United States (USMission to ASEAN 2020).
ASEAN makes the most of its institutional weaknesses to attract assistance from regional states while emphasizing the importance of theASEAN Way to prevent external actors from interfering excessively. In sodoing, ASEAN has been relatively successful in utilizing these institutionalframeworks in countering COVID-19 since January 2020.

Countering Emerging Infec tious Diseases and COVID -19

4

55

Three Challenges to ASEAN’s Collaboration in Countering
Infectious Diseases

There is no guarantee that ASEAN can sustain the development model it
has adopted in the future. At the global level, in April 2020 the Access to
COVID-19 Tools (ACT) Accelerator was launched by the WHO, the European
Commission, France, and the Bill & Melinda Gates Foundation. This aims
to ensure diagnosis investment, equal distribution of treatment, and accessto vaccines in developing states including some ASEAN member states(under the so-called ‘COVAX’ programme; [WHO, n.d.(c)]). Nevertheless,the international community has yet to find an effective way to contain
COVID-19. Many countries have experienced second and third waves sincelate 2020 and the spread of mutated COVID-19 variants has also occurredin numerous places. In this context, there are three main challenges to
ASEAN’s health governance.
The first is to reduce ASEAN’s dependence on external actors for materials, particularly for financial assistance. ASEAN effectively created its own
institutional system to establish health governance mechanisms withexternal assistance from regional major powers. However, the negative
impacts of COVID-19 have severely affected the financial capabilities of somestates in the region. In the short-term, these states will continue to offer
ASEAN a certain amount of assistance. However, if the situation worsens, it
is not clear how sustainable their assistance will be and the degree to which
ASEAN’s health governance mechanisms can maintain their operations.
The second challenge is to manage the normative constraints that are
created by ASEAN’s adherence to the ASEAN Way. To be sure, the ASEAN
Way has been a useful tool for the member states to maintain their politicalautonomy and independence in Southeast Asia. Nevertheless, given thehigh degree of trade interdependence among ASEAN member states, themishandling of COVID-19 or another EID by member states, through suchthings as the imposition of trade restrictions, would affect the entire region(e.g., Pitakdumrongkit 2020). It is not realistic to see any radical change
in ASEAN’s traditional norms and rules in the near future, and ASEAN’s‘Strategic Framework for Public Health Emergency’ has advanced its own
coordination mechanism. However, ASEAN’s emphasis on state sovereignty
would make it difficult for the association to manage complex emergency
situations, such as those where a national government collapses or becomes
dysfunctional because of EIDs.
The third challenge is to balance ASEAN’s geostrategic position in thecontext of intensified US-China great power rivalry. While regional health56 Kei KOGA

cooperation in Asia is based on transnational interests, such cooperation isstill influenced by regional politics. At the heart of the Indo-Pacific region,
ASEAN is located in a geo-strategically important area. Its multilateralframeworks have been, and continue to be, a source of political legitimacy
in East Asia, which attracts many regional powers, including the UnitedStates, China, Japan, India, and Australia (Koga 2019, 288, 300). These regional
powers are important for ASEAN member states, because they help toprovide technical and financial resources to enhance ASEAN’s capacity incountering EIDs. However, if the strategic rivalries between these powers
continue to intensify, ASEAN will have to carefully and collectively assess
its position. It will need to determine from which regional powers, andunder what conditions, it can accept financial and medical resources. Thisis because if the United States and China, in attempting to expand theirspheres of influence, drive a wedge between different ASEAN member statesby offering them economic, medical, and technical assistance, then theorganization will face difficulties in maintaining its unity. This will thenin turn affect ASEAN’s ability to collectively respond to EIDs.
These three challenges are inherently related to each other. It is not possible, or even advisable, for ASEAN to pursue complete autonomy. However,
it is important to mitigate the negative impacts that may come from external
factors. Essentially, prevention is the most cost-effective means of managing
EIDs, and thus, the enhancement of ASEAN’s preventive capabilities isimperative for national and regional security.

5

Conclusion

ASEAN has seen relative success in formulating its health governancemechanisms in the post-SARS era. By consolidating its political cooperative frameworks during the 2000s, ASEAN gradually nurtured functional
cooperation in countering EIDs. This involved the creation of the ASEANECO Network and ASEAN+3 FETN. Facing the COVID-19 pandemic, ASEAN
utilized these mechanisms and activated new ones, such as ABVC. Thisculminated in the production of the 2020 ‘Strategic Framework for Public
Health Emergency’, which included a set of standard operating procedures,
as well as the establishment of ACPHEED in 2020.
This became possible because ASEAN constructed its own regional
institutional system. Through this system, ASEAN can maintain its own
political autonomy, provide political legitimacy in East Asia by promoting
regional multilateralism, and gain political support and material assistanceCountering Emerging Infec tious Diseases and COVID -19

57

from regional powers, including the United States, China, and Japan. Thisis partly why ASEAN has been able to utilize regional arrangements,
particularly the APT, in facilitating its health governance mechanisms.
Nevertheless, it is not clear whether ASEAN can sustain this institutional
advantage in the future. It faces the challenges of intensifying US-China
strategic competition and the ongoing negative consequences of COVID-19.
The year 2020 clearly shows that international relations in East Asia areshaped not only by power politics, but also by transnational security issues, suchas threats which the COVID-19 pandemic poses. ASEAN’s institutional focus on
non-traditional security issues has thus far provided venues for Southeast Asianand Northeast Asian states to coordinate their policies and collectively respondto the COVID-19 pandemic. However, in the future, ASEAN’s success ultimately
depends on how member states build their own capacity to adequately respond
to EIDs without significant assistance from external actors.

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no. 5. Accessed 14 January 2021. https://asean.org/asean-socio-cultural/aseanhealth-ministers-meeting-ahmm/publications-documents/#b75bf704f98b4dbc3.
Djalante, Riyanti, Laely Nurhidayah, Jonatan Lassa, Hoang Van Minh, Yodi
Mahendradhata, Nguyen Thi Ngoc Phuong, Angelo Paolo L Trias, Michelle
Ann Miller, Susanti Djalante, and Muhammad Sabaruddin Sinapoy. 2020. ‘The
ASEAN’s responses to COVID-19: A Policy Sciences Analysis.’ April. Accessed
14 January 2021. https://psyarxiv.com/8347d/download/?format=pdf.
Emmers, Ralf. 2009. ‘Comprehensive security and resilience in Southeast Asia:
ASEAN’s approach to terrorism.’ The Pacific Review vol. 22, no. 2: 159-177.
—. 2018. ‘Unpacking ASEAN Neutrality: The Quest for Autonomy and Impartiality
in Southeast Asia.’ Contemporary Southeast Asia vol. 40, no. 3: 349-370.
Koga, Kei. 2017. Reinventing Regional Security Institutions in Asia and Africa: Power
shifts, ideas, and institutional change. Oxon and New York: Routledge.
—. 2018. ‘ASEAN’s Evolving Institutional Strategy: Managing Great Power Politics
in South China Sea Disputes.’ The Chinese Journal of International Politics vol. 11,
no. 1: 49-80.
—. 2019. ‘Japan’s ‘Free and Open Indo-Pacific’ Strategy: Tokyo’s Tactical Hedging andthe Implications for ASEAN.’ Contemporary Southeast Asia vol. 41, no. 2: 286-313.
—. 2020. ‘Japan-Southeast Asia Relations: Great Disruption: Uncertainty overthe Indo-Pacif ic.’ Comparative Connections vol. 22, no. 1: 137-148. Accessed
14 January 2021. http://cc.pacforum.org/wp-content/uploads/2020/05/14_2001_JapanSea-1.pdf.
Pitakdumrongkit, Kaewkamol Karen. 2020. ‘COVID-19 and ASEAN Cooperation:
The State of Play and Ways Forward.’ AsiaGlobal Online, 7 October. Accessed
14 January 2021. https://www.asiaglobalonline.hku.hk/covid-19-and-aseancooperation-state-play-and-ways-forward.

Countering Emerging Infec tious Diseases and COVID -19

61

Tan, Hsien-Li. 2020. ‘From SARs to COVID-19: Reflections on ASEAN’s Collective
Response to Public Health Crises.’ The Business Times, 1 June. Accessed 14 January 2021. https://www.businesstimes.com.sg/asean-business/from-sars-to-covid19-reflections-on-asean%E2%80%99s-collective-response-to-public-health.
Tan, See Seng. 2013. ‘Herding Cats: The Role of Persuasion in Political Change
and Continuity in the Association of Southeast Asian Nations.’ International
Relations of the Asia Pacific vol. 13, no. 2: 233-265.
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COVID-19.’ 31 March. Accessed 14 January 2021. https://asean.usmission.gov/
fact-sheet-u-s-support-for-asean-in-fighting-covid-19/.
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Implement the IHR.’ Accessed 14 January 2021. https://www.who.int/ihr/
howtheywork/10things/en/.
—. n.d.(b). ‘MERS outbreak in the Republic of Korea, 2015.’ Accessed 14 January 2021.
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About the Author
Kei KOGA is an Assistant Professor at the Public Policy and Global Affairs
Programme, School of Social Sciences, Nanyang Technological University(NTU). His research focuses on international relations theory, International
Security, International Institutions, and East Asian security, including thetransformation of US-bilateral security networks and ASEAN-led institutions in the Indo-Pacific region. His recent publications include the book
Reinventing Regional Security Institutions in Asia and Africa (Routledge2017), ‘Japan’s “Indo-Pacific” Question: Countering China or Shaping a New
Regional Order?’, International Affairs (2020), ‘The Concept of “Hedging”
Revisited: The Case of Japan’s Foreign Policy Strategy in East Asia’s Power
Shift’, International Studies Review (2018), and ‘ASEAN’s Evolving Institutional
Strategy: Managing Great Power Politics in South China Sea Disputes’,
Chinese Journal of International Politics (2018). His current book project isManaging Great Power Politics: ASEAN, Institutional Strategy, and the South
China Sea.

3

The Outbreak of Infectious Disease
and Trust in Government in AsianCountries
Yumi ISHIKAWA and Miki KOHARA

Abstract
During infectious disease outbreaks, governments issue various public directives to curb disease spread. Disease containment measures sometimes
include strong behavioural restrictions. Compliance with these publichealth restrictions depends on people’s trust in government. This chapter
applies statistical analysis to study the impact of the SARS outbreak on
the levels of public trust in government in Asia. The analysis shows thatthe 2003 SARS outbreak reduced people’s trust in government in Asian
countries. It also indicates that this loss was mitigated when there wascollaboration between the government and the World Health Organization (WHO). This finding suggests that a collaborative relationship withinternational organizations such as the WHO encourages the public tocomply with restrictive measures implemented by governments.
Keywords: public trust, World Health Organization (WHO), SARS, publichealth, political legitimacy, East and Southeast Asia

Introduction
What is the relationship between the outbreak of an infectious disease andpublic trust in government in Asian countries? The relationship should be
examined because it has important policy implications. During the outbreakof an infectious disease, governments issue various public directives to curb
its spread. These can include not only individual preventive behaviour, suchas hand hygiene and mask wearing, but also social behavioural restrictions

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_ch03

64 

Yumi ISHIK AWA and Miki KOHAR A

including quarantine and store closures. Whether these restrictions arefollowed (i.e., whether people follow the government’s instructions) depends
to a large degree on trust in government. In countries where an infectious
disease outbreak reduces trust in the government, restrictions will not beeffective to prevent the spread of disease, whereas in countries where publictrust in government is higher, the spread will be controlled more easily.
This chapter examines how infectious disease outbreaks affect publictrust in government in Asian countries, focusing on the 2003 SARS epidemic
as a case study. Specifically, the chapter clarifies how social trust changedin the affected countries after the serious SARS epidemic. It also illustrates
how the collaboration between the respective government and health-relatedorganizations such as the World Health Organization (WHO) affects thelevel of trust. Networking with the WHO may contribute to alleviating
failing public trust in government if the organization successfully shares
crucial information with national governments.
Many academic studies suggest that unexpected negative shocks damage
trust in governments. These unexpected shocks include natural disasters(Lazarev et al. 2014, 641; Nicholls and Picou 2013, 344), financial crises(Armingeon and Guthmann 2014, 423; Kroknes, Jakobsen, and Grønning 2015,700), and infectious disease outbreaks (Sibley et al. 2020, 618; Kye and Hwang
2020, 1; van der Weerd et al. 2011, 1; Bangerter et al. 2012, 1). Recent studies
regarding pandemics, however, show opposite results. Sibley et al. (2020, 618)
found that trust in government improved during the first eighteen days oflockdown amid the COVID-19 outbreak in New Zealand. Using individual
panel data, Kye and Hwang (2020, 1) also showed that the level of trust in
government in South Korea increased after the COVID-19 outbreak. In thecase of the 2009 influenza (H1N1) pandemic, public trust in government washigh in the early phase of the outbreak but decreased in the latter phase of
the pandemic (van der Weerd et al. 2011, 1; Bangerter et al. 2012, 1).
These contrasting studies demonstrate that the level of trust in government varies depending on the type of negative shock as well as the response
provided by the government to the crisis. In the case of infectious disease
outbreaks, it is necessary for the government to assess correct data, understand scientific evidence, and provide reliable information to the public.
Most people in society have limited medical knowledge, which can cause anincrease in anxiety. People may believe misleading emotional information
more than scientific evidence. This could lead to non-compliance with publichealth measures, or to secondary effects of the outbreak such as increases
in violent crimes and mental health problems.
When a national government seeks to provide effective assessment andtransmission of reliable information, the WHO can play an important role.

The Outbreak of Infec tious Disease65

As will be explained in the next section, in the early stages of the 2003 SARS
epidemic the WHO launched a collaborative research project on SARS
diagnostics. This established an international network among research
centres to share outcomes of investigations of clinical samples of SARS
cases in real time. The members of this collaborative research effort wereresearch institutes, parts of universities or academies around the world.
During the 2003 SARS crisis, those countries with a research group thatjoined this WHO project could get prompt and accurate information. As
such, it was easier for these countries with a WHO research collaboration
to publish scientific evidence quickly and urge their populations to adopt
appropriate preventive behaviour. These countries could also devise effective
policies to mitigate the spread of infection based on reliable information.
The discussion in this chapter is based on a statistical investigation of aunique dataset containing information on public levels of trust in different
Asian countries before and after the 2003 SARS epidemic. Our empiricalresults show that, after the onset of the SARS epidemic, public trust in
government declined in those countries that were seriously affected. The
deterioration in trust, however, was alleviated in countries hosting a WHO
Collaborating Centre in a domestic research institute. The next section
summarizes how the 2003 SARS epidemic affected Asian countries andhow the governments coped with the outbreak.

2003 SARS Epidemic and Reactions by Governments and theWHO
SARS was the first severe novel infectious disease of the 21st century, affecting 26 countries (29 regions) and causing 8096 cases and 774 deaths (WHO2003a, 1, 2005). According to the WHO (2003a, 1), the novel coronavirus
emerged in Guangdong Province, China, in November 2002. However,details about this infectious disease were not reported to the WHO until
11 February 2003. Meanwhile, the virus began to spread outside the province,
causing infection clusters (for example, those in a Hong Kong hotel). The
virus then spread to other countries via infected but undiagnosed travellers.
The first case was identified in Hanoi, Vietnam, on 26 February 2003. Thiscase was tied to the infection cluster in the hotel in Hong Kong. Soon after
the first reported case in Vietnam, the virus spread to other parts of Asia.
The WHO issued a global epidemic alert on 12 March 2003, and identified
a newly discovered coronavirus as its cause. The WHO then issued safety
guidelines and warnings against traveling to the infected regions, including
Guangdong, Hong Kong, Taiwan, and Toronto, Canada. At the same time,

33

37

Singapore

TaiwanNumber of
SARS
deaths16

10

WHO responses– Closed a large wholesale market- Video conference with
where a cluster infection occurred and Singaporean officials (May 12,
issued 1200 home quarantine orders 2003)– Used highly sensitive case definition
for surveillance– Worked with military forces to conduct contact tracing and thoroughly
enforce home quarantines– Conducted screenings at airport andseaports– Concentrated patients at a single
SARS-designated hospital– Disallowed visitors at all public
hospitals– Began a private ambulance service
to transport all possible cases to the
SARS-designated hospital– Identified the sources of all but one
case that occurred in the country– Established a field team (March– Imposed a mandatory 14-day
24, 2003)
quarantine on all incoming travelers– Expert team arrived in Taipei
from China, Hong Kong, Singapore,(May 3, 2003)
Macau, and Toronto (April 28, 2003)– Disclosed delays in case report– Upgraded its surveillance system
ing that caused ambiguity in– Implemented infection control atdaily case information because
hospitals– Instituted a logistics system for efficientboth old and new cases haddelivery of protective equipment
been reported together (May22, 2003)– Began mass education campaigns– Passed a new law to punish for delays
in case reporting– Established fever clinics

LengthGovernment responses
betweenfirst case& last case(week)

Joint
researchwith theWHO

23,73014,06622.6
millionGDP per
capita(USD,
2003)

4.1 million

Population(2003)

76.5

79.0Life expectancy
at birth(year,
2003)semi-presidential
republic

parliamentary
republic

World
Government type
top 500
universities (2003)

Table 3.1 Socio-Demographics, SARS Epidemiological Data, and the Responses of Governments and the WHO in Target Regions

66 
Yumi ISHIK AWA and Miki KOHAR A

0

0

2

2

0

2

Indonesia

Japan

Malaysia

Philippines

South
Korea

Thailand

11

2

10

6

2

7

– Recognized the outbreak early– Consolidated SARS patients at asingle hospital– Implemented strict infection control– Conducted diligent contact tracing– Investigated all rumored cases

LengthGovernment responses
betweenfirst case& last case(week)– Expert team assisted healthauthorities (March 16, 2003)– Sent 300 kilograms of protective equipment and medical
supplies to Hanoi (March 24,
2003)– Established a field team (March24, 2003)

WHO responses



Joint
researchwith theWHO

34,808

4,462

127.7
million24.7
million

14,6732,359

47.9 million
64.6
million

1,048

1,066

220.3
million83 million

481

GDP per
capita
(USD,
2003)

82.3
millionPopulation(2003)

76.5

77.2

68.9

73.2

81.8

66.6

73.7

Life expectancy
at birth(year,
2003)

presidential
republic
parliamentary constitutionalmonarchyfederalparliamentary constitutionalmonarchypresidential
republicpresidential
republic
constitutionalmonarchycommunist
state

World
Government type
top 500
universities (2003)

Sources: WHO (2003c,2004,2005), The World Bank (2021a,b,c), DGBAS (2021a,b), Ministry of Health and Welfare in Taiwan (2018), Shanghai Ranking Consultancy (2003), CIA (2021).

5

VietnamNumber of
SARS
deathsThe Outbreak of Infec tious Disease

67

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Yumi ISHIK AWA and Miki KOHAR A

the WHO began investigations in mainland China in March and then in
April reported on the infection situation, giving more specific numbers(WHO 2003a). For example, on 16 April the WHO warned that the number ofpeople infected could be five times higher than the number reported by the
Chinese government (WHO 2003b). On 7 May, the WHO gave an estimatedcase fatality rate, indicating that SARS mortality was quite high. The WHO
eventually declared the end of the epidemic on 5 July 2003.
Table 3.1 summarizes the responses to SARS of different countries orregions, listing both SARS epidemiological data and the responses bygovernments and the WHO to the cases examined in this chapter. There
are several notable points in the table.
First, the severity and duration of SARS infections varied among countries(see first and second columns). We categorized a group of countries andregions as being ‘seriously affected’, where these had many fatalities and alengthy infection period. These places include China, Hong Kong, Singapore,
Taiwan, and Vietnam. The remaining countries, Indonesia, Japan, Malaysia,
the Philippines, South Korea, and Thailand, were categorized as a ‘nonseriously affected’ group.
Second, within the seriously affected group, the socio-demographicsof the countries/regions are diverse; some possess good economic, health,and education conditions, while others do not. Political systems also differ
within this group.
Third, measures taken by the governments varied among countries in theseriously affected group, especially regarding information dissemination.
Singapore and Hong Kong seemed to have conveyed infection information
to the public promptly, while Taiwan was criticized for a delay in casereporting. Although China was also criticized for concealing or not disclosing
infection cases during the initial outbreak, the Chinese authorities changed
this approach later on and provided the WHO with daily information aboutcases and deaths by province.
Fourth, the degree of collaboration with the WHO also differed among
countries/regions. In the seriously affected group, for example, Vietnam’s
government collaborated closely with the WHO to control the outbreak.
In contrast, the Chinese government only began working closely with the
WHO and introduced a series of responses after the global alert in March.
There was variation in the amount of collaboration between thesecountries/regions and the WHO. The WHO issued a global alert about anewly identified coronavirus on 12 March 2003. At the same time, it also
launched a collaborative centre research project on SARS. The purposeof this research network was to detect the SARS agent and to develop adiagnostic test. The laboratories that joined this research project shared

The Outbreak of Infec tious Disease69

samples and investigation findings in real time, and their findings werevalidated immediately in several laboratories (WHO 2003c). The research
network was comprised of eleven laboratories in nine countries.
Table 3.1 illustrates two important points. First, the research collaboration
involved countries and regions that were both more severely and less severely
affected by the SARS outbreak. A Japanese laboratory joined the project eventhough Japan was not severely hit by SARS. Several laboratories in China
joined the project, while none in Vietnam did, although both countries
were seriously affected.
Second, the research collaboration did not necessarily involve only
economically and/or scientifically developed countries/regions. South
Korea and Taiwan did not participate in the collaboration, despite having
a comparatively high gross domestic product (GDP) per capita and highly
ranked universities. Chinese institutes joined the project, although China’s
GDP per capita was relatively low in 2003 compared to other countries. The
next part of this chapter presents the empirical strategy that we have usedand describes the data we have analysed to study public levels of trust in
government during the SARS epidemic.

Methodology and Data
This chapter addresses two research questions regarding the 2003 SARS
epidemic:
1 Did the SARS epidemic lead to a deterioration in the public’s trust in
government in Asian countries?
2 Did research collaboration with the WHO mitigate the loss of social trust?
These questions were answered based on two kinds of empirical analysis. The
first empirical analysis used the ‘Difference in Differences’ (DID) method. Thistakes advantage of the unexpected and sudden spread of SARS in early 2003
(November 2002-February 2003), and the large differences in infection statusamong Asian countries. To employ the DID method to quantify the impact of
the epidemic on social trust, we used information about both SARS-affected
and SARS-non-affected groups before and after the epidemic. SARS-affected
countries and regions are defined as those that had local SARS transmission
by the time the WHO issued its global SARS epidemic alert (WHO 2003d). As
defined in the previous section, these include China, Hong Kong, Singapore,
Taiwan, and Vietnam. Indonesia, Japan, Malaysia, the Philippines, South Korea,
and Thailand are defined as SARS-non-affected. In a DID framework, theformer is referred to as the ‘treated’ group and the latter as the ‘control’ group.

70 

Yumi ISHIK AWA and Miki KOHAR A

We used data about East and Southeast Asia from the World Values Survey
1993-2014.1 We selected this sample period to balance the number of years
before and after the 2003 epidemic. This survey directly asked respondents
about their level of trust in government and collected respondents’ personal
characteristics. This allowed us to analyse the impact of the SARS outbreakon changes in trust levels, while eliminating differences caused by personal
characteristics, such as age, socioeconomic conditions, medical environment,
and lack of interest in politics. By tracking each country over multiple
time frames, our analysis was also able to remove differences in trust in
government caused by historical, cultural, and geographic circumstances,
as well as the political system in the country/region. In other words, theanalysis isolated and identified the impact of an infectious disease outbreakon public trust in government.
Level of trust, the dependent variable in this analysis, reflects individual
trust in government. It was measured with the question: ‘Could you tellme how much confidence you have in the government: is it a great deal of
confidence, quite a lot of confidence, not very much confidence, or noneat all?’ Answers were recorded on a four-point scale, from 1 = none, to 4 =a great deal of confidence. Analysing the responses to this question, we
examined whether the level of trust in government fell only in the treatedcountries/regions (or those labelled SARS-affected).
The second part of the analysis used a ‘triple-difference’ (DDD) method
to examine how the impact of the epidemic on trust in government differedin countries with a WHO collaborating centre. Since decisions about thepartnerships were made at the early stage of the SARS epidemic, we could
examine whether becoming a member of the WHO joint research project
mitigated the loss of trust in government.

Results
1 Negative Effect of the SARS Epidemic on Trust
Figure 3.1 shows the average level of trust in government. The black andstriped bars show the average respondent’s trust in the treatment and control
1 The World Values Survey (WVS) began in 1981 and consists of nationally representative
samples of over 100 countries that use a common questionnaire (Inglehart et al. 2014). Many
studies on social trust use WVS data (for example, see Knack and Keefer 1997, 1251; Mikucka et
al. 2017, 1; Kentmen and Cin 2012, 971).

The Outbreak of Infec tious Disease

Figure 3.1

71

Average level of trust in sample governments

groups respectively. Figure 3.2 shows the average level of trust over time
for the treatment and control groups. These figures show that the levels oftrust in government were relatively high in the SARS-affected countries
both before and after the outbreak. Low public trust, therefore, did notcharacterize SARS-affected countries. The striking feature in Figure 3.2 isa decline in trust only for the treatment group (or SARS-affected countries)
from 1999-2002 to 2005-2008.2 The loss of public trust in government canbe attributed to the SARS outbreak.
This drop was further confirmed by our empirical examination using
29,320 observations. The DID analysis showed a statistically significant
drop of trust in government only in the SARS-affected countries (treatmentgroup) after the outbreak. The results are robust. The negative coefficientsremained significant even after changing the estimation specifications.3
2 The occurrence and reoccurrence of the SARS epidemic corresponds to the timeframes
between the two mentioned periods, which suggests the existence of ‘cut-off points’ before andafter the epidemic was declared and eventually considered over. This is taken into account in
our DID estimation.
3 The estimation results using the 29,320 observations in sample countries are:
ST̂ Gi = -0.268SARS ∙ Posti + 0.786SARSi + 0.208Posti + 4.814 (0.021) (0.019) (0.013) (0. 149)
Herein, is a measure of social trust in government of individual i; is a dummy variable indicating

72 

Yumi ISHIK AWA and Miki KOHAR A

Figure 3.2 Average level of trust in the SARS-affected (treatment) and nonaffected (control) groups

It is notable that people in the SARS-affected countries, compared with thosein non-affected countries, tended to have higher public trust in government
both before and after the SARS outbreak. Thus, the decrease in levels oftrust found in the SARS-affected countries should not be attributed tocountry characteristics that existed even before the outbreak. It is also
notable that there is an upward trend of public trust in government after
2003 in non-affected countries. As such, the drop in social trust after 2003
in the SARS-affected countries cannot be explained by a time trend. These
highlight the negative impact of an infectious disease outbreak on trust in
government: the loss of public trust in government was due to the epidemic.
What was the public attitude in general? We checked how the trust ofmembers of the public in other people changed with the occurrence of SARS.
that a country was affected by SARS, which equals 1 if a respondent i lives in a SARS-affected
country and 0 otherwise; is a dummy variable indicating the period after the SARS epidemic,
which equals 1 if a survey year was in or after 2003, and 0 otherwise. The coeff icient on the
focal interaction term of is significant at the 1% significance level. Although the results are notshown in the equation, the estimate also controls for individual characteristics, such as age,gender, marital status, education, employment status, income level, and country’s economic
and medical environments (e.g., per capita GDP and life expectancy at birth) in the country
where individual i lives, and country dummies. The country-level data are from the World
Development Indicators (2020) and country-level indicators for Taiwan from Taiwan Healthand Welfare Indicators (2018). The detailed results and descriptive statistics of the dataset areavailable upon request.

The Outbreak of Infec tious Disease73

To do this, we also used the DID methodology, but replaced public trust in
government with trust in other people as the dependent variable. We foundthat social trust in people increased significantly in SARS-affected countries
after the outbreak. This contrasts with the previous result on public trustin government. In other words, the spread of SARS reduced public trust in
government, whereas it raised social trust in people. People may feel theneed for social connectedness in times of serious disease outbreaks, so as
to allay their fear of unpredictable threats.
One possible explanation for the negative effect of SARS on public trustin government is that people’s anxiety increases because of a lack of reliable
information. For example, during the SARS epidemic Taiwan was criticizedfor delaying case reporting until mid-May, as mentioned in the previous
section.
2 The Alleviating Effects of WHO Research Collaboration
This section examines how research collaboration with the WHO affected
the decline in public trust in government after the epidemic. The investigation, using a DID approach, found a statistically significant difference inthe effect of the SARS outbreak on trust in government for those countries/
regions with and without research collaboration with the WHO. Specifically,
the drop in public trust in government after the 2003 SARS outbreak was
smaller in the countries hosting WHO collaborating centres. 4
It might be argued that, rather than their participation in the WHO
research collaboration, it was instead the presence of good research environments in these countries/regions that actually prevented people from losing
their trust in government after the epidemic.
However, the findings of our study do not support this argument. First,
people in well-developed societies with better health and educational
environments are not likely to show higher trust in government. Second,
the presence of a high-ranked university in a country (which can indicate a
4 Estimated results using the 29,320 observations in sample countries are:
ST̂ Gi = -0.54SARS ∙ Post i + 0.52SARS ∙Posti ∙ Collabi + 0.77SARSi + 0.22Posti
(0.03) (0. 05) (0. 02) (0.02) (0. 03)-0.08Collab ∙ SARSi −0.12Collab ∙ Post i + 4.10,
(0.04) (0.03) (0.15)
where Collabi is a dummy variable with the value 1 if respondent i’s country has a research
institute joining the WHO project network, and the value 0 otherwise. The equation includes
control variables such as individual and country characteristics as well as country dummies,
although the results are not reported here. The detailed results are available upon request.

74 Yumi ISHIK AWA and Miki KOHAR A

well-developed scientific environment) was not found to have a statisticallysignificant mitigating effect on the loss of trust in government after the SARS
epidemic.5 In other words, joining the WHO collaborative centre, and not
simply having advanced research institutes, played a key role in mitigating
the loss of trust in government after the SARS epidemic.
What explains this finding? There are two possible reasons. The firstreason is what we have labelled as reputation effects. The WHO is widely
recognized as the main UN agency responsible for disease control andmitigation. It thus has greater legitimacy to act in times of disease outbreaks.
National governments would also gain legitimacy and public trust when
officials can claim that they ‘have worked closely with the WHO’.
The second reason is what we have labelled as information sharing effects.
One of the main aims of setting up the WHO research collaboration on
SARS was to share the outcomes of investigations of clinical samples from
actual cases in real time (WHO 2003c). Daily assessments of research results
were based on diagnostic tests conducted in member institutes. Results oflaboratory diagnostic tests are important for governments to understandthe pathways of transmission and implement preventive measures. Laboratory results are equally crucial in convincing people that they must follow
measures to stop the spread of diseases.
Importantly, our findings suggest that reputation effects cannot consistently explain the mitigating effect of WHO research collaboration on theloss of trust in government in the wake of the SARS epidemic. Cooperation
between national governments and the WHO can be attained in many
ways other than research collaboration. For example, as mentioned in theprevious section, Vietnam had a good cooperative relationship with the WHO
during the SARS outbreak. Vietnam, however, did not have any domestic
institutes that joined a WHO collaborative research project. Because lossof trust in government was mitigated by research collaboration with the
WHO specifically, rather than by a general cooperation with the WHO, in
Vietnam’s case there was no mitigating effect of its more general cooperation
with the WHO. The data therefore do not suggest the existence of reputation
effects for Vietnam.
However, information sharing effects also do not thoroughly explain ourfindings. The results indicate that rather than the existence of top scientificuniversities, the existence of the WHO research collaboration made the5 High-ranked universities are those ranked in the top 500 (based on Academic Ranking ofWorld Universities published in 2003). For estimations, we used a dummy variable taking thevalue 1 if a country has at least one high-ranked university, and 0 otherwise.

The Outbreak of Infec tious Disease

75

difference in mitigating loss of trust after the epidemic. Notably, there areseveral important aspects of information assessment. Information should
be quickly transmitted, scientifically accurate, and credible. Information
satisfying these aspects cannot be made available by domestic researchers
if they cannot access patients’ medical reports and if the country does notexperience the outbreak. Furthermore, transmission of credible information
cannot be guaranteed if the general public does not trust domestic researchgroups/institutes.
As such, information sharing under multilateral collaboration implemented by a third party that can be trusted is beneficial. A third party, suchas the WHO, can call upon countries to join a research collaboration. The
SARS-affected countries which engaged in WHO research collaboration
successfully avoided epidemic-driven declines in trust in government after
the pandemic, because they could obtain rapid, scientifically accurate, andcredible information from the research network.
What are the implications of this for the COVID-19 pandemic? Our findings suggested that quick transmission of scientifically credible information
by government collaboration with a third party such as the WHO would
have a mitigating effect on the loss of trust in government. During the
COVID-19 pandemic, the WHO has been less successful in providing a
rapid response to preventing the spread of disease based on academicallytrustworthy findings.
During the SARS epidemic, the WHO international team of experts
began investigations in the Chinese province of Guangdong on 3 April 2003
(three weeks after the WHO issued the global epidemic alert). The WHOthen presented its official interim report on 9 April 2003 (WHO, 2003b). In
contrast, when COVID-19 emerged in 2020, the WHO international teambegan investigations in the Chinese city of Wuhan on 29 January 2021
(one year after the WHO declared the virus a Public Health Emergency ofInternational Concern). It then presented its official report on 30 March 2021
(WHO, 2021).
Scientifically credible information was not transmitted to the publicin the early stages of the spread of COVID-19. Had there been informationtransmission through collaboration between countries and the WHO, this
could have contributed to maintaining public trust in government, andhelped governments to control the spread of COVID-19. Impeded collaboration can be harmful for both governments and the WHO. While national
governments lose public trust as a result of impeded collaboration, theWHO is less able to effectively fulfil its role of helping to stop an outbreakturning into a pandemic.

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Conclusion
This chapter has examined how the 2003 SARS epidemic affected public trustin government, and how this negative effect was mitigated by collaboration
with the WHO. The analysis was based on the DID method, which takes
advantage of the unexpected, sudden spread of SARS in early 2003, and thelarge differences in infection rates in Asian countries. This analysis useddata for East and Southeast Asia from the World Values Survey 1993-2014,
which included information on respondents’ levels of trust in their respective
governments, their personal attributes, and the countries or regions in which
they resided. This allowed us to identify the impact of an infectious disease
outbreak on public trust in government, eliminating differences causedby personal attributes, and countries’ historical, cultural, and geographic
circumstances.
The analysis showed that the 2003 SARS outbreak reduced people’s trustin governments in Asian countries. Importantly, this does not mean thatpublic trust in government was initially low in countries with high infectionlevels, or that public trust fell simply because of the severity of the SARS
outbreak. This is neither consistent with a general uptrend in public trustlevels, nor with the uptrend in social trust in people such as neighbours.
Thus, it is possible to conclude that the outbreak of an infectious diseases
damaged the level of trust in government. Overall, there was a clear effectof the SARS outbreak on the loss of public trust in government among
Asian countries.
The analysis further showed that this loss was mitigated in the countries
with research institutes participating in WHO research collaboration.
The results highlight the importance of scientific collaboration with the
WHO on health-related issues. Joint research with a third party, such as
the WHO, enables swift dissemination of credible scientific information,and facilitates the promotion of appropriate preventive measures among
the general public. Information sharing through collaboration may also
allow national governments to implement effective policies. While many
Asian governments lost public trust due to the SARS outbreak, prompt
dissemination of accurate evidence-based information may have led to anincrease in trust in other people in society.
By cooperating with international organizations such as the WHO toprovide objective scientific evidence during the spread of an infectious
disease, governments can effectively encourage people to take necessary
action without losing public trust.

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77

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Bangerter, Adrian, Franciska Krings, Audrey Mouton, Ingrid Gilles, Eva Green, andAlain Clémence. 2012. ‘Longitudinal Investigation of Public Trust in Institutions
Relative to the 2009 H1N1 Pandemic in Switzerland.’ PLoS One vol. 7, no. 11: 1-8.
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Central Intelligence Agency. 2021. ‘The World Factbook East Asia/Southeast
Asia.’ Accessed 8 February 2021. https://www.cia.gov/the-world-factbook/east-asia-southeast-asia/.
Freimuth, Vicki S., Don Musa, Karen Hilyard, Sandra C. Quinn, and Kevin Kim.
2014. ‘Trust During the Early Stages of the 2009 H1N1 Pandemic.’ Journal of
Health Communication vol. 19, no. 3: 321-339.
Inglehart, R., C. Haerpfer, A. Moreno, C. Welzel, K. Kizilova, J. Diez-Medrano, M.
Lagos, P. Norris, E. Ponarin and B. Puranen (eds.). 2014. ‘World Values Survey: All
Rounds – Country-Pooled Datafile Version.’ Accessed 8 February 2021. https://www.worldvaluessurvey.org/WVSDocumentationWVL.jsp.
Kentmen Cin, Cigdem. 2012. ‘Blaming the Government for Environmental Problems:A Multilevel and Cross-National Analysis of the Relationship between Trust in
Government and Local and Global Environmental Concerns.’ Environment andBehavior vol. 45, no. 8: 971-992.
Knack, Stephen, and Philip Keefer. 1997. ‘Does Social Capital Have an Economic
Payoff? A Cross-Country Investigation.’ The Quarterly Journal of Economics
vol. 112, no. 4: 1251-1288.
Kroknes, Veronika, Tor Georg Jakobsen, Lisa-Marie Grønning. 2015. ‘Economic
Performance and Political Trust: The Impact of the Financial Crisis on European
Citizens.’ European Societies vol. 17, no. 5: 700-723.
Kye, Bongoh, and Sun-Jae Hwang. 2020. ‘Social Trust in the Midst of Pandemic Crisis:
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Lazarev, Egor, Anton Sobolev, Irina Soboleva, and Boris Sokolov. 2014. ‘Trial by
Fire: A Natural Disaster’s Impact on Support for the Authorities in Rural Russia.’
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Mikucka, Mickuka, Francesco Sarracino, and Joshua K. Dubrow. 2017. ‘When
Does Economic Growth Improve Life Satisfaction? Multilevel Analysis of theRoles of Social Trust and Income Inequality in 46 Countries, 1981-2012.’ World
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Nicholls, Keith, and Picou, J. Steven 2013. ‘The Impact of Hurricane Katrina on Trustin Government.’ Social Science Quarterly vol. 4, no. 2: 344-361.
Shanghai Ranking Consultancy. 2003. ‘Academic Ranking of World Universities.’
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Overall, Carol H. Lee, and Carla A. Houkamau. 2020. ‘Effects of the COVID-19
Pandemic and Nationwide Lockdown on Trust, Attitudes toward Government,
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Van der Weerd, Willemien, Danielle R. Timmermans, Desiree J. Beaujean, Juriaane
Oudhoff, and Jim E van Steenbergen 2011. ‘Monitoring the Level of Government
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Population.’ 28 January. Accessed 8 February 2021. https://eng.stat.gov.tw/point.
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worldbank.org/indicator/SP.POP.TOTL.
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8 February 2021. https://www.who.int/csr/media/sars_wha.pdf.
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The Outbreak of Infec tious Disease79—. 2003c. ‘WHO Collaborative Multi-Centre Research Project on Severe AcuteRespiratory Syndrome (SARS) Diagnosis.’ Accessed 8 February 2021 https://www.who.int/csr/sars/project/en/.
—. 2003d. ‘Cumulative Number of Reported Cases (SARS).’ Accessed 8 February 2021. https://www.who.int/csr/sars/country/2003_03_24/en/.
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—. 2021. ‘WHO-Convened Global Study of Origins of SARS-CoV-2: China
Part.’ Accessed 7 April 2021. https://www.who.int/publications/i/item/
who-convened-global-study-of-origins-of-sars-cov-2-china-part.

About the Authors
Yumi ISHIKAWA is a PhD student at the Osaka School of International Public
Policy (OSIPP), Osaka University. Her interest is primarily in public health.
She completed her Master’s at OSIPP and a MSc in Global Health at King’s
College London. She has research experience at the WHO headquarters(2017) and WHO country office in Cambodia (UN Volunteer, 2019-2020).
Miki KOHARA is a professor at Osaka School of International Public Policy,
Osaka University. Her research field is Labour Economics and Applied
Econometrics. She has a special interest in family behaviours of labour
supply, consumption and health-preventive-behaviours. She is also interested
in the evaluation of health and labour policies.

PART II
The Future of Global Health Governance in Asia

4China and the World HealthOrganization
Not an Easy Road for Either
Xue GONG and Xirui LI

Abstract
The role of the World Health Organization (WHO) as a global healthagency has come under mounting pressure since the start of the COVID-19
pandemic. Many have linked the WHO’s negligence and mistakes tothe strong influence of the People’s Republic of China (PRC) over theorganization. However, this chapter argues that China’s leadership potential in the WHO has been constrained by three factors: its insignificant
contribution to the WHO compared to the traditional donors, its illiberaland fragmented domestic governance structures, and its assertive healthdiplomacy. Despite the US withdrawal from the WHO under the Trumpadministration, it would be incorrect to assume that China currently has
sufficient resources to take on a leadership role in the WHO.
Keywords: China (People’s Republic of China), COVID-19, global healthgovernance, World Health Organization, China-United States relations,multilateral institutions

Introduction
Since the outbreak of the COVID-19 pandemic in China on 31 December 2019
(World Health Organization 2020), the WHO has been thrust into theinternational spotlight. Governments across the world have criticized theorganization for its handling of the pandemic. The WHO’s slow response
and heavy reliance on the Chinese authorities has drawn sharp criticism,

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_ch04

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particularly from the US. One accusation has been that the WHO has become
an accomplice of the People’s Republic of China (PRC) in handling the global
health crisis. After the WHO’s Director-General lauded the PRC’s ‘speed,
scale and efficiency’ (Pilling 2020) in reacting to the spread of COVID-19,
many American think tanks and media outlets expressed their concernthat the organization was ‘bowing to China’ (Schaefer 2020). The WHO was
accused of ‘acting too slowly’ (Hernández 2020), of being ‘fully controlled
by China’ (Archyde 2020), and was seen as ‘misleading the world’ (Berger
et al. 2020). The then US president Donald Trump initially threatened to
cut US funding and eventually declared a formal withdrawal from theorganization. In contrast, Chinese president Xi Jinping gave high-profile
opening remarks at the WHO annual assembly in May 2020, reiterating thecountry’s support for the organization. Xi also pledged to donate another
USD$2 billion to help other countries fight against the virus in the next
two years (Xi 2020).
Against this backdrop, this chapter asks: Is China a leader in global healthgovernance? And is China able to overshadow the US’s global leadership?
Although it has been argued that China’s fast response to the domestic healthcrisis may indicate a change of international order (Campbell and Doshi2020), this chapter argues that China’s leadership potential in the WHO has
been constrained by three factors: its insignificant contribution in the WHOcompared to the traditional donors; its illiberal and fragmented domestic
governance structures; and its assertive health diplomacy. This chapter also
proposes that it is misleading to argue China’s influence on the organizationis the only factor that explains the WHO’s missteps in handling the crisis.
The chapter is organized as follows: the next section discusses China’srole in the WHO and assesses China’s domestic governance capabilities.
Following this, there is a discussion about the impact of China’s healthdiplomacy.

China’s Role in Global Health Governance and the WHO
For the past few decades, China’s health governance capability has beensustained by an architecture established by the US (Huang 2015). With its
ascendancy, China has been increasing its level of participation in, andengagement with, existing multilateral institutions, while also building
new institutions. For instance, in 2017 China began promoting its HealthSilk Road (HSR) within the WHO. China also established the Global Health
Drug Discovery Institute, a partnership with the Gates Foundation that has

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Figure 4.1 Number of Statements Submitted to the WHA by China, the EU, andthe US* The Archives of the WHA only show statements submitted by member states in the 68th, 71st,
72nd and 73rd WHA;** Figure 4.1 shows only the number of statements the EU made collectively. EU member states
submitted individual statements in the 68th and 73rd WHA, while they submitted statements
collectively in the 71st and 72nd WHA.
Source: Authors’ summary based on WHO website (World Health Organization 2020a).

the aim of fighting epidemics. China has extended its influence throughdifferent regional mechanisms, such as the China-Africa Health Ministers
Conference and the BRICS Health Ministers Conference. Given China’s
increased engagement in global health, some have argued that global healthgovernance will come under China’s leadership (Huang 2017). But is thislikely?
To assess the extent of China’s leadership role in the WHO, this chapter
examines China’s influence in three aspects of governance: agenda setting,funding, and expertise. The assessment criteria are not exhaustive, but they
are frequently overlooked or misunderstood by international society. Besides,
they can also give an overview of China’s influence in the internationalorganization.
Agenda SettingFirst, the depth and scope of China’s participation in the WHO are limited.
As shown in Figure 4.1, China did not make any statements in the 68th,
71st, and 72nd meetings of the World Health Assembly (WHA), the annual86 

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Figure 4.2 WHO Assessed Contributions by Countries (Updated until Q2 2020)

Source: Authors’ calculation based on the data from WHO website (World Health Organization
2020b).

decision-making meeting held by the WHO.1 In contrast, the United Statesand European Union (EU) both submitted statements during these meetings.
It was only at the 73rd WHA in 2020 that China submitted two statements:
one on COVID-19 and the other on the One-China policy.2
Funding
According to the WHO, in 2020 the majority of its funding came from specified voluntary contributions (55.62% of total funding) and projected funding(27.2% of total funding), while assessed contributions accounted for 14.26%.
Within the assessed contributions, the US together with the EU and Japan
provided over 60% of funding; the Chinese contribution of US$129,287,000(or 13.5% of total assessed contributions) is comparatively insignificant (seeFigure 4.2). Similarly, Figures 4.3 and 4.4, which respectively show voluntary
contributions and projected funding, also indicate that most of the donors
are from the West while China is a relatively insignificant player.
1 The WHA is the annual meeting of the WHO member states. Members are ‘to determine
the policies of the Organization, appoint the Director-General, supervise financial policies, andreview and approve the proposed programme budget (World Health Organization a).’2 The One-China policy states that ‘Taiwan is an inalienable part of China’ and holds there
is only one China (Taiwan Affairs Office and the Information Office of the State Council 2000).

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Figure 4.3 WHO Specified Voluntary Funding by Parties (Updated until Q2 2020)

Source: Authors’ calculation based on the data from WHO website (World Health Organization
2020b).

Although China’s contribution to the organization has grown in the past
few years, the increase is largely within the assessed contributions while
over half the WHO funding comes from specified voluntary contributions.
When all the funding contributions are put together (see Figures 4.3-4.5),
China’s share is extremely small compared to the contributions being madeby Western state donors, or those made by private donors such as the Bill
& Melinda Gates Foundation.
Expertise
China’s influence over the WHO can be measured through the participationof its health and medical experts with the organization. The majority of
WHO staff are US nationals (Glassman and Datema 2020) who play key
roles in the WHO’s operations as members of the WHO advisory committee.
Apart from the former Director-General of the WHO, Margaret Chan, who
is of Hong Kong origin and who helped to promote Traditional Chinese
Medicine, the role of Chinese experts in the organization has been minimal
when compared to their US counterparts.
China’s limited contribution is also apparent in its involvement with
the WHO collaborating centres (institutions such as research institutes
and universities designated by the WHO Director-General to carry out
activities in support of the organization). As of September 2020, of the 844

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Figure 4.4 WHO Projected Funding by Parties (Updated until Q2 2020)

Source: Authors’ calculation based on the data from WHO website (World Health Organization
2020b).

WHO collaborating centres worldwide, 181 were located in the US and 130 in
China. When comparing the width and depth of collaborating centres, thosein the US are more specialized (see Figure 4.5). For instance, China does nothave any WHO collaborating centres for water and sanitation, aging, cancer,
and cholera, while the US has at least one centre for each of these categories.
The above analysis corresponds to existing research that has shown that
the WHO is heavily dependent on major donors (Gostin 2015). As describedabove, China’s donation to the organization is comparatively low. Constrainedby its structural limits, the WHO has to walk a fine line between the needfor cooperation and information-sharing from member states and the needto hold them accountable for mistakes. As such, WHO officials tend to use
diplomacy instead of confrontation in order to ‘coax more information’ andfoster cooperation (Associated Press 2020). The WHO’s overdependence onfunding from major donors constrains its enforcement and policing powers.
In other words, the WHO’s mishandling of the crisis is not a direct result ofChina’s influence but is largely because of its organizational constraints.

Domestic Constraints
China’s influence in global health governance is also limited by its deficient
domestic health governance. Since the 1980s, China’s healthcare system
has undergone several reforms (Xinhuanet 2019) and has made progress inChina and the World Health Organization

89

Figure 4.5 WHO Collaborating Centres in the US and China by Subjects (Pending
and Active)

Source: Authors’ drawing based on WHO Collaborating Centres Global Database. Accessed
19 September 2020 (World Health Organization 2020c).

improving overall health conditions domestically (World Bank 2018). Despite
these achievements, China still faces numerous challenges in domestic
healthcare. For instance, healthcare provisions in China are quite imbalanced and such imbalance continues to worsen. Leng (2019) reports that, in
2019, over 2300 top-tier public hospitals could barely meet the demand for
medical care services, while almost 950,000 lower-tier healthcare institutions
faced difficulties in attracting patients.
More tellingly, the medical system is fragmented (Yip and Hsian 2008),
which further weakens the government’s capacity in supervision and policy
coordination (Ramesh, Wu, and He 2014). For instance, in the Twelfth FiveYear Plan, health informatization (using digital technology to facilitate andimprove on public access to data and information) was recognized as a
crucial part of medical reform in China (Li et al. 2019). However, fragmented
management hinders data consolidation. For example, electronic healthrecords are managed by the National Health Commission (NHC), while data90 

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about insurance claims is managed by the National Healthcare Security
Administration (Yip et al. 2019). The lack of information sharing between
these two separate entities makes effective coordination hard to achieve.
Moreover, the persistent central-local tensions in Chinese politics have significantly limited China’s preparedness for public crises. Local governments
tend to be defensive when handling public crises to secure their legitimacy. As
a result, maintaining stability (weiwen 维稳) has become a means of conflictand crisis resolution in China (Benney 2016). In times of crisis, both local andcentral governments tend to cover up problems and maintain a low profile.
It was for this reason that Li Wenliang, a doctor who was one of the first toraise the alarm about signs of a new type of coronavirus, was arrested forsharing information with colleagues. The Wuhan government then attempted
to secretly report the disease outbreak to the central government.
The fragmented bureaucracy has posed a significant challenge to China’s
capacity for timely response. At the national level, the Chinese Centre for
Disease Control and Prevention (CCDC), which is responsible for handlingnational health crises, is under the leadership of the National HealthCommission (NHC).3 When COVID-19 broke out in Wuhan, local officials
reportedly withheld information for the purpose of maintaining stability(Wong, Barnes, and Kanno-Youngs 2020). The Wuhan CDC first reported theoutbreak to the Wuhan Municipal Health Commission, under the Wuhan
municipal government, instead of reporting the cases to the national-level
CDC. In this way, fragmentation leads to delays in information sharing andreveals central-local frictions. The former mayor of Wuhan, Zhou Xianwang,
indicated that the release of information was delayed because the municipallevel officials did not obtain authorization from Beijing, implicitly shifting
the blame to the central government (BBC News Chinese 2020).
This domestic political factor, namely fragmented bureaucracy, in China
appear to result in the slow release of information about the pandemic.
China has become more transparent in disease control and prevention since
the SARS crisis in 2003. Nevertheless, the outbreaks of H1N1 in 2009, and of
African swine fever in 2019, reveal that China continues to misrepresent orcover up disease outbreaks. Zhong Nanshan, a well-known Chinese expert
who participated in the fight against SARS in 2003 and who is currently headof the High-Level Expert Group of the NHC, pointed out that: ‘CDC in countries
like the US can directly report to the central government instead of reporting
3 There are multiple vertical lines of authority within these two agencies. For example, atthe provincial level there is usually a provincial CDC and a provincial Health Commission inplace.

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the issues level by level […] in China, what the CDC can do is to report to the
local government and nothing else’ (Zhang 2020, author’s translation).

Assertive Health Diplomacy
Because of China’s early missteps and cover-ups, it has come under the
scrutiny of international society. Australia, the US, and other countries havecalled for an independent probe into the outbreak (Dziedzic 2020). Several
US senators even sought an investigation into the WHO’s role in the global
health crisis (Tsirkin, Hunt, and Haley 2020).
Facing these accusations, the PRC government has attempted to reshapenarratives about the origins of the virus (Erlanger 2020) and its approach tohandling the health crisis. In early February 2020, with the domestic containment of the virus proving effective, China began to provide international
assistance. The Chinese government lauded the quantity of its medical
support for Europe, Africa, and other parts of the world. In early March,
China announced a US$20 million donation to the WHO (CGTN 2020) andalso pledged another US$30 million (Ministry of Foreign Affairs 2020). In
May 2020, President Xi (2020) made a speech at the opening ceremonyof the 73rd World Health Assembly (WHA), where he announced US$2
billion assistance to support COVID-19 responses and economic and social
development in affected countries over the next two years. In the same
speech, Xi also claimed that China would assist in building the Africa
Centre for Disease Control (CDC) headquarters and make the vaccine a
global public good once it was ready (ibid.).
To mitigate concerns over its early missteps and cover-ups and to redeem
its reputation on the international stage, China launched a series of public
diplomacy campaigns, contrasting its own response to COVID-19 with the
responses of the US and several European nations (The Straits Times 2020).
The Chinese leadership instructed diplomats to publicize China’s generosityand praise the Chinese approach in handling the crisis, seeking to tell a goodstory of its experience with the hope of getting support and understanding(Embassy of People’s Republic of China in the United Kingdom 2020).
However, many have suggested that China’s attempts to enhance its
image by reshaping the narrative have been seriously undermined by its
assertive and provocative diplomacy, which has been labelled by some as‘wolf warrior’ diplomacy (Zhao 2020). Since March 2020, the coercions andthreats made by aggressive Chinese diplomats, together with the strident
defence of China’s image by online Chinese nationalists, have triggered

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outcries in Thailand, Australia, and elsewhere. For example, Cheng Jingye,
the Chinese Ambassador to Australia, threatened to use economic coercion
to counter Australia’s call for an independent review into the origins andspread of the coronavirus in China. It has also been reported in the media
that, when providing medical assistance to other countries, the Chineseside demanded that recipients officially recognize this assistance (Erlanger2020). These anecdotes demonstrate the growing global scepticism towards
China’s increasing leadership on the world stage.

Conclusion
This chapter argues that China’s influence in global health governance has
been exaggerated. Given China’s funding of the organization, its involvement in agenda setting, and its provision of expertise to the WHO, China’srole in global health governance pales in comparison to its status as theworld’s second largest economy. China’s domestic political institutional
deficiencies have likewise limited China’s capacity to offer timely medical
responses, thus hindering the Chinese leadership in global health governance. It is evident that China has demonstrated some degree of leadershipin fighting against the COVID-19 pandemic by pledging financial, medical,
and professional assistance to virus-stricken countries. However, China’s
credibility in global health governance has suffered due to its missteps,
including misinformation in the initial phase of the COVID-19 pandemic,
and aggressive and incoherent narratives about the pandemic. Even if the
US initial mismanagement of the pandemic serves to weaken its role as theleader of global health governance, neither China nor the rest of the worldis ready for China to take over leadership in this area of global governance.

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what-world-health-organization-without-united-states.
Gostin, Lawrence O. 2015. ‘The Future of the World Health Organization: Lessons
Learned From Ebola.’ The Milbank Quarterly vol. 93, no. 3: 475-479. https://www.
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Not Alone.’ The New York Times, 29 May. Accessed 15 October 2020. https://www.nytimes.com/2020/04/08/world/asia/trump-who-coronavirus-china.html.
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94 

Xue GONG and Xirui LI—. 2017. ‘China’s Response to the 2014 Ebola Outbreak in West Africa.’ Global
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About the Authors
Xue GONG is Assistant Professor at the S. Rajaratnam School of International Studies, Nanyang Technological University, Singapore. Her researchinterests include international political economy, Asian regionalism and96 

Xue GONG and Xirui LI

global governance. She has contributed to peer-reviewed journals such as
World Development, International Affairs, the Pacific Review, Contemporary
Southeast Asia, and Harvard Asia Quarterly. She co-edited Securing the Beltand Road Initiative: Risk Assessment, Private Security and Special Insurances
Along the New Wave of Chinese Outbound Investment (Palgrave Macmillan2018), and has contributed to several book chapters on China’s economic
statecraft in Southeast Asia. She has also contributed various Op-Ed articles.
Xirui LI is a PhD student at the S. Rajaratnam School of International Studies,
Nanyang Technological University. Her research interests include Global
Economic Governance, Regional Integration and Central-Local Relations in
China’s International Political Economy. She is the translator of Power andits Logics (Chinese version, Social Science Academic Press (China), 2020)and has contributed several commentaries in The Diplomat.

5South Korea and the WHO during the
COVID-19 Crisis1
Brendan HOWE

Abstract
The World Health Organization (WHO) has faced uncooperative great
powers in managing global health crises. The contemporary operating environment has given middle powers the opportunity to shine.
South Korea, in particular, has seized the chance to gain more bang forits diplomatic buck by demonstrating its good global citizenship. This
chapter evaluates how the Republic of Korea (ROK) has not only followed
and promoted WHO guidelines, but also has been at the forefront ofdeveloping measures to combat the coronavirus. In doing so, it has gained
significant political capital. The ROK is likely to continue and even increase
its support of WHO governance precisely because it is in the country’s
national interest to do so.
Keywords: international organizations, South Korea (Republic of Korea),
World Health Organization, multilateral institutions, international healthmanagement, national interest

Introduction
Global pandemics throw into stark relief the dualistic paradox of international organization and global governance through internationalorganizations (IOs). International organization is a transitional process,from the international anarchic conditions that generate conflict towards
1 The author is deeply grateful for the assistance of Sukyung Kim, graduate student at Ewha
Womans University Graduate School of International Studies, in carrying out research for thischapter.

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_ch05

98 Brendan HOWE

the aspiration of global governance. Through this process states are actively
brought together to solve common problems, reconcile conflicting interests,
and generate collective good, including a more peaceful and secure operating
environment. International organizations (IOs) represent the phase ofthat process which has been reached at a given time (Claud 1963, 4). These
institutions form a key plank of the liberal international order, but remain
controversial, and are increasingly coming under attack. On the one hand
IOs are creations of the states that make up their membership and which
they serve so as to make the sovereign interstate system function better.
On the other hand, as I have explored elsewhere, IOs require a degree ofalienation or transference of state sovereignty (Howe 2020b, 18).
The liberal international order of international cooperation throughmultilateral institutions such as the United Nations (UN), the World Trade
Organization (WTO), and the World Health Organization (WHO), championing the policy platforms of open markets, collective security, and thepromotion of liberal democracy, is further challenged by the abdication ofleadership by the United States (US) and increasing contestation between the
US and China and Russia. In addition, as I have also examined in a related
publication, non-traditional security (NTS) issues such as COVID-19 andother pandemics, pose major challenges for the traditional state-centricmodels upon which much strategic decision-making is based (Howe2020a). Nowhere is this truer than in the state-centric East Asian operating
environment.
The responses of the three great powers (the US, China, and Russia) to
the COVID-19 crisis, as well as those of some second-tier powers such as
the United Kingdom (UK), Brazil, and India, have left much to be desired interms of both international and domestic leadership. Japan’s response has
also received at best mixed reviews. These countries have not only demonstrated a lack of leadership, but also their responses have been relatively
unsuccessful. Indeed, they have, on the whole, contributed to the challenges
faced by the WHO, rather than supporting the organization in carrying out
its global governance and systemic health security mission (Howe 2020a).
In contrast, middle powers, particularly those in the Asia-Pacific region
such as the Republic of Korea (ROK),2 Taiwan, Vietnam, and New Zealand,
have received glowing evaluations of their responses and their support for
multilateral health governance efforts. Salmon (2020) has noted that perhaps
the most startling trend seen during the global COVID-19 pandemic has been

2

ROK and South Korea are used interchangeably in this article.

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99

the vast difference between East Asia and the West. East Asia has handled
and contained the pandemic far better than the West on nearly all metrics.
This chapter first assesses the shortcomings of great power leadershipin international health management and the great powers’ lack of support
for the WHO’s global governance mission. It then turns to analyse South
Korea’s response to the pandemic, contrasting the country’s close adherence
to WHO guidelines and support of international health management withthe failings of the great powers. Finally, the chapter argues that we can be
optimistic about continued ROK leadership in these fields. The ROK is likely
to continue showing leadership not only because of a moral commitment
to normative foreign policy, but also because it is in its national interest toact in this way.

Divergent Responses
Chinese and US responses to global health crises and pandemics can beviewed as two ends of a continuum between authoritarian and libertarian
influenced governance (Howe 2017). In China a lack of transparency, anda lack of freedom of information and speech, has allowed pandemics tospread and endanger vulnerable individuals and groups in the country, theregion, and across the globe. When the Chinese government has acted, it has
tended to act unilaterally and in an authoritarian rather than open manner,
imposing comprehensive lockdowns that exacerbated socio-economic
vulnerabilities. In contrast, during the current COVID-19 pandemic, theUS government agencies were slow to respond to the pandemic, due toconcerns about economic impacts of restrictions, but also out of concern
for the impact restrictions would have upon civil liberties and individual
freedoms. These concerns have also created pressures for a premature liftingof restrictions (Howe 2020b, 18). As a result, the US is now the most severely
impacted country in the world (Worldometers 2020).
Internationally, China and the US have focused on blaming each otherfor the impact of COVID-19. They have resorted to national interest security
promotion rather than collective action and have shown inconsistent support
for the WHO’s mission and even outright hostility towards it.
The ways that great power obstruction could hinder the WHO in carryingout its global health governance were also evident during the 2002-2004
SARS coronavirus (SARS-CoV) outbreak. SARS-CoV first infected humans
in the Guangdong province of southern China in 2002. It rapidly turned intoa pandemic that affected 26 countries and resulted in more than 8000 cases

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in 2003, before dying out with only a small number of cases in 2004 (WHO2020a). The Chinese authorities were initially unwilling to cooperate with
the WHO due to considerations of national interest and state sovereignty(Wong and Zheng 2004). Lack of epidemiological information about thedisease hampered the prompt application of effective control measures,
something that was also the case with the Hong Kong authorities where
the disease soon spread. Because of inadequate communication, ‘panic
developed in the community and weakened cooperation and support fromthe public’ (Hung 2003, 376).
During the current COVID-19 crisis, the WHO has once again faced an
uncooperative great power. This time, however, it has been the US hegemon
working against the global governance mission. On 29 May 2020, President
Donald Trump said he would make good on his threat to withdraw fromthe WHO. This has been described as ‘an unprecedented move that could
undermine the global coronavirus response and make it more difficult
to stamp out other disease threats’ (Ehley & Ollstein 2020). The US gave
US$893 million to the WHO between 2018-2019, of which US$237 million
were assessed contributions (the dues countries pay in order to be a memberof the Organization). It still owes approximately US$392 million throughvarious multiyear cooperative agreements (Liberman 2020). As by far thelargest state donor to the organization, the US’s conflict with the WHO
could have a devastating impact on the latter’s global health governancemission. In one of his first acts as President, Joe Biden did walk back theformer administration’s plan to withdraw the US from the WHO, but there
remain concerns about ‘perfidious America’ in this, as well as other areasof global governance.
Despite these concerns, even at existing levels of support, there is hopefor the WHO governance mission in the form of support from middle powers
and non-state actors. While the US may be the largest donor, the top ten
donors list is rounded out by three middle powers, namely the UK, Germany,and Japan. Also in the top ten are four civil society organizations, the Bill &Melinda Gates Foundation, the GAVI Alliance, Rotary International, and the
National Philanthropic Trust. Then there are two IOs, the United Nations(UN) Office for the Coordination of Humanitarian Affairs (UNOCHA) andthe European Commission (WHO 2020b).
The dominance of small and medium-ranked powers, as well as civilsociety organizations, is even more pronounced when it comes to Core
Voluntary Contributions (CVCs). CVCs are fully unconditional (flexible),
meaning the WHO has full discretion on how these funds should be used
to fund its programmatic work. The main providers of CVCs, in order ofSouth Korea and the WHO during the COVID -19 Crisis

101

support, are the UK, Sweden, Norway, Australia, the Netherlands, Belgium,
Denmark, Switzerland, Luxembourg, France, the Estate of Mrs. Edith
Christina Ferguson, Spain, the Estate of the Late Marjory Miller Thompson,
Monaco, and Miscellaneous (ibid.).
The extensive support given to the WHO by middle powers means it isimportant to examine how states such as the ROK relate to the organization.
In the following sections, this chapter first looks at how the ROK is actingin accordance with the global health governance mission of the WHO. It
then discusses what potential South Korea may hold for future leadershipin the field.

The ROK, the WHO, and Respiratory Pandemics
South Korea joined the WHO in 1949. It was covered by the WHO Representative Office in Taipei, Republic of China (Taiwan) between 1959 and 1965,
when the WHO Representative Office in the ROK was established. The
WHO Country Liaison Office had been established in 1962, and this thenbecame a Representative Office in 1965 before changing back to a Country
Liaison Office in 1999 (WHO 2020c). During the 2003 SARs-CoV outbreak,the ROK government worked closely with the WHO, taking rapid action
to prevent further spread of the virus (The Briefing 2020). As a result, only
three confirmed cases were reported in South Korea, and no deaths. Thiswas despite the country being close to the epicentre of the virus in China
and also having many ties to it. The low numbers in the ROK compare witha global total of 8437 probable cases and 813 deaths cases (WHO 2003).
South Korea did not, however, escape so lightly when the region was
struck by a second respiratory pandemic. In 2015, MERs-CoV inflicted
186 laboratory-confirmed cases and 38 deaths (WHO 2015). Unlike during
the SARS-CoV epidemic, the ROK government’s response to MERs-CoV
was widely criticized by the Korean public, particularly its initial reaction(Yonhap 2015). Yet the ROK learned important lessons (both positive andnegative) from dealing with these two epidemics. These lessons were to
stand them in good stead with the outbreak of COVID-19, which was firstreported in Wuhan, China, at the end of December 2019 (Kim 2020).
The South Korean Ministry of Health and Welfare (MOHW) reported thisnew disease to its population on 3 January 2020. It announced strengthened
surveillance for pneumonia cases in health facilities. On 20 January 2020, thefirst case of infection in South Korea was reported. The government accordingly scaled up its national alert level from blue to yellow and established102 Brendan HOWE

more intense guidelines (MOHW 2020).3 More proactive measures against
the virus were implemented from the end of January. These were put inplace after the meeting of the Emergency Committee of the WHO where
the Director General declared a ‘Public Health Emergency of International
Concern (PHEIC)’. The Korea Centers for Disease Control and Prevention(KCDC) started to closely monitor the changes in the international situation
to prepare its response system. They also held a risk assessment meeting. In
September 2020, the KCDC had its status upgraded to become an independent government agency, the Korea Disease Control and Prevention Agency,
or KDCA, in recognition of its performance (KBS 2020).
As the situation worsened, and other countries gradually closed theirborders to people from China, there were great pressures for the ROK to
do the same. Despite this, the Korean government announced that South
Korea would not entirely restrict entry from China unless explicitly advised
to do so by the WHO (Kim and Kim 2020). As the situation continued todeteriorate, public dissatisfaction towards president Moon Jae-in and theWHO’s conservative approach grew (Kang 2020). An unpredictable andblurred situation led to increasing demand for Personal Protective Equipment (PPE), especially masks, which then surged in price (SBS 2020).
Government guidelines for wearing masks were initially ambiguous,leaving the public confused. In the middle of February, therefore, the Korean
Medical Association (KMA) and the Ministry of Food and Drug Safety
jointly provided advice regarding the use of masks, referring to the WHO
guidelines published in late January (Yonhap News 2020a). In contraventionof the WHO mask guidelines, the government still controversially allowed
its population to reuse disposable masks if these were not too contaminated.
They did this out of concern that panic buying could lead to potential mask
shortages for the medical field and vulnerable individuals and groups (Jeon
2020). A few days later, however, the government published new guidelines
citing the WHO advice that keeping social distance was more important
than wearing a mask (Yonhap News 2020b).
Furthermore, when masks did run low, and there was a temptation tohoard or increase prices, the government stepped in and rationed the numberof price-controlled masks that could be bought by an individual. Depending
on date of birth, each citizen was allotted a day on which they could buy
masks. Early in the pandemic, free hand sanitizer was to be found next toand in the elevators of every building. With a slight resurgence of infections
3 South Korea operates a four-colour warning system: 1: Blue – Exercise normal precautions;
2: Yellow – Exercise increased caution; 3: Orange – Reconsider travel; 4: Blue – Do not travel

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103

in May 2020, tens of thousands of people were tested within days. People
who were potentially infected were contacted to six degrees of separation.
The government cooperated with phone companies and bank card issuers
to carry out this contact tracing. In May, the wearing of masks on all formsof public transport also became mandatory (Howe 2020a).
South Korea’s response to the crisis, while initially a little slow, has seen
a combination of governmental policy and domestic constituency societal
engagement that has won praise from around the world. Of course, there havebeen many infected, and the economy has been dealt a serious blow. Yet the
WHO guidelines have found a champion in the ROK. The main ways South
Korea has been able dramatically to reduce infections while not resorting toeconomically devastating lockdown are through a combination of aggressive
testing and contact tracing and universal mask use. On the government side,
due to the previous pandemic scares, preparations were already in place to ramp
up dramatically the production of tests, masks, and PPE. Likewise, work had
already been done on contact tracing technology in South Korea, which has
one of the most connected societies in the world. On the society side, people are
already well-used to wearing masks due to the pollution, and out of considerationfor others when suffering from a cold, and are willing to accept a degree ofinvasiveness in their lives due to national security considerations (Howe 2020a).
South Korea has also taken on part of the international burden of tackling
COVID-19, as well as other infectious diseases. After being designated in
2019, South Korea has become a member of the WHO’s executive board forthe period 2020 through to 2023. This will allow it to play an important rolein screening the WHO’s budget and in policy implementation and strategy
development. The ‘Korea-WHO Country Strategy 2019-2023’ outlines theregional and global leadership role that the ROK will perform and invites
South Korea to open global forums and lead regional commitment forstrengthening health regulatory systems (WHO 2019).

Middle Powers, Niche Diplomacy, and Global Health Governance
South Korea has therefore stepped forward to stand at the vanguard of thequarantine management system. As one of the most successful infection control
cases, with its transparency and innovative testing strategy, South Korea’s
effort to combat COVID-19 has earned the praise of the WHO. In addition, theWHO has revealed its intention to participate in the domestic cohort research
conducted by Korean medical teams (Herald Economy 2020). The WHO has
also asked South Korea to supply test kits to the African region, which have104 Brendan HOWE

been requested by over 120 countries (Shin and Park 2020). In addition, throughweb-conferencing, the ROK government has been sharing their know-how andpromoting the Korean quarantine system as a way of responding to COVID-19.
The South Korean knowledge sharing activity includes regular web
seminars about ‘K-Defence Prevention’ with health care officials around theworld. It also includes the holding of tripartite health minister conferences
between ministers from Korea, China, and Japan. At these conferences, theROK has stressed the need for international solidarity against the virus anddiscussed support for the WHO and the WHO Western Pacific Regional Office. At the 73rd World Health Assembly (WHA), which addressed responses
to the COVID-19 pandemic, President Moon announced in his keynote
speech that the government planned to provide US$100 million worth ofadditional humanitarian assistance (Korea Herald 2020). This is a verysignificant increase given that South Korea’s assessed contribution to the
WHO in 2020-2021 had been US$54 million dollars (WHO 2020d).
Beyond simply promoting the K-defence system, South Korea has been at
the forefront of seeking international cooperation. A ROK-led multilateral
cooperation group, the Support Group for Infectious Disease Response(G4IDR), based in Geneva, brings together a number of countries alongwith the eight core members (Singapore, Turkey, United Arab Emirates,
Morocco, Kenya, Mexico, and Peru) to collaborate with the WHO and otherglobal health organizations like Unitaid (MOFA 2020). In addition, theKorean Ministry of Foreign Affairs (MOFA) has hosted a conference, headed‘COVID-19 situation by region and response status of overseas diplomatic
missions, future Corona 19 response and policy direction’, to establish andpromote the development cooperation initiative (Ministry of Interior and
Safety 2020). As part of these efforts, a total of 36 billion won (US$31 million)
worth of aid has been announced, under the name of ‘Comprehensive
Emergency Support Program for Corona 19 Response’. This aid will be given
to India (New Southern), Ethiopia (Africa), Uzbekistan (New Northern),
Colombia (Latin and South America), and five ASEAN target countries.
South Korea has been criticized in the past for only pursuing normative
foreign policies when doing so garners some benefit to the country (Kalinowski
and Cho 2012, 249). Unlike some other donors, however, these national interest
considerations mean that the ROK is likely to follow through on all its pledges
and abide by all its humanitarian commitments. The government headed byPresident Moon Jae-in has been in power throughout the period when COVID-19,
this greatest of humanitarian challenges, has impacted upon domestic andinternational governance. The normative foreign policy activism of the Moon
administration fits well with the ROK tradition of middle power niche diplomacy.

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105

Middle powers like South Korea lack ‘compulsory power’, in that they do
not have the military resources to dominate other countries or the economic
resources to bribe them. They differ, however, from the small or ‘system ineffectual’ states which have little or no influence because they are, potentially,‘system affecting states’ that can have significant impact within a narrower
policy area or in conjunction with others (Vom Hau, Scott, and Hulme 2012,
187-8). To maximize their relevance and impact, a degree of selectivity on
the part of these middle powers is required. This means the pursuit of ‘niche
diplomacy,’ which involves concentrating resources in specific areas best
able to generate returns worth having, rather than trying to cover the field,
allowing them to ‘punch above their weight’ (Henrikson 2005, 67).
In search of a diplomatic ‘niche’, successive recent administrations inSeoul have stressed a commitment to variations of ‘principled foreign policy’.
The Moon administration has not directly identified its diplomatic characteras that of a middle power. Yet there is evidence of such thinking in its ‘onehundred major policy tasks’ which includes a section describing foreign
policy goals. In these, the overarching themes of the administration include‘responsibility’, ‘multilateralism’, and ‘values’. In this context, ‘responsibility’means that South Korea will fulfil its regional and global governance duties.
This, it can be argued, is one of the characteristics of a middle power in theinternational community. Given this, it can be expected that contemporary
South Korean foreign policy will focus on multilateralism with an emphasis
on universal values, such as human rights, democracy, and rule of law.

Conclusion
Although the Moon Administration has not explicitly branded itself as a middle
power, its de facto foreign policy strategy remains deeply wedded to middlepower diplomacy. Indeed, these elements of the Moon Administration’s foreign
policy platform represent a continuation of regional and global humanitarian
multilateralism. President Moon’s aspirational project for a ‘Northeast Asia
Plus Community’ (NEAPC) of responsibility aims to build a sustainable systemof regional cooperation.4 This project has an ambition to ultimately produce
a people-centred peace community that advocates co-prosperity.
4 This community is envisaged as bringing together states and frameworks within and beyond
the region including the US, China, Japan, Russia, Mongolia, Australia, New Zealand, ASEAN(and its member states), the Trilateral Cooperation Secretariat (TCS), the UN, NATO, EU, andOSCE.

106 Brendan HOWE

President Moon (2020) has sought to use the current crisis as a driving
force for new opportunities and development. He aspires to realise ‘a Republicof Korea that takes the lead in the world’. These statements, delivered to markthe third anniversary of his inauguration, represent a continuation of Korea’s
humanitarian middle power niche diplomacy, but also an attempt to drive
it forward by taking advantage of the post-COVID operating environment(Howe 2020b). As such, therefore, the government of the ROK is likely tocontinue and even increase its support of WHO governance precisely because
it is in the country’s national interest to do so.

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learned?’ Journal of the Royal Society of Medicine vol. 96, no. 8: 374-378.
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that Reusing Masks and Cotton Masks Are Also Safe.’ HanKyung, 3 March. Accessed 1 January 2021. https://www.hankyung.com/society/article/2020030333111.
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Kang, Tae-jun. 2020. ‘Public Anger Swells in South Korea over Corona Virus Outbreak.’ The Diplomat, 28 February. Accessed 1 January 2021. https://thediplomat.
com/2020/02/public-anger-swells-in-south-korea-over-coronavirus-outbreak/.
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from a Previous Coronavirus Outbreak: MERS.’ The Bulletin, 20 March. Accessed 1 January 2021. https://thebulletin.org/2020/03/south-korea-learnedits-successful-covid-19-strategy-from-a-previous-coronavirus-outbreak-mers/.
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Entrant Has Not Been Discussed, No Decision Without WHO’s Advice’.’ Money
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php?no=2020012716147694900.
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articleView.html?idxno=382.
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108 Brendan HOWE

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0602053400017?input=1195m.
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109

About the Author
Brendan HOWE is Dean and Professor of International Relations at Ewha
Womans University Graduate School of International Studies, and Presidentof the Asian Political and International Studies Association. His research
focuses on traditional and non-traditional security in East Asia, human security, comprehensive peacebuilding, middle powers, post-crisis development,
and conflict transformation. He has authored, co-authored, or edited morethan 90 related publications including The Niche Diplomacy of Asian Middle
Powers (Lexington Books, 2021), UN Governance: Peace and Human Security
in Cambodia and Timor-Leste (Springer, 2020), Regional Cooperation for
Peace and Development (Routledge, 2018), Peacekeeping and the Asia-Pacific(Brill, 2016), Post-Conflict Development in East Asia (Ashgate, 2014), and The
Protection and Promotion of Human Security in East Asia (Palgrave, 2013).

6

Escaping the ‘Realist Trap’
The ROC’s Participation in Global Health Governance Under
the One-China Principle
Catherine Yuk-ping LO
Abstract
Drawing on the perspectives about global governance offered by realist
international relations theory, this chapter aims to demonstrate thatinternational institutions of global health governance are just anotherarena of world politics that is vulnerable to manipulation by powerfulstates. The utility of realism in understanding global health governanceis examined by looking at the case of Taiwan, also named the Republicof China (ROC), and the COVID-19 pandemic. The case study shows how
the One-China Principle has restricted interactions between the World
Health Organization (WHO) and the ROC during health emergencies.
While the constraints seem formidable, this paper argues that the ROC
can potentially escape the ‘realist trap’ because of its de facto status,
participating in global health governance in a meaningful way
Keywords: Taiwan (Republic of China), One-China Principle, global healthgovernance, realism, World Health Organization (WHO), COVID-19

Introduction
There has been an ongoing debate in the field of international relations
about the role of international institutions (Schweller and Priess 1997, 2).
Institutionalists claim that international institutions can move states
towards cooperation to promote the general welfare of states (Schweller
and Priess 1997, 8). In contrast, realists perceive institutions as arenas for
great powers to secure and advance their national interests (Mearsheimer

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_ch06

112 Catherine Yuk-ping LO

1994/1995, 7). In light of this debate, this chapter considers the influencethat the People’s Republic of China (PRC) has had on the engagement of the
Republic of China (ROC) in the World Health Organization (WHO) during
the COVID-19 pandemic. The chapter shows that this demonstrates therealist prediction of the vulnerability of international institutions to great
power politics.
With the increasing pressure exerted on the ROC by the PRC, and theambiguous international status of the former, scholars have argued that the
ROC’s participation in global health governance is minimal and insignificant(Chen 2018, 264). However, this chapter posits that the de facto status of the
ROC to a certain extent helps it escape the so-called ‘realist trap’ that state
actors often encounter in global health governance.1 This realist trap refers
to the way in which states that seek to engage in international cooperation
face problems, including other states freeriding in the cooperation, or otherstates failing to comply with norms and regulations (Mearsheimer 1994/1995,
12). By escaping realist entrapment, the ROC can potentially participate inglobal health governance in a meaningful way. This chapter proceeds asfollows: It begins with an overview of the ROC’s participation in the WHO.
Applying a realist perspective, the chapter evaluates how, before and during
the COVID-19 pandemic, the PRC has sought to secure its national interest
regarding the ROC in the international community. The chapter concludes
with a discussion of the future participation of the ROC in global healthgovernance.

The ROC in Global Health Governance and the One-China
Principle
The Republic of China (Taiwan) used to be a key player in global healthgovernance, and was one of the founding members of the WHO in 1948.
After the communists won control of mainland China, during the Chinese
Civil War that lasted until 1949, the Chinese nationalists (Kuomintang)retreated to Taiwan. Since then, both the PRC and ROC have claimed sole
representation of the Chinese nation. However, after the end of the civil
war, the ROC remained a member of the WHO and other United Nationsorganizations. Following the US rapprochement with China in the early
1 The term ‘realist trap’ comes from an article written by Davenport (2011, 40) which argues
for the entrapment of Marxism in realist thoughts: Davenport, Andrew. 2011. ‘Marxism in IR:
Condemned to a Realist fate?’ European Journal of International Relations vol. 19: 27-48.

Escaping the ‘Realist Trap’

113

1970s, in 1971 the PRC replaced the ROC as the sole Chinese representativeat the UN (Winkler 2012). The ROC’s loss of its UN membership triggereda domino effect, with many other states then ‘de-recognizing’ the ROC’s
statehood. Between 1971 and 1979, at least 46 governments broke relations
with the ROC (Hickey 2007, 9).
Meanwhile, the PRC began campaigns against the ROC’s membership ininternational institutions under the One-China Principle. The One-China
Principle is the name referred to by the PRC, while the same arrangement
is referred to as ‘the 1992 Consensus’ by the ROC. Under the One-China
Principle/the 1992 Consensus, both the PRC and ROC acknowledge that
there is ‘one China’ but each side has its own interpretation of what ‘China’means. From the PRC’s perspective, Beijing is the sole legitimate government
representing the whole of China, and Taiwan is not a sovereign state but
rather a ‘breakaway’ province. Based on this perspective, the ROC should
be replaced and represented by the PRC in all international organizations
where membership is given to states (Li 2006, 598).
Because of the PRC campaigns carried out in the 1970s, the ROC lost
representation in numerous international organizations, including the WHO(Li 2006, 598). Being excluded from the international health regime, theROC government no longer had access to timely and first-hand information
regarding global infectious disease outbreaks. It could not participate in
WHO meetings discussing disease mitigation strategies or receive direct
assistance in disease control and surveillance. However, the 2003 Severe
Acute Respiratory Syndrome (SARS) crisis led to greater international
concern over the absence of the ROC from global responses to disease
outbreaks. The crisis served as a wake-up call, pointing to the need for
the WHO and other states to reconsider the ROC’s role in global healthgovernance. As a result, the ROC itself, as well as several member states
started calling for its inclusion as an observer in the World Health Assembly(WHA), the WHO’s decision-making body (Hickey 2007, 105), for statehood
is not a requirement at the WHA.
The ROC’s engagement in global health governance was boosted when
it was granted observer status in the WHA in 2009. The WHO’s decision
was based on an ad hoc arrangement as part of the One-China Principle.
This arrangement stated that the ROC’s participation in internationalorganizations would be ‘based on the agreement reached through consultations between the Chinese government and the internationalorganizations [i.e., the WHO in this case] concerned’ (Li 2006, 602).
This pre-screening mechanism was established to provide the PRC withsome flexibility to manage the issue, while preventing the ROC from114 Catherine Yuk-ping LO

utilizing increased global participation to push for de jure independence(Glaser 2013).
However, despite gaining the possibility to participate in the WHO,
Taiwan’s ability to engage in the WHO’s work and technical activities
remained limited. One important reason for this was that, in 2005, the
PRC government signed a secret Memorandum of Understanding (MOU)
with the WHO secretariat. This memorandum acknowledged the PRC
government’s power over the ROC’s participation in the WHO/WHA (Glaser2013). This meant that ROC experts who planned to attend WHO meetings were required to apply five weeks in advance, submitting participantlists to the PRC government for approval. If ROC experts were invited toa conference, then the WHO was also required to invite experts from the
PRC. In addition, higher-level ROC officials were restricted from attending
any WHO activities. All communications between the ROC and the WHO
were to be made through the PRC.
In the ROC elections of 2016, the Democratic Progressive Party (DPP)
candidate Tsai Ing-wen, who is very sceptical of the PRC, was elected aspresident. Following this, the One-China Principle was explicitly mentioned
for the first time as a ‘precondition’ for the ROC’s invitation to participate
in the WHA (deLisle 2016, 552). Because Tsai Ing-wen and the ruling DPP
refused to affirm the One-China Principle, the ROC’s participation in the
WHA has been suspended since 2017. Referring to the ROC’s participationin the WHA, a PRC white paper published in 2000 stated that ‘everythingcan be discussed under the One-China Principle’ (Chu 2000, 62). In otherwords, if the ROC accepts the One-China Principle, ‘all other issues regarding
Taiwan’s international status and international space can be discussed
and [it is possible to] find solutions’ (Chu 2000, 62). The way in which the
PRC has determined the ROC’s participation in the WHA arguably offers
proof of the realist idea that international institutions, such as the WHO,are arenas for great powers to secure and advance their national interests.

The ROC and the WHO During the COVID-19 Crisis
The vulnerability of the WHO to great power influence is even more apparent
during global health crises. After receiving news about patients falling sickwith a mysterious unidentified form of pneumonia in Wuhan, the ROC’s
health officials directly contacted the WHO for more information. It also
warned the organization on 31 December 2019 of the possibility of humanto-human transmission, referencing the International Health Regulations

Escaping the ‘Realist Trap’115(IHR). However, the WHO only responded with a short message, statingthat the information provided by the ROC had been forwarded to expert
colleagues (Taiwan CDC 2020b). On 14 January 2020, the WHO wrote on thesocial media platform Twitter that there was ‘no clear evidence’ that thecoronavirus could spread between people (Watt 2020). This Twitter post
was made on the same day that the WHO’s technical leader on COVID-19,
Maria Van Kerkhove, gave a press briefing in Geneva warning of the potential
for rapid spread. A middle-ranking WHO official had reportedly told theWHO’s social media team to post a tweet that balanced the Van Kerkhove
briefing, because the warning in this briefing conflicted with the initial
Chinese findings (Corcoran 2020).
The WHO has also been accused of delaying the declaration of a Public
Health Emergency of International Concern (PHEIC; Wenham et al. 2021,
1856). The designation of an outbreak as a PHEIC grants the WHO directorgeneral additional powers to issue recommendations for how countries
should respond. While countries can ignore those directives, such an announcement can increase global attention to an outbreak. Such declarations
are made when the outbreak poses a risk to more than one country andrequires a coordinated international response. Nevertheless, the WHO
did not declare the outbreak to be a PHEIC until the end of January. On
23 January, the same day that the PRC’s central government announced
a lockdown in Wuhan and two other cities, the WHO convened an emergency committee. The committee asserted that the coronavirus did not yet
constitute a PHEIC and that the extent of human-to-human transmission
was still unclear (WHO 2020). This was despite the widespread reportingof cases across Asia, with cases reported in Thailand on 13 January, in Japanon 16 January, in South Korea on 20 January, in Taiwan on 21 January, andSingapore and Vietnam on 23 January. It was only when the virus had spreadto all provinces and major cities in the PRC on 30 January, that the WHOdetermined that the outbreak constituted a PHEIC.
Some commentators speculated that the WHO avoided declaring a PHEIC
right after the Wuhan lockdown because it was concerned this would havebeen perceived by Chinese authorities as distrust of their capability to control
the disease (Mazumdaru 2020). Officials at the WHO were also aware thatangering the PRC leaders over the ROC could result in Chinese officials
sharing less information with the international community or barring
WHO experts from investigating the origins of the virus (Mazumdaru 2020).
Despite the fact that the WHO praised the PRC in public, it has been reportedby the media that officials privately complained that the PRC authorities
were not sharing enough data to allow them to assess how effectively the116 Catherine Yuk-ping LO

virus spread between people or what risk it posed to the rest of the world(The Associated Press 2020).These political calculations, and the desire not
to upset the PRC, has arguably meant that the WHO has downplayed theissue of the ROC ’s participation during the current crisis.
This has been despite the fact that, during the early stages of COVID-19,
the ROC led the world as the most-prepared and best-equipped region tofight the pandemic. The ROC authorities began screening passengers arrivingfrom Wuhan as they disembarked at the airport on the same day that theyfirst sent inquiries about COVID-19 to the WHO. The ROC also officially
activated its Central Epidemic Command Center (CECC) on 20 January.
This has allowed coordination with various ministries to enact policies andstrategies already in place before the first case was reported on Taiwanesesoil on 21 January (Taiwan CDC 2020a). At a time when other countries wereexperiencing a severe shortage of medical equipment, the ROC government
implemented a rationing system for the public, allowing National Health
Insurance cardholders to buy two masks per week at designated pharmacies.
This number of masks was later increased to three per week, then nine every
fortnight, after which an online ordering system was introduced (Taiwan
CDC 2020c). When global infections reached one million in April 2020,
the ROC government launched the Mask Donation Scheme that allowed
Taiwanese people to donate their quota of surgical face masks to othercountries that were in short supply. Taiwan likewise pledged to donate ten
million face masks to different countries, including EU member states andthe US (Peel and Hille 2020).
During the f irst year of the COVID-19 pandemic, the ROC was very
successful in handling the virus. By the end of January 2021, only eightpeople in Taiwan had died from COVID-19 and it had seen a total of just911 cases (JHU CSSE 2021). These statistics have been compared by somecommentators with those of the PRC, which saw more than 89,500 cases of
COVID-19. In making this comparison, some have also pointed to differences
between the ROC’s democratic approach to handling the pandemic and theauthoritarian approach of the PRC. Therefore, the success that the ROC has
had without WHO membership has increased international support for ROC
membership in the organization (Lynch 2020). Supporters claimed that the
WHO’s exclusion of the ROC is seen to have prevented it from effectively
sharing its strategy and information.
Trust in the WHO’s objectivity on the matter has increasingly been eroded.
This has been worsened by negative international media coverage. For
example, during an interview with Radio Television Hong Kong (RTHK),the reporter Yvonne Tong asked the assistant director-general of the WHO,

Escaping the ‘Realist Trap’117

Bruce Aylward, a question about the ROC not being granted membershipof the WHO. Aylward responded by claiming not to hear the question,with some commentators suggesting that he was pretending not to hear it
and was refusing to discuss the ROC’s participation (Watt 2020). When he
was asked the same question again, he replied: ‘we’ve already talked about
China’ (Watt 2020).
There have been accusations that the WHO is being influenced by the
PRC. One Japanese minister, for example, said that the WHO should be
renamed as the ‘Chinese Health Organization (CHO)’. Meanwhile Facebook
users renamed the WHO as the ‘Winnie (the Pooh) Health Organization’,referring to Chinese President Xi, who has been compared to Winnie the
Pooh in online memes. Critics have also accused the director-general of the
WHO of serving Chinese interests in responding to COVID-19 because of his
personal connections with China, or the China connections of the Ethiopian
government with which he is linked. The current director-general of theWHO, Tedros Adhanom Ghebreyesus, was Ethiopia’s Minister of Foreign
Affairs from 2012 to 2016. During his tenure, an electrified Ethiopia-Djibouti
railway line was built by China Railway Group and China Civil Engineering
Construction, with the PRC’s Exim Bank financing 70% of the construction
costs (BBC News 2016). The line connects to Djibouti, which houses the firstand only PRC military base overseas. A connection between the PRC andEthiopia can similarly be seen in the fact that the former director-general of
the WHO, the Chinese-Canadian Margaret Chan, supported Tedros in theselection process of the new director-general. Although these facts do notnecessarily mean that the WHO has fallen prey to Chinese influence, theycreate suspicions at a time when public trust in the organization is faltering.

Escaping the ‘Realist Trap’: the Future of the ROC’s Participationin Global Health Governance
Recent years have seen the suspension of the ROC’s invitation to participate in the WHA and the consequent exclusion of Taiwan from the WHO.
Alongside this, the ROC’s international space has been further dwindlingas a number of its diplomatic partners have switched allegiance to the
PRC (Ministry of Foreign Affairs, Republic of China, 2020). Taiwan had
fifteen diplomatic partners at the time of writing. In the global healthregime, given the vulnerability of the WHO to great power influence, it
seems that there is little the ROC can do but to accept reality. The PRC is arising economic and military power and it is also a greater source of global

118 Catherine Yuk-ping LO

health threats. This means that the WHO and other international healthorganizations will likely choose the PRC over the ROC, in order to keep
the former engaged in international cooperation. With the ROC’s current
international status, it seems that achieving ‘meaningful participation’ inglobal health governance is near to impossible in the absence of statehood(Chen 2018, 264). This chapter, however, argues the opposite. Owing to its
de facto status, in its participation in global health governance the ROC isable to overcome two main constraints that realists claim that states face ininternational cooperation, namely free-rider and non-compliance problems(these constraints are here referred to as the ‘realist trap’).
Free-rider Problem: From a realist perspective, states see no obligation to
help other states unless doing so will further their own national interests.
National governments may provide public goods nationally, but there are
few incentives for national governments to provide public health goods
for other countries (Ng and Ruger 2011, 10). The provision of public healthgoods hence becomes the business of the hegemon (with the current global
hegemon being the US; Min 2003, 23). While the hegemon provides public
goods from which all other states benef it, its ‘rivals’ do not contributeto providing these goods. They therefore enjoy a ‘free-ride’ owing to thenon-excludable nature of these goods or the fact that the hegemon cannot
stop even those non-contributing states from receiving them (Min 2003,
23). Nobody is willing to pay unless there is a mechanism (i.e., taxationand fines) to enforce contribution. In this sense, realists argue that the US
is reducing its contribution to global public goods to avoid the long-term
relative decline of its hegemonic power. The cuts to US funding of Development Assistance for Health, the Global Health Security Agenda, and The
President’s Emergency Plan for AIDS Relief programmes under the Trumpadministration are cases in point.
Non-compliance Problem: A second constraint on global health cooperation is the way in which states can claim state sovereignty to justify
non-compliance with norms in global health governance (Stevenson andCooper 2009, 1379). Fighting the spread of viruses without international
cooperation can be nearly impossible. Therefore, to fight viruses, states haveto cede sovereignty to a certain extent in specific cases to ensure adequate
provision of health security as a global public good (Huang 2016). Froma realist perspective, states fear losing sovereignty, and in an anarchicalinternational system they might only be willing to make a ‘discount onsovereignty’ when it comes to pragmatic problem solving (Florini 2011, 30).
Neither of these two constraints on cooperation apply to the ROC. As
a de facto state, ROC officials want to gain sovereignty and international

Escaping the ‘Realist Trap’

119

recognition. Therefore, the ROC’s leaders have been acting as though it is amember state that is responsible for paying for public health goods and forcompliance with the norms that form the global health regime. As part ofthe international community’s response to the outbreak of Ebola in West
Africa in 2014, for instance, the ROC government donated US$1 million tointernational aid efforts and provided 100,000 sets of personal protective
equipment for use by medical workers (Mainland Affairs Council, Republicof China 2015). Despite not being a WHO member state, the ROC has signed
agreements with countries seeking help in overcoming the coronavirus,
including the US. The ROC authorities announced the donation of two
million surgical masks to the US.
The ROC has also contributed to disease control and mitigation at theregional level. For example, it organized training workshops for Asia-Pacificand Southeast Asian health professionals to improve the regional capacity
to detect and respond to dengue fever, Ebola, Middle East Respiratory
Syndrome (MERS), and Zika virus (Lee and Fang 2016). The ROC’s commitment to health governance at the regional level is likewise shown by
the ‘New Southbound Policy’ that the Tsai administration established.
This policy strengthened the ROC’s relationships with the ten countriesof ASEAN, six states in South Asia (India, Pakistan, Bangladesh, Nepal, Sri
Lanka, and Bhutan), Australia, and New Zealand (Taipei Economic andCultural Off ice in Brunei Darussalam 2016). The ROC announced thatsix medical centres would be established in India, Indonesia, Malaysia,
the Philippines, Thailand, and Vietnam to promote medical cooperation(Department of Information Service, Executive Yuan 2018). Escaping
the realist fate, the ROC shows it can meaningfully participate in global
health governance even in the absence of state-aff iliated membershipof the WHO.

Concluding Remarks
The ROC is one of the ‘theatres’ of the souring relations between the PRC
and the US. In March 2020, the then US president Trump signed the Taipei
Act requiring Washington to advocate the ROC’s inclusion in international
bodies like the WHO (Watt 2020). Furthermore, the then US Health Chief
Alex Azar made a rare trip to the ROC. He was the highest-level American
official to visit the ROC in decades (Wong 2020). All this posturing towards
the ROC is a violation of the One-China Principle in the eyes of the PRC
government. Considering the suspension of the ROC’s participation in the120 Catherine Yuk-ping LO

WHA, plus the de facto status of the ROC, a realist perspective would argue
that its contribution to and involvement in global health governance haveto be minimal and limited. However, as this chapter shows, the de facto
status helps the ROC escape this supposed ‘realist trap’, namely the free-rider
and non-compliance problems that rational-choice theorists believe state
actors face in global health governance. As long as the ROC upholds theprovision of public health goods and compliance to global norms, it canachieve meaningful participation in health governance at both the global
and regional levels.
Acknowledgement
I want to thank Yow Shuning for helping me with the data collection. Anyerrors remain my own.

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About the Author
Catherine Yuk-ping LO is an Assistant Professor at University College Maastricht, Maastricht University. She specializes in international relations andglobal health. Her current research interests include HIV/AIDS in China
and India, infectious disease responses in Northeast and Southeast Asianstates, antimicrobial resistance (AMR) challenges in the Global South andNorth, and also global health diplomacy. She is the author of HIV/AIDS in
China and India: Governing Health Security (Palgrave Macmillan, 2015). Herbook won the 2017 International Studies Association (ISA) Global Health
Section Book Prize. Her works appear in such journals as the Australian
Journal of International Affairs, Health and Policy Planning, Globalizationand Health, and the Journal of Global Security Studies.

7

From Pneumonia to Pragmatism
The Role of the WHO in Japan During Public Health
Emergencies
Anoma P. VAN DER VEERE
Abstract
Over the past three decades, Japan has faced multiple public health crises.
This chapter examines the role of the World Health Organization (WHO)in the formulation of Japan’s responses to the SARS, MERS, and COVID-19
public health crises. During these crises, the WHO was used as a neutral
and scientif ic source of information and thus managed to influence
Japan’s responses. However, trust in the organization has faltered due toits connection with China. Japanese policymakers have questioned theneutrality of the organization. This chapter shows that the importanceof the WHO in Japanese policymaking has declined and will continue todo so as long as the organization’s neutrality is doubted, and as long as its
advice and guidelines conflict with Japan’s domestic agenda.
Keywords: Japan, World Health Organization (WHO), public health crises,
domestic policymaking, national agenda, COVID-19

Introduction
This chapter examines the role of the World Health Organization (WHO)in the formulation of Japan’s responses to the SARS, MERS, and COVID-19
public health crises. During these crises, the WHO was used as a neutral
and scientific source of information, and thus managed to influence Japan’s
responses. However, trust in the organization has faltered due to its connection with China. Japanese policy makers have questioned the neutrality ofthe organization. This chapter argues that Japan has pragmatically balanced

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_ch07

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declining trust in the organization with domestic policy aims, with theseaims often taking precedence. It shows that the importance of the WHO
in Japanese policymaking has declined and will continue to do so as longas the organization’s neutrality is doubted, and as long as their advice andguidelines conflict with Japan’s domestic agenda.
Although the scale of the SARS, MERS, and COVID-19 crises cannot becompared, the ways in which Japan has organized its national response tothese three crises have followed similar patterns. During public health crises
the Japanese cabinet establishes an ad hoc task force to formulate containment policies. Those policies directly related to health are implemented by
the Ministry of Health, Labour, and Welfare (MHLW), while policies related
to international traffic of people and goods are implemented by the Ministryof Foreign Affairs (MOFA) and the Ministry of Justice. The main scientificresearch centre in Japan dealing with emerging infectious diseases is the
National Institute of Infectious Diseases (NIID). The NIID is tasked withcooperating with other national institutes and international organizations,and it reports back directly to the MHLW (NIID 2018). Informed officials at
the MHLW are consequently involved in policy making through cooperation
with the cabinet and parliamentary questioning in the Japanese NationalDiet.
The analysis in this chapter relies on official parliamentary records
published during the three public health crises. I have included Diet meetingsand MHLW public documents from 1 November 2002 to 31 July 2003 (SARS),
1 April 2014 to 31 December 2015 (MERS), and 1 December 2019 to 31 May 2020
(COVID-19) in the data set. I have collected records of the National Diet
meetings from the National Diet database (National Diet Library n.d.).

Japan and the World Health Organization
The 2003 SARS outbreak
SARS was first identified in November 2002 in southern China, evolving
into a global outbreak between February and July 2003 (WHO 2003, 81).
Twenty-six countries were eventually affected and by 31 December 2003
there were 8096 infections and 774 fatalities (WHO 2015). The outbreaklasted several months and according to the WHO was eventually subdued
as a ‘result of monumental efforts on the part of governments and healthcare staff, supported by a well-informed and cooperative public’ (WHO2003a, 218).

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The WHO issued a global alert concerning ‘cases of atypical pneumonia’ on
12 March (WHO 2003b), with these later being identified as SARS. After thisalert, regional quarantine stations in Japan started sending out information
to medical institutions and the national Japan Medical Association about
the possibility of a new infectious disease entering Japan.1 In the following
months, travellers were warned of the risk of infection before departure,
while incoming passengers from mainland China, Hong Kong, Taiwan,
and Canada were required to report their health status and have theirbody temperature measured. Visitors from these countries and regions
were also asked to self-quarantine for ten days after arrival (MHLW 2001,
National Diet 2003b).
In response to the alert, the MHLW started formalizing patient reportingand collecting information concerning the infrastructural capacities of
medical institutions (i.e. private rooms, negative pressure rooms; National
Diet 2003c, National Diet 2003i).2 Over the course of the SARS outbreakboth the incumbent administration, under the leadership of then-Prime
Minister Koizumi Junichirō (former Minister of the MHLW 1996-1998), andthe MHLW, consistently deferred to the standards and guidelines of the
WHO in their response (National Diet 2003f).3
In late March 2003, the MHLW’s leading expert, Takahara Ryōji (19472013), was called for questioning in the House of Representatives of the
National Diet, Japan’s main legislative body. He confirmed that the MHLW
had implemented a standardized patient reporting system that followed
the WHO’s guidelines. He also frequently stated that Japanese laboratories, including the NIID, had engaged in cooperation with the WHO andresearch institutions abroad (National Diet 2003i, National Diet 2003).
Takahara used the information that he had obtained from this cooperation
with these institutions to inform the cabinet and members of parliament
about the nature of the SARS virus. He clarified, for example, that humancoronaviruses are the cause of SARS, and he repeatedly emphasized the
1 Quarantine stations are tasked with regulating incoming goods and passengers that posea risk to public health. For an overview of Japan’s quarantine stations, see: https://www.mhlw.
go.jp/english/policy/health-medical/health/dl/contact_list_jqs.pdf.
2 In March 2003 there were 22 negative pressure rooms nationwide equipped to deal withSARS patients.
3 The MHLW officially stated that the WHO, together with UNAIDS, formed the two main
pillars of Japan’s international cooperation efforts in battling infectious diseases. See: MHLW,White Paper Heisei 15, page 346. In parliament, Minister of State Ōgi Chikage also stated that
‘we will do our utmost to implement the domestic and international manuals designated by
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importance of the WHO’s criteria in reporting new infections (National
Diet 2003c, National Diet 2003).
Despite the testimony given by Takahara, members of the National Diet
remained critical. They argued that the decentralization that had been
carried out in previous years, especially under the Koizumi administration,
had led to a laissez-faire approach to governance that extended to publichealth policy. They said this meant that during the SARS crisis local healthinstitutions, such as quarantine stations, had to contact the MHLW on theirown initiative when they faced possible cases of SARS (National Diet 2003a).
In fact, local governments were tasked with creating their own responses
when they encountered outbreaks of infection (National Diet 2003b). The
responses from these local governments were therefore formulated ona case-by-case basis (National Diet 2003a). There were no clear nationalguidelines for the back-and-forth chain of command that was required whenthese responses were being formulated, further increasing the amount oftime it took these local governments to respond to outbreaks of infection.
It was seen how officials relied on the WHO for information. This led tocalls to set up a permanent, centralized, national task force that could allow
Japan to deal with pandemics itself, instead of principally relying on the
WHO (National Diet 2003b, National Diet 2003d). However, despite thesecalls, the MHLW instead set up an ad hoc task force (National Diet 2003b).
As part of this task force, an emergency system remained in place during
the SARS crisis (MHLW 2001). This emergency task force was dissolved once
the immediate threat from SARS came to an end.
During the SARS crisis it became clear that Japan was not equipped todeal with a major outbreak (National Diet 2003a). Tokyo, for example, only
had ten locations that were equipped to deal with SARS patients, despite
it being the most populous metropolitan area in the world. The MHLW
focused primarily on information distribution, rather than implementing
concrete changes to Japan’s medical infrastructure (MHLW 2001). There wasno system in place to regulate the quarantining of incoming passengers,which essentially made this a voluntary procedure (National Diet 2003b).
Consequently, opposition politicians continued to be critical of the lack ofa streamlined national response and clear guidelines (National Diet 2003a).
The SARS crisis also incited fears about contaminated food crossing into
Japan (National Diet 2003a, National Diet 2003g, National Diet 2003e). Thiswas because of the way SARS came shortly after the world had encounteredoutbreaks of bovine spongiform encephalopathy, which is better known
as mad cow disease. During the SARS crisis, Takahara was called in toparliament a second time. As with his earlier position, he deferred to theFrom Pneumonia to Pragmatism

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WHO and argued there was ‘no epidemiological evidence that contact
with objects or animals [had] led to human infection with SARS’ (National
Diet 2003g). Despite the way that sceptical opposition politicians called
for stricter import regimes to avoid the entry of contaminated food, thecabinet supported Takahara’s position. It used the conclusions reached by
the WHO which Takahara had cited to justify its decision to keep import
restrictions out of its response (National Diet 2003g, National Diet 2003h).
Because the initial outbreak of SARS was located in China, which was andremains Japan’s largest trade partner, an import blockade would have haddisastrous consequences for the economy.
In fact, Japan made a gesture of goodwill during the SARS crisis byproviding support to China. It sent out health experts and around eighteen
million yen worth of medical supplies and instruments. This was despitea significant cooling of the bilateral relationship being seen at this time,
which was the result of Koizumi’s growing assertiveness, and some would
argue hostility, towards China (Lam 2005). For a short period between
April and May 2003, the SARS crisis dominated the bilateral relationshipbetween the two countries (Przystup 2017). However, political distrust of
China persisted. This was compounded by the way that Taiwan was excluded
from the WHO as a result of China’s interference, something which led
to questions in Japan about the effectiveness of the WHO (National Diet
2003a). Distrust of China extended beyond the opposition in the Diet. For
example, the Deputy Minister of the MHLW, Kimura Yoshio, suggested thatthe officially reported number of people infected in China did ‘not reflectreality’ (National Diet 2003g). However, restrictions on trade with China
were blocked by the ruling cabinet. Bilateral lines of communication were
eventually opened with the affected nations and regions, including Taiwan,
to circumvent the WHO’s limitations (National Diet 2003i). This indicatedhow Japan’s response was pragmatic when its domestic needs superseded
the limits of the WHO’s collaborative framework.
The 2014-2015 MERS threat
MERS was discovered in 2012 (WHO 2019). There have been several different
outbreaks of the virus affecting twenty-seven countries and leading to 2442
infections and 842 fatalities between 2012 and May of 2019 (Donnelly et al.
2019). The MERS outbreak among medical personnel in Saudi Arabia in 2014,
although not leading to the WHO declaring an international public healthemergency, did lead the WHO to make several emergency preparedness
announcements directed at all member states (WHO 2014, WHO 2014a, WHO

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2014b). In response, in Japan the MHLW started sending out information
to medical institutions in a similar way to that which it had done during
the SARS crisis. Reporting of possible cases was formalized and a regional
approach to decision-making was adopted (MHLW 2014). In short, in Japanthe MERS response was a continuation, if not a duplication, of the SARS
response.
In July 2014, the incumbent cabinet, under Prime Minister Abe Shinzō,
officially designated MERS as an infectious disease under the Act on Prevention of Infectious Diseases and Medical Care for Patients with Infectious
Diseases, which had been published in 1998 (MHLW 2014a). This designationof MERS meant that anyone entering Japan from an affected country who
had a heightened body temperature, or who had been in contact with aconfirmed MERS patient, had to report to the local quarantine station uponlanding. Passengers who had visited any of the affected countries were also
required to self-declare at the quarantine station upon arrival in Japan(MHLW 2017, National Diet 2015b). Those under suspicion of infection wererequired to take a PCR test (MHLW 2014b). The information concerning
MERS symptoms, signalling, and which countries were affected, was takenfrom WHO reports (MHLW 2014c).
Throughout 2014, the MHLW mainly followed WHO guidelines in its
response to MERS, following the International Health Regulations (IHR,
for details see the introduction of this volume) that had been establishedin 2005 (National Diet 2015b). In a way similar to the response to the 2003
SARS crisis, the cabinet and the MHLW continued to focus on information
distribution (National Diet 2014a).
Policy makers became increasingly alarmed following a major outbreak of
MERS which occurred in South Korea in June 2015 (Park and Munroe 2015).
This outbreak, which was labelled as a ‘superspreading event’, saw a single
MERS patient infecting dozens of other people in the space of a few weeks(Kupferschmidt 2015, 1183). The WHO reviewed the incident and blamed it
on a number of factors including South Korea’s lack of medical expertise, its
inadequate infection control measures, its admission of too many foreign
visitors, as well as the practice of so-called ‘doctor shopping’ where patients
visit various medical facilities in search of the right physician (WHO 2015a,
National Diet 2015b). As a result of this, in the same month as the outbreakoccurred in South Korea, the WHO released a risk assessment regarding
MERS. This concluded that the outbreaks of MERS did not qualify as aninternational public health emergency (National Diet 2015b, WHO 2015b).
This announcement by the WHO was picked up in the Japanese National
Diet. Its view that South Korea failed in its response to MERS was taken over ad

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verbatim by both the incumbent administration and the opposition (National
Diet 2015b). However, due to South Korea’s geographic proximity and its
popularity as a tourist destination, worries remained about the virus ‘slipping
through the cracks’ and crossing into Japan (National Diet 2015c). As a result,the Ministry of Foreign Affairs established contact with the health authorities
in South Korea in order to gain insight into the movement of people suspectedof infection. However, information about non-Japanese patients could not becollected through these means (National Diet 2015c) and could also not be
obtained through the WHO. A general consensus formed in Japan that the
information provided by the WHO was insufficient, particularly because
this information did not track the movement of specific cases across borders
and so made it difficult to prevent possible outbreaks (National Diet 2014).
Under these circumstances, the head of the MHLW’s Health Bureau,
Shinmura Kazuya, was called into parliament to clarify Japan’s response
to MERS. Restating the need for a regional approach, Shinmura attempted
to solidify the existing status quo amid rising fears of a possible outbreak(National Diet 2014). Critical members of the opposition argued that the current approach would be insufficient in quelling a major outbreak, pointing
to Japan’s lack of medical infrastructure and local experts (National Diet
2015b). For example, Okamoto Mitsunori, the former Deputy Minister ofthe MHLW, called the response a ‘just-in-time’ game (National Diet 2015c).
Members of the opposition questioned the cabinet and the MHLW about
Japan’s capacity to treat patients and its transportation capabilities. Referring to an October 2014 survey, the Deputy Minister Nagaoka Keiko statedthat 87, out of 141 municipalities in Japan, had a total of 206 vehicles fortransporting patients. For the other 54 municipalities, local networks had
been established with fire departments and local governments to provide
emergency transportation (National Diet 2015). Whether this number was
sufficient to deal with a national outbreak was not discussed.
The head of the MHLW’s Health Bureau, Shinmura, also said that there
were 300 medical institutions with 1500 beds available for infected patients,and said that he believed this to be adequate (National Diet 2015b). However,
he was forced to acknowledge the shortage of infectious disease experts
in Japan, which had been a chronic issue for years. The National Center
for Global Health and Medical Research had previously tried to educate
more local experts, to no avail (National Diet 2014a). Consequently, theincumbent Minister of the MHLW, Shiozaki Yasuhisa, was also forced toacknowledge the shortage. He confirmed that in June 2015 only 1232 doctors
were certified by the Infectious Diseases Society of Japan as specialists, anumber well below national standards (National Diet 2015).

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There had been attempts to increase the number of experts in Japan bysending more people abroad through the WHO framework to gain experience
in infectious diseases (National Diet 2014a, National Diet 2014). The concurrent outbreak of Ebola in Africa had been an opportunity to do so. However,instead of focusing on domestic policy goals and the MERS response, thecabinet viewed the Ebola outbreak as an opportunity to position itself asa regional leader. As a result, Japan mostly postured and sent few experts
abroad, despite the fact that it was trying to ‘train a large number of experts
in infectious diseases’ (National Diet 2015b). In the end, neither Japan’s
domestic shortcomings nor the limitations of the WHO’s global information
network were properly addressed during the MERS outbreaks seen in 2014.
The 2020 COVID-19 pandemic
The first case of COVID-19 in Japan was discovered on 14 January 2020
(MHLW 2020). Since then, the government has taken different steps tocontain its spread, including information campaigns, public emergencies,
and travel restrictions. The first concrete measure was taken on 21 January,
when the Japanese government enacted travel restrictions for the Wuhan
region of China where COVID-19 was first seen. At the time of writing, thepandemic has not been contained in Japan, so new measures continue
to be taken. The Japanese government’s decisions have been influenced
considerably by international guidelines set by the WHO. However, Japan’s
approach has not been consistent. Domestic priorities have led policymakers
to adopt a pragmatic approach in which the WHO’s guidelines are used tolegitimize various new policies, even when these policies are contradictory.
The then-Prime Minister Abe Shinzō was first questioned about Japan’s
COVID-19 response during discussions in the House of Representatives
on 23 January 2020. During this questioning, Abe made reference to theemergency risk assessment meetings held by the WHO in order to argue forstrengthened quarantine measures and for the need to prepare the national
healthcare system (National Diet 2020l). However, few measures were takenin the early stages of the pandemic. Even though a combination of factors
resulted in this slow response to COVID-19, criticism was aimed at Abe forprioritizing the Tokyo 2020 Olympic and Paralympic Games over addressing
the newly emerging infectious disease (Kingston 2020).
The Tokyo 2020 Games were eventually postponed in late March. Whether
the Games had a direct effect on Japan’s lagged response remains debatable.
Nevertheless, the fact remains that the cabinet was slow to implement
concrete steps to address COVID-19. For example, in early 2020 Katō

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Katsunobu, then Minister of the MHLW stated only that the cabinet would‘continue to monitor the situation in Japan on a daily basis’. He consistently
referenced the decision by the WHO to refrain from designating the disease
an emergency and the government’s compliance with WHO guidelines(National Diet 2020d). The initial assessment of COVID-19 by the WHO,and its decision to refrain from designating the disease as a public healthemergency of international concern (PHEIC), legitimized the incumbent
cabinet’s restrained response during the first weeks of the pandemic (WHO
2020, National Diet 2020r).
From 20 January 2020, the MHLW started publicly reporting on COVID-19
via their website. However, these reports contained updates on the development of the disease rather than practical policies (MHLW 2020a). As wellas their criticism about the lack of an immediate response, throughout
January and February, members of the Diet also criticised this limited flowof information to the public. Diet members questioned the government’s
ability to counter unreliable information about COVID-19, or what waslabelled an ‘infodemic’ in reference to the WHO’s public warning against
the spread of inaccurate information without a scientific basis (National
Diet 2020n, WHO 2020a).
Surprisingly, some of this early criticism came from within the rulingparty. One member of the Liberal Democratic Party (LDP) openly questioned
why no permanent administrative body had been set up. They asked why it
was necessary for a new task force to be formed during each public healthcrisis. Pressed on the matter, the Minister of the MHLW at the time, Katō,acknowledged the deficiencies of the (regional) approach that the MHLW
had taken during earlier public health threats. He stated that the government
was setting up a new collaborative framework with the NIID and relevant
agencies and ministries to formulate a national response (National Diet
2020d). However, on 31 January, in response to the WHO’s official designationof COVID-19 as a public health emergency of international concern (or PHEIC;WHO 2020b), another emergency task force was established to address
the developing pandemic (National Diet 2020f). Although set up under
the auspices of the National Security Council, a cabinet-led body charged
with national security issues, the task force dealing with the pandemic wasestablished separately, in stopgap fashion. The establishment of this task
force therefore continued the practice of creating ad hoc emergency task
forces to deal with public health emergencies (National Security Council2020).
The announcement by the WHO that COVID-19 was a public healthemergency of international concern (PHEIC) hastened Japan’s designation of

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the virus as an infectious disease (National Diet 2020f, National Diet 2020u).
This enabled the Japanese government to enact the Infectious Disease Law
in order to implement pandemic policies. Nevertheless, the expert meetingthat would serve as the scientific basis for the national approach was heldon 14 February. According to the former opposition leader Saitō Renhō, who
was head of the Constitutional Democratic Party, this was a month and ahalf too late (National Diet 2020g). In fact, no concrete and coordinatednational policy was formulated. The central government effectively delegatedresponsibility for the containment of infections to prefectural and municipal
governments, without providing a national framework for local governments
to fall back on, something which left national coordination in a fractured
state (Van der Veere 2020). This lack of central governance coincided withdecreasing public trust in the WHO, further debilitating an already fragile
COVID-19 response.
Only a few days after the WHO announced that COVID-19 was a PHEIC,
Watanabe Shū (Constitutional Democratic Party of Japan) publicly expressed
doubts about the neutrality of the WHO. Referencing an article from the
French newspaper Le Monde, he asked Katō what his opinion was on thepossibility that the WHO had refrained from designating COVID-19 in thisway because of pressure from China. He went as far as to suggest that the
WHO Director-General Tedros Adhanom Ghebreyesus was under strong
Chinese influence because of the fact that his home country of Ethiopia
had hosted a Chinese-built African Union building and had long been therecipient of major Chinese investments. Katō, in turn, refused to engage
with the subject, falling back on the need for international cooperation(National Diet 2020s, National Diet 2020h).
Generally, officials from the various ministries, in particular the MHLW
and MOFA, as well as cabinet members, refrained from answering criticalquestions concerning the WHO. The WHO’s guidelines consistently served
as justification for many of the policies implemented in later months. The
MHLW obtained its information primarily from WHO reports, particularly
data concerning the spread of COVID-19 in China (National Diet 2020n,
National Diet 2020w).
The estimate made by the WHO about COVID-19’s incubation period also
led Japan to adopt a fourteen-day quarantine rule (National Diet 2020t).
This quarantine measure was then adopted for passengers of the Diamond
Princess Cruise ship (National Diet 2020o). Passengers were locked on theship for weeks while government workers attempted to track and trace thespread of the virus among them only to catch it themselves due to a lackof proper protective measures and without proper government support.

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135

When Katō was asked by Saitō why passengers were eventually allowed todisembark despite the potential health risk, he cited passenger complaints
and a ‘certain amount of evidence and professional judgement’, rather thanrelying on factual evidence (National Diet 2020g).
The Japanese government was heavily criticized by several countries,
the media, and the WHO, for its mishandling of the case (National Diet
2020o, National Diet 2020v, Rich and Yamamitsu 2020). Nevertheless, Katō
repeatedly stated that the WHO’s guidelines were being followed and thatthe occurrence of four new infections among MHLW staff was simply‘unfortunate’ (National Diet 2020p). The case of the Diamond Princess
exemplifies the way in which the WHO’s advice and guidelines served
as justification for specific measures, even when this required a flexible
interpretation of these guidelines.
The cabinet and Ministry of Foreign Affairs (MOFA) set up stringent
travel bans, ignoring the WHO Director General’s public warning thatwidespread travel bans were not necessary (Nebehay 2020). The director of
the Immigration Department and Immigration Control Office attempted
to justify the travel bans by arguing they were a direct result of the way
the WHO had designated COVID-19 a PHEIC (National Diet 2020m), evenwhile the WHO publicly criticized this policy (Nikkei 2020).
The issue of nationwide closure of schools also illustrates the pragmatic
approach that Japan has taken to following the WHO guidelines. Whilecabinet members claimed that the WHO advocated a ‘multi-sectoral approach’ that justified closing schools, members of the opposition pointed
to a lack of evidence that schools formed clusters for infections and argued
that transmission from children to adults had yet to be confirmed (National
Diet 2020g). LDP representative Koga Yūichirō later used the same ‘evidence’to challenge claims that children were less of an infection risk, pointing
to the way in which the coronavirus spread mainly among households(National Diet 2020). In fact, the WHO had recommended school closures,
whilst also stating that this was a ‘political choice’. Although members of
the opposition in the Diet pointed this out, Abe was consistent in deferringto the recommendation as a legitimate reason for closing schools (National
Diet 2020b).
However, this pragmatic approach to following WHO guidelines had
to be balanced with a growing distrust of the WHO in Japan. In early
March 2020, the WHO announced that South Korea, Italy, Iran, and Japan
were considered its ‘greatest coronavirus concerns’. This announcement
touched a nerve among Japanese politicians, especially as China was left
out of the list (Nebehay 2020a). There were immediate calls for the WHO136 

Anoma P. VAN DER VEERE

Director-General Tedros to resign as he was seen as ‘unfit’ for his position.
One ruling party member openly questioned why Japan was contributing
so much to the WHO and buying so little influence, while in contrast China
was ‘able to exert a huge amount of influence with a small amount of money’(National Diet 2020j).
Although the cabinet and officials attempted to refrain from directly
criticizing the WHO, this was not always successful. One high official let
slip that he believed that Tedros had shown China too much consideration(National Diet 2020v), while Deputy Prime Minister and Minister of Finance
Asō Tarō went a step further by calling the WHO a ‘suspicious organization’,saying there were calls to rename it the ‘Chinese Health Organization’(National Diet 2020i). Unsurprisingly, there was little resistance in the
National Diet to subjecting the WHO to an independent review, a resolution
pushed by Japan during the 73rd World Health Assembly in May 2020. The
only issue that split the ruling party from the opposition was the timing of
the review: during or after the pandemic (National Diet 2020c).
The issue of Taiwan’s participation in the WHO gradually became a symbolof these concerns. In 2016, following the election of the anti-Beijing Tsaiadministration in Taiwan, China successfully pressured the WHO into barring
Taiwan’s participation in the World Health Assembly, the organization’sannual meeting. This remained the situation at the start of the COVID-19
pandemic (Kassam 2020). Although 29 countries petitioned for Taiwan’s participation as an observer during the assembly in May 2020, it was still unable
to join. Japan took the public position that ‘there should be no geographicalgaps in global health’ and continued lobbying, although with little effect(National Diet 2020c). In the Japanese National Diet this was interpreted
as a lack of Japanese influence and also seen as an indication of a strong
Chinese presence in the WHO (National Diet 2020e, National Diet 2020k).
The Japanese government is therefore actively lobbying for high positions
within the WHO to increase its influence (National Diet 2020i, National
Diet 2020q). This is not to say that Japan has little sway over the WHO. The
Abe administration already enjoyed a strong relationship with the WHO
before the pandemic. Abe published an opinion piece in the Washington
Post co-authored with Tedros arguing that ‘all nations should have universal
health care’ (Abe and Ghebreyesus 2019). In early February 2020, Abe also
boasted about the fact that Japan had already dispatched health experts
via the WHO to countries with fragile medical systems (National Diet
2020t). Moreover, the WHO immediately granted an MHLW request thatcases related to the Diamond Princess cruise ship were listed separatelyfrom Japanese domestic cases in WHO global communications (National

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137

Diet 2020v). Despite the WHO’s initial criticism of Japan’s approach tothe pandemic, when Japan complained about its inclusion in the ‘greatest
coronavirus concerns’ list, these complaints gained a prompt exhortatory
response from the WHO, Tedros, and the UN Secretary-General António
Guterres (National Diet 2020a).
Nevertheless, the distrust of the WHO persisted. As Kokuba Kōnosuke,
the incumbent Chief Secretary of the LDP, remarked, ‘Japan should not only
rely on the WHO,’ but should strengthen its own capabilities in countering
emerging infectious diseases (National Diet 2020v). The ruling cabinet
was forced to balance its reliance on the WHO and an increasing distrustof the organization. It did this by exerting pressure wherever the WHO’s
information directly contradicted domestic policies. The cabinet largely
refrained from criticizing the WHO and its information, while also agreeing
with the general talking points produced by the opposition (questioning
the WHO’s neutrality and mentioning Chinese influence, Taiwan, andthe independent review). In this way, the cabinet was able to rely on the
WHO to justify domestic policies while also not directly contradicting theincreasing distrust expressed in the National Diet.

Conclusion
Japan has been confronted with several public health emergencies overthe course of the 21st century. One consistent factor during each outbreak
was the role of the WHO as a mechanism for providing information andguidelines. However, the distrust of China seen during the SARS crisis becamea distrust of the WHO’s neutrality during the COVID-19 pandemic. It was
already clear during the 2014-2015 MERS outbreak that there were domestic
shortcomings in Japan’s ability to handle such infectious diseases, including
a chronic deficit of local experts on infectious diseases, and also that there
was a limit to the information the WHO could provide. However, unrelated
domestic priorities often took precedence over responding to the publichealth threats, leaving these issues unaddressed. Japan’s eventual decision
to bypass the WHO’s information network during the MERS outbreak, bydirectly establishing contact with Taiwan and other affected countries andregions, further weakened the WHO’s standing in public health policy making.
This prioritization of the domestic agenda became apparent once again
during the COVID-19 pandemic. The WHO’s guidelines and information
were not followed strictly, but used pragmatically, and only when they
coincided with domestic policy goals. The continued reliance on ad hoc

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task forces in all three public health emergencies covered in this chapter,
despite calls for a permanent one, is a clear example of this prioritization.
Moreover, the distrust of China, and by extension the WHO, worsened overthe course of the COVID-19 pandemic. This worsening distrust is evidenced
by the pragmatism with which Japan followed WHO guidelines. It is also
symbolized by Japan’s support of Taiwan’s participation in the World Health
Assembly and calls for an independent review of the WHO’s functioning. In
conclusion, the WHO’s importance in Japan’s policy making has declined
since the SARS crisis in 2003. It will continue to decline unless the WHO’s
guidelines and advice coincide with Japan’s domestic agenda, and unlesspolicy makers are assured of its neutrality.

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About the Author
Anoma Phichai VAN DER VEERE is a Researcher of Modern Asia within
the Leiden Asia Centre at Leiden University, and a Research Fellow at the
IAFOR Research Center at the Osaka School of International Public Policy.
He is currently based at Osaka University, Japan, and has published onhealth and labour policy, sports, technology, and human rights in Asia
and Europe. His latest publications include: ‘Japan’s Fragmented Response:Technology, Governance, and COVID-19’ (Leiden Asia Centre, 2020), ‘The
Tokyo Paralympic Superhero: Manga and Narratives of Disability in Japan’(Asia Pacific Journal: Japan Focus, 2020), and ‘The Technological Utopia:
Mimamori Care and Family Separation in Japan’ (AsiaScape: Digital Asia,

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2019). He is currently the principal investigator in the Road to Tokyo 2020
project about local policymaking in disability sports in Tokyo in the run-up
to the 2020 Olympic and Paralympic Games, and the ‘Understanding theLimitations and Future of Transnational Migrant Labor and Global Health
Governance in Asia’ project, both funded by the Leiden Asia Centre.

PART III
Domestic Responses to COVID-19
in a Globalized Asia

8

The COVID-19 Pandemic
Socio-Economic Issues, Health Care, Health Security andthe Rapid Response in Vietnam
Anh Tuyet NGUYEN
Abstract
The COVID-19 pandemic has significantly impacted healthcare systems
and health security in lower- and middle-income countries. In Vietnam thenumber of infections and deaths has remained relatively low compared toother countries owing to an early and aggressive response. Nevertheless,the impacts on vulnerable groups in Vietnam have been severe. This
chapter discusses the socio-economic impacts of COVID-19 on healthcare
and health security in Vietnam by focusing on economically disadvantaged
groups and the elderly, thereby showing that despite Vietnam’s relatively
successful response to COVID-19 during 2020, it remains necessary toprovide social support to those who are most vulnerable during publichealth crises.
Keywords: health security, Vietnam, COVID-19, social support, healthcare
systems, early response

Introduction
COVID-19 is a pandemic and global public health crisis that has had significant socio-economic impacts. In particular, the healthcare systems
and health security in lower- and middle-income countries have becomestrained. In Vietnam, owing to an early and aggressive response, the numberof infections and deaths has remained relatively low when compared toother countries. Nevertheless, the impacts on vulnerable groups in Vietnam
have been severe.

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_ch08

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This chapter argues that the early response and strict policies in Vietnam limited the spread of COVID-19 during 2020. An examination ofVietnam’s response alongside the World Health Organization’s (WHO)response and the guidelines it issues shows that Vietnam was pro-active
in its response, and was ahead of the curve in the early stages of the global
pandemic. However, this chapter also discusses the socio-economic impactsof COVID-19 on healthcare and health security in Vietnam. It describes
the national healthcare challenge the country now faces. By focusing on
economically disadvantaged groups and the elderly, the chapter argues
that despite Vietnam’s relatively successful response to COVID-19 during
2020, it remains necessary to provide social support to those who are mostvulnerable during public health crises such as the COVID-19 pandemic.
Vietnam has a population of just over 97 million and shares a border with
China, where the COVID-19 pandemic originated (Worldometer 2020a). The
first case of COVID-19 in Vietnam was reported on 23 January 2020. As of
22 September 2020, Vietnam had reported 1068 confirmed COVID-19 casesand 35 related deaths (Ohya 2020). In terms of total number of cases, in
April 2020 the Worldometer (2020b) ranked Vietnam 172 out of 221 COVID-19
affected countries and territories. Of the 35 COVID-related deaths in Vietnam
that had occurred by the autumn of 2020, 65% were people aged 60 andover (ThuVienPhapLuat 2020b).
The effects of COVID-19 in Vietnam during 2020 can be divided into two
waves (see Figure 8.1). The first wave occurred between 23 January and
25 June 2020. The number of confirmed cases reached 352 and no deaths
were reported in this period (DaNang Today 2020). In the second wave,
the coastal city of Danang became the epicentre of COVID-19 outbreaks in
Vietnam. In response to this, the Vietnamese government implemented
fifteen days of lockdown measures on 28 July in Danang. Only essential
services, such as pharmacies, hospitals, and supermarkets were allowed
to open (Bohane 2020). While the future remains hard to predict, during2020 Vietnam proved to be successful in handling the COVID-19 pandemic.
The Vietnamese central government has sought to actively prevent the
spread of COVID-19. At the onset of the outbreak, the authorities framed
the virus as ‘a common foreign enemy’ through various directives (Ha Son
Thai 2020, see also Le and Nicolaisen chapter in this volume). This message conveyed that the whole nation needed to be ready ‘to fight’ against
COVID-19 (Ha et al. 2020, 2). The authorities carried out proactive quarantineof close contacts, as well as aggressive contact tracing, to minimize therapid spread of the virus (CDC 2020). The government also tracked infected
people (recognized as ‘F0’ patients), individuals who had direct or indirect

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Figure 8.1 The Number of Confirmed and Daily New Confirmed COVID-19 Cases inVietnam

Source: European CDC-Last updated 22 September 2020

contact with F0 patients, as well as suspected cases (recognized as F1, F2 [close
contact with F1], all the way up to F3), all of whom were required to reportto their local Medical Centre (Thuvienphapluat 2020a; DaNang Today 2020).
Such local Medical Centres, and specifically the grassroots health system in
Vietnam, have played an important role as a first line of defence during the
COVID-19 pandemic. The Vietnamese health care system consists of four
administrative levels: the central level, provincial level, district level, andcommune level (Takashima et al. 2017, 2). By the end of 2019, the numberof health insurance enrolments in Vietnam had reached nearly 86 million
people, making up 89% of the country’s population (Anh Kiet 2020). Notably,
these health care facilities have a strong focus on disease prevention, andrely on grassroots health networks that include approximately 700 district
hospitals and over 8000 community health stations (Tran, Bach Xuan etal. 2020, 2). During the COVID-19 pandemic, these grassroots establishments
have provided health education on preventive measures for residents at thecommunity and district levels. They have provided information to individuals
who have had close contact with COVID-19 patients and to those who havereturned from areas where the pandemic had taken hold. These establishments provided guidance to individuals throughout medical procedures andidentified local quarantine points or facilitated home isolation with medical
checks, providing referrals to specialists when needed (Ha et al. 2020, 3).
At the same time as dispensing information in this way the Vietnamese government has also implemented other COVID-19 related measures. It restricted150 

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travel, suspending all international flights. It also closed schools at an early stage
and shut down non-essential service facilities. All health facilities, agencies,
and unions in the country acted together to prevent the spread of COVID-19
within the community (Ministry of Health 2020b). Although those containment
measures have helped to protect the lives and health of Vietnamese citizens, they
have also resulted in a massive reduction in economic activities, as discussed
below (ILO 2020). In other words, for Vietnam the pandemic has not only
presented a global public health crisis but also a socio-economic crisis that hasseriously affected economically disadvantaged groups, including the elderly.
This chapter looks at how Vietnam responded to the early emergence of
COVID-19 alongside the ways in which the WHO was responding to the virus
at the same time. This chapter uses Vietnam’s handling of COVID-19 as a casestudy to compare Vietnam’s response with that of the WHO. This analysis aims
to show that Vietnam implemented early and strict policy responses during
different stages of the outbreak. In addition, this chapter discusses the socioeconomic impacts of COVID-19 on healthcare and health security. It details
the national healthcare challenges Vietnam faces as a result of the pandemic.

The Vietnamese Government’s Response to the COVID-19
Pandemic and the WHO’s Response Plan
The COVID-19 pandemic has created an unprecedented challenge for global
healthcare systems. During the pandemic, the WHO has been a central
figure leading disease preparedness and responses worldwide. In the earlystage of the global outbreak, Vietnam quickly recognized the devastating
nature of the pandemic. It began to prepare for the outbreak even before
it had recorded its first case (Trevisan, Le, and Le 2020; BBC News 2020).
The strict policies enacted by the Vietnamese government were generally
put in place before the WHO issued its recommendations, especially in theinitial stages of the global outbreak (see Table 8.1; United Nations 2020). Ha
and colleagues (2020b) have argued that Vietnam’s limited financial andtechnological resources would have been exhausted by a huge numberof infected patients. Vietnam therefore had an urgent need to take rapid
and strict measures. Vietnam has been affected by a number of different
viruses in the past, including Severe Acute Respiratory Syndrome (SARS),
the so-called ‘avian flu’ or Influenza AH5N1, and Influenza A subtype H5N6
(USAID 2020). Because of these previous experiences and lessons learnedin containing these viruses, the Vietnamese government has pooled its
resources to create a more resilient healthcare system.

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Table 8.1 A summary timeline of nationally implemented policies in Vietnam andthe WHO’s recommendation and response plan
Timeline with Vietnam’s response plan

Timeline with WHO’s response plan

5 Jan: The WHO issued the first outbreaknews report (WHO 2020c).
9 Jan: Ministry of Health (MOH) warns ofmysterious pneumonia in China (NhandanNews 2020).
11 Jan: The WHO publishes a comprehensive COVID-19 commodity package.
16 Jan: The MOH issued Decision No. 125/
QD-BYT on the first guidelines for diagnosis
and treatment of coronavirus infections(MOH 2020d).

23 Jan: The first case from a Chinese visitor
is found (Gardaworld 2020).
28 Jan: The Prime Minister signs Directive
No. 05/CT-TTg on the prevention andcontrol of the Coronavirus outbreak, which
immediately requests the establishment of a
Rapid Response Team and also requests that
the Ministry of Health reports daily on thesituation to the Prime Minister.

29 Jan: The MOH issues Guidelines about
the supervision of people in close contact
with CoV confirmed cases and those who
returned from pandemic areas (Ministry ofTransport 2020).

30 Jan: MOH issues Decision No. 255/QĐ+DBYT on the establishment of Rapid Response
Teams (MOH 2020e).
The Prime Minister issues Decision No.
170/QD-TTg on establishment of National
Steering Committee for controlling theoutbreak.

‘The mode(s) of transmission of the nCoV are
currently unknown. Available informationsuggests that the nCoV is zoonotic and causes
infections in humans through contact with
infected animals (to be confirmed). Current
data suggests that there is no or limited
human-to-human transmission’ (WHO 2020f).

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Timeline with Vietnam’s response plan

31 Jan: The Prime Minister issues Decision
No. 16/CT-TTg, a Response Plan for each
Level of Acute Respiratory Disease Due to anovel Corona (nCoV) strain.

Anh Tuyet NGUYEN

Timeline with WHO’s response plan

30 Jan: The Director-General declares thenovel coronavirus outbreak a public healthemergency of international concern (PHEIC),
the WHO’s highest level of alarm (WHO
2020g).

7 Feb: The National Steering Committee for3 Feb: The first draft of the Strategic
prevention and control of the Coronavirus
outbreak issues Decision No. 80/QD-BCDQG Preparedness and Response Plan (WHOon the establishment of Sub-committees to 2020).
respond to the outbreak (Dam 2020).

5 Mar: Vietnam successfully produces virus
detection test kits (RT-PCR and real-time
RT-PCR (MOH 2020c).

7 Mar: The WHO issues a consolidated
package of existing guidance covering the
preparedness, readiness, and response
actions for four different transmission
scenarios (WHO 2020g).
7 Apr: Guidance on prevention of COVID-19
infection and care for the elderly and people
with chronic diseases (MOH 2020f).

18 Apr: The Ministry of Health launches anonline medical examination and treatment
system to support hospitals in remote areas.

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The COVID -19 Pandemic

Timeline with Vietnam’s response plan

Timeline with WHO’s response plan
9 Jul: The WHO Director-General announced
the co-chairs of the Independent Panelfor Pandemic Preparedness and Response(IPPR) to evaluate the world’s response to
the COVID-19 pandemic (WHO 2020a).

23 Jul: Guidance on COVID-19 for the care ofelderly people (WHO 2020b).
8 Aug: Establishment of an inspection teamfor COVID-19 pandemic prevention.

On 16 January, during the early days of the outbreak in China, the Vietnamese
Ministry of Health issued guidelines for the diagnosis and treatment ofcoronavirus infections (MOH 2020d). Vietnam recorded its first cases on
23 January. Shortly after, on 30 January, the Vietnamese government stepped
up its response by organizing the National Steering Committee on Epidemic
Prevention (Phuc 2020b). This was the same day when the WHO declared theoutbreak a Public Health Emergency of International Concern (PHEIC; WHO
2020f). In response to increasing concern about vulnerable groups, on 9 April,
the government issued guidelines on how to prevent and manage COVID-19
infections and how to care for the elderly and people with chronic diseases(MOH 2020f). Three months later, on 23 July, the WHO published additionalguidelines on the care of elderly people living in long-term care and othernon-acute care facilities, as well as guidelines on home care (WHO 2020b).
National responses to the COVID-19 pandemic vary between countries
as a result of different socio-economic contexts, healthcare systems, andthe political party in power at the time (Han et al. 2020; Boin, Lodge, andLuesink 2020). The positive outcomes in Vietnam can therefore be attributed
to the rapid response and precautions taken by the government in the earlystages of the pandemic.

The Socio-Economic Impact of COVID-19
Although containment measures have helped to protect the lives and healthof Vietnamese citizens, these measures have also resulted in a massive
reduction in economic activities (Monitor 2020). The socio-economic impactof the COVID-19 pandemic is likely to be more severe for economically154 

Anh Tuye t NGUYEN

disadvantaged groups and the elderly in two ways: (1) an increase in poverty
that makes the already vulnerable worse off, and (2) an increase in socioeconomic inequalities that will lead to increased health and food insecurity.
Although Vietnam’s economy has been less affected than other countries,
the economic impact of the pandemic has still been significant. According
to the Statistics Office of Vietnam, the country’s GDP grew 1.81% in the firsthalf of 2020, the lowest growth rate since 2010 (General Statistics Office2020a). In addition, about 35 million workers do not have social insurance,
particularly those working in the agriculture and informal sectors (Nation2020). For workers who are involved in production, a sector that heavily
relies on imports, UNICEF has predicted that poverty rates would increase
from 18% to 31% (UNICEF 2020).
The outbreak thus threatens access to basic essential services among
these segments of society and negatively affects their already vulnerable
livelihoods (Nation 2020). These economically disadvantaged groups havealso been hard-hit by rising out-of-pocket expenditures, which have in turnbeen exacerbated by a loss of income because of confinement and isolation(P. B. Tran et al. 2020). In the first half of 2020, around 66,500 people acrossthe country suffered from food shortages, showing a sharp increase of
74.6% compared to the same period in the previous year (General Statistics
Office 2020a).
The pandemic has also had a serious impact on the elderly in Vietnam.
More than 60% of elderly people aged 60 to 69, and 30% percent of those
aged 70 to 79, are still working. The majority of elderly workers in Vietnam(81%) are informal workers (Vietnam Women Union 2012). The informal
labour force, such as self-employed household businesses, motorbike andtaxi drivers, and farmers, has been the group most severely affected by
COVID-19. It accounts for the majority of the workforce in four out of fiveof the sectors that have been hit hardest (HelpAge 2020b). In addition, alarge proportion of elderly people in Vietnam are reliant on the support oftheir children (32%; Vietnam Women Union 2012). With more than 86% ofbusinesses negatively affected by COVID-19, the financial support by children
for elderly parents is expected to decline (General Statistics Office 2020b).
In response to increasing concerns about vulnerable people during the
pandemic, the Vietnamese government issued a US$2.6 billion relief package
for cash support from April to June 2020 (Vietnam News 2020). In addition,
the authorities have planned an expanded fiscal package to strengthen
the national health systems and provide financial support for the mostvulnerable and impoverished (MOH 2020a). Specifically, the Minister ofPlanning and Investment has discussed a support package for people inThe COVID -19 Pandemic

155

difficulties due to the COVID-19 pandemic of 62,000 billion Vietnamesedong (approximately US$2.6 million). About 20 million people are expected
to receive support through this (K. Nguyen 2020).

The Impact of COVID-19 on Health Care
COVID-19 has disrupted health and health services in Vietnam in different ways. For example, the loss of daily earnings and the need for social
distancing have led to economic and psychological stress. This loss may
also increase levels of domestic violence (UNICEF 2020). In a recent study in
Vietnam, a high proportion of respondents said they had suffered symptomsof psychological stress during the first national lockdown (Le et al. 2020).
Notably, being unemployed or retired was connected to a higher score of
intrusion and hyperarousal related to negative emotions, which means
people had increased trouble sleeping and concentrating.
The pandemic occurred in a period of already growing mental healthissues among more vulnerable population sectors in Vietnam. The fact thatthe country has a weak mental health system with few mental health policies
in place has led to an ineffective action plan for addressing this problem(Vietnam News 2020). In response to increasing mental health concerns
during the pandemic, the Ministry of Health has issued guidelines for mental
health care in the context of the COVID-19 pandemic (MOH 2020i). However,it remains critical for Vietnam to formulate an effective strategy for thescreening of psychological problems and the implementing appropriate
interventions, especially among high-risk groups, such as the elderly.
Older people in Vietnam have experienced higher levels of psychologicaldistress during the COVID-19 pandemic (Le et al. 2020). The elderly (above
60 years) are also at a higher risk of suffering serious illnesses or COVID-19
related deaths (ThuVienPhapLuat 2020b). Elderly people in Vietnam are more
likely to live in larger households and less likely to live in nursing homes;
only about 0.6% of the elderly live in long-term care facilities (General
Statistics Office 2020a). Stay-at-home orders are potentially harmful for
elderly people because they threaten to increase the potential for violence,
abuse, or neglect (HelpAge 2020a). In addition, the need for social distancing
has made the elderly’s ongoing healthcare difficult.
Moreover, many elderly people have refrained from consulting theirdoctors for check-ups and treatments because of a fear of infection (Gharib2020). Healthcare services have only been provided for urgent cases (MOH
2020c). The provision of home check-up services is only available in big

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cities, such as Ho Chi Minh City and Hanoi. Payment is also an issue, ashome check-ups are only covered by health insurance for those who areover the age of 80, or those who already have serious health problems. Thishas meant that people over 60 who are in need of healthcare have had torely on family carers, who typically have little or no training. The situation
has been exponentially worse for those living alone (Age International2020).
There is therefore an urgent need to collect data about access to essential services, particularly about access to social and health services
among the most vulnerable groups. The grassroots health system provides
primary health care services (Ha et al. 2020b). This health system, namely
district-based health centres, also plays an important role as a first-line
defence during medical emergencies, such as the COVID-19 pandemic (B.
X. Tran et al. 2020). While serving this role in helping to tackle COVID-19,
the majority of elderly patients in rural areas also need to continue to use
these local centres for their personal health care (Nguyen and Giang 2021,
24). The district-level system in place in rural areas has been vulnerable
during the pandemic (B. X. Tran et al. 2020). It is therefore necessary to
formulate an effective plan for the distribution of financial support andhuman resources to strengthen the grassroots health system in the longrun. It is also necessary to make sure that health centres at the local levelcan continue to provide elderly people with health care, even during global
outbreaks of infectious diseases.

Conclusion
Vietnam quickly recognized the devastating nature of the COVID-19 pandemic and prepared for the outbreak before it had recorded its first case,well before the WHO issued its first warning. The WHO’s recommendations
therefore played no role in Vietnam’s response to the COVID-19 pandemic
in the initial stages. Vietnam’s strategies can be considered an effectivemodel for containing infectious diseases in settings where resources arelimited. However, at the time of writing the pandemic remains far from over,and Vietnam’s most vulnerable groups had been struggling. The COVID-19
pandemic highlights the need to care for economically disadvantaged
groups, such as the elderly, in order to prevent long-term adverse healthoutcomes. To conclude, there is an urgent need in Vietnam for a social andhealth protection package, combined with improved access to essential
services, particularly for vulnerable groups.

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library/detail.aspx?g=114e140a-881e-477b-ba58-fbffdd46738b.
Phuc, Nguyen Xuan. 2020a. ‘Chỉthịsố 05/CT-TTg 2020 của Thủtướng Chínhphủvềphòng,chống virus Corona [Directive No. 05 / CT-TTg 2020 of the Prime Minister onCorona Virus Prevention and Control].’ 30 January. Accessed 12 April 2021.
http://www.medinet.hochiminhcity.gov.vn/giam-doc-cac-benh-vien-canbiet/chi-thi-so-05ct-ttg-2020-cua-thu-tuong-chinh-phu-ve-phong-chong-viruscorona-cmobile13465-23380.aspx.
—. 2020b. ‘Quyết định số 170/QĐ-TTg của Thủ tướng Chính phủ : Về việcthành lập Ban Chỉ đạo Quốc gia phòng, chống dịch bệnh viêm đường
hô hấp cấp do chủng mới của vi rút Corona gây ra [Decision No. 170/
QD-TTg on Establishing the National Steering Committee for Prevention
and Control of Acute Respiratory Infections Caused by New Strains ofCorona Virus]. http://vanban.chinhphu.vn/portal/page/portal/chinhphu/
hethongvanban?class_id=2&_page=1&mode=detail&document_id=198963.
—. 2020c. ‘HướngdẫnthựchiệnChỉthị 16/CT-TTgvềcáchlyxãhội [Guidance on the
Implementation of Directive 16 / CT-TTg on Social Isolation].’ 4 April. Accessed
12 April 2021. https://moh.gov.vn/hoat-dong-cua-lanh-dao-bo/-/asset_publisher/
TW6LTp1ZtwaN/content/huong-dan-thuc-hien-chi-thi-16-ct-ttg-ve-cach-lyxa-hoi.
Takashima, Kyoko, Koji Wada, Ton Thanh Tra, and Derek R. Smith. 2017. ‘A Review
of Vietnam’s Healthcare Reform through the Direction of Healthcare Activities(DOHA).’ Environmental Health and Preventive Medicine vol. 22, no. 1 (74). https://doi.org/10.1186/s12199-017-0682-z.
ThưViệnPhápLuật. 2020a. ‘Vềviệc ban hành “hướngdẫncáchly y tếtạinhà,nơilưutrúphòngchốngdịchCOVID-19 [Guidance on How Medical Diversion at
Home and Places to Residence COVID-19].’ 12 March. Accessed 12 April 2021.
https://thuvienphapluat.vn/van-ban/The-thao-Y-te/Quyet-dinh-879-QDBYT-2020-Huong-dan-cach-ly-y-te-tai-nha-noi-luu-tru-phong-chong-dichCOVID-19-437036.aspx.
—. 2020b. ‘Nguyênnhântửvongcủacácbệnhnhânmắc COVID-19 tại Việt Nam[The Cause of Death of COVID-19 Patients in Vietnam].’ 3 September. Accessed
12 April 2021. https://thuvienphapluat.vn/tintuc/vn/thoi-su-phap-luat/thoisu/30265/tong-hop-nguyen-nhan-tu-vong-cua-cac-benh-nhan-mac-covid-19.
Tran, Bach Xuan, Men Thi Hoang, Hai Quang Pham, Chi Linh Hoang, Huong
Thi Le, Carl A Latkin, Cyrus SH Ho, and Roger CM Ho. 2020. ‘The Operational
Readiness Capacities of the Grassroots Health System in Responses to Epidemics:
Implications for COVID-19 Control in Vietnam.’ Journal of Global Health vol. 10,
no. 1. https://doi.org/10.7189/jogh.10.011006.

The COVID -19 Pandemic161

Tran, Phuong Bich, Gunnel Hensing, Tom Wingfield, Salla Atkins, Kristi Sidney
Annerstedt, Joseph Kazibwe, Ewan Tomeny, Olivia Biermann, Jennifer Thorpe,
Rachel Forse, and Knut Lönnroth. 2020. ‘Income Security during Public Health
Emergencies: The COVID-19 Poverty Trap in Vietnam.’ BMJ Global Health vol. 5,
no. 6: 3-6. https://doi.org/10.1136/bmjgh-2020-002504.
Trevisan, Maurizio, Linh Cu Le, and Anh Vu Le. 2020. ‘The COVID-19 Pandemic: A
View from Vietnam.’ American Journal of Public Health vol. 110, no 8: 1152-1153.
https://doi.org/10.2105/AJPH.2020.305751.
UNICEF. 2020. ‘Viet Nam Country Off ice.’ Situation Report, 8 April. Accessed
12 April 2021. https://reliefweb.int/report/viet-nam/unicef-viet-nam-countryoffice-covid-19-situation-report-no-1-reporting-period-1.
United Nations (UN). 2020. ‘Economic Response Plan United Nations in Vietnam.’
United Nations in Viet Nam. Accessed 12 April 2021. https://unsdg.un.org/sites/
default/files/2020-10/VNM_Socioeconomic-Response-Plan_2020.pdf.
USAID. 2020. ‘Threats, Pandemic Influenza and Other Emerging Threats.’ Accessed
12 April 2021. https://www.usaid.gov/vietnam/pandemic-influenza-and-otheremerging-threats.
Vietnam News. 2020. ‘Gov’t Considering Unprecedented US$2.6b Support Package
for Vietnamese Hit by COVID-19.’ Viet Nam News Politics & Law. Last updated
2 April 2020. Accessed 24 February 2021. https://vietnamnews.vn/politicslaws/674554/govt-considering-unprecedented-us26b-support-package-forvietnamese-hit-by-covid-19.html.
Vietnam Women Union. 2012. Vietnam Aging Survey (VNAS) 2011: Key Findings.
Hanoi: Women Publishing House.
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Strategic Preparedness and Response Plan.’ February. Accessed 12 April 2021.
https://www.who.int/docs/default-source/searo/whe/coronavirus19/covid19-sprp-whe-searo-feb-2020.pdf?sfvrsn=9ee49760_2.
—. 2020a. ‘Announced, Independent Evaluation of Global COVID-19 Response.’
9 July. Accessed 12 April 2021. https://www.who.int/news-room/detail/0907-2020-independent-evaluation-of-global-covid-19-response-announced.
—. 2020b. ‘Guidance on COVID-19 for the Care of Older People and People Living
in Long-Term Care Facilities, Other Non-Acute Care Facilities and Home Care.’
5 October. Accessed 12 April 2021. https://www.who.int/publications/i/item/
WPR-DSE-2020-015.
—. 2020c. ‘Listing of WHO’s Response to COVID-19.’ 29 June. Accessed 12 April 2021.
https://www.who.int/news/item/29-06-2020-covidtimeline.
—. 2020d. ‘Statement on the Second Meeting of the International HealthRegulations (2005) Emergency Committee Regarding the Outbreak of Novel
Coronavirus (2019-NCoV).’ 30 January. Accessed 12 April 2021. https://www.who.

162 

Anh Tuye t NGUYEN

int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-theinternational-health-regulations-(2005)-emergency-committee-regarding-theoutbreak-of-novel-coronavirus-(2019-ncov).
—. 2020e. ‘Statement on the Second Meeting of the International Health Regulations(2005) Emergency Committee Regarding the Outbreak of Novel Coronavirus(2019-NCoV).’ 30 January. Accessed 12 April 2021. https://www.who.int/news/
item/30-01-2020-statement-on-the-second-meeting-of-the-international-healthregulations-(2005)-emergency-committee-regarding-the-outbreak-of-novelcoronavirus-(2019-ncov).
—. 2020f. ‘Novel Coronavirus (NCoV) V1.’ COVID-19 Case Management,
6 March. Accessed 12 April 2021. https://www.who.int/publications/i/item/
disease-commodity-package---novel-coronavirus-(ncov).
—. 2020g. ‘Timeline of WHO’s Response to COVID-19.’ 29 June. Accessed
12 April 2021. https://www.who.int/news-room/detail/29-06-2020-covidtimeline.
Worldometer. 2020a. ‘Reported Cases by Country, Territory, or Conveyance.’
Accessed 12 April 2021. https://www.worldometers.info/world-population/
population-by-country/.
—. 2020b. ‘COVID-19 Coronavirus Pandemic.’ Accessed 12 April 2021. https://www.
worldometers.info/coronavirus/?utm_campaign=homeAdvegas1?#countries.

About the Author
Anh Tuyet NGUYEN is a PhD student at the Osaka School of International
Public Policy (OSIPP), Osaka University. Her current research interests
are public health, inequality, aging population, Asian studies, and applied
econometrics. Her most recent publications include ‘Socio-economic-related
Health Inequality in Non-communicable Diseases Among Older People inViet Nam,’ D.D. Le, R. Leon-Gonzalez, T.L. Giang, and A.T. Nguyen (2020),
Ageing & Society, and ‘Factors Associated with Regional Disparity in Utilization of Healthcare Services Among Vietnamese Older People,’ A.T. Nguyen
and T. Giang (2020), Journal of Population and Social Studies. Previously,
she worked as a senior credit assessment officer in the Risk Management
Department at a local bank in Vietnam for eight years. This position, at a
dynamic financial institution, gave her valuable practical experience about
large corporate issues, as well as a deep understanding of the domestic
economic industry in Vietnam and other developing countries.

9

The Coordination of COVID-19
Responses in Malaysia
Efforts and Challenges
Nurliana KAMARUDDIN and Zokhri IDRIS

Abstract
Historically, Malaysia has demonstrated good, coordinated strategies
in dealing with disease outbreaks. However, COVID-19 has been larger
in scale than previous pandemics and the country was in the midst ofpolitical upheaval when the first case was detected in the country. This
chapter examines the coordination between political actors and analyses
the challenges Malaysia faced as a result of the outbreak, specificallyregarding the treatment of migrant workers and strict border controls.
It highlights the country’s need for consistent policies for workers andshows that Malaysia needs to balance health security, political stability,and economic growth in order to successfully manage the pandemic.
Keywords: Malaysia, health security, political stability, public health,
COVID-19

Introduction
When the first COVID-19 case was detected in Malaysia on 4 February 2020,
the country was in the middle of political unrest. The historic change ofMalaysia’s ruling coalition that occurred in the 2018 general election, from
Barisan Nasional (BN) to Pakatan Harapan (PH), had lasted for a mere twoyears. Then PH fell apart due to infighting and changing party allegiances.
Following the withdrawal of BERSATU (one of the parties that made up theruling coalition) from PH on 23 February 2020, PH no longer held a majority

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_ch09

164 Nurliana K AMARUDDIN and Zokhri IDRIS

of parliamentary seats. This led to the resignation of the then Prime Minister
Mahathir Mohamad.
Between 24 and 28 February, Malaysia did not have a Prime Minister orcabinet members. Muhyiddin Yassin, then Minister of Home Affairs, was appointed Prime Minister by the King on 1 March 2020. Other cabinet members
were sworn in on 7 March, after there had been no cabinet members in office
for fourteen days. As a result, Malaysia witnessed a lack of coordination in
infectious disease control, leading to a spike where there were 25 cases of
COVID-19 in February (Ministry of Health Malaysia 2020a). Despite thecountry losing ground during the initial stage of the outbreak, the newly
formed government was quick to implement measures, prioritizing testing,tracing, and containment.
This chapter will examine the Malaysian government’s actions in tackling
the COVID-19 crisis. It will first examine the coordination between politicalactors and civil servants, including health and security practitioners, as wellas the economic support provided by the government. It will then examine
the challenges Malaysia has faced as a result of the outbreak as well as
the policies implemented to contain the virus. Finally, it will conclude by
discussing how Malaysia might move forward in these uncertain times.

Coordinating Public Services during the Pandemic
Malaysia’s f irst COVID-19 cases were detected when three out of eight
Chinese nationals entering the southern state of Johor Bahru tested positiveon 25 January 2020. The first major cluster of local cases came from a religious
gathering that was held in the suburb of Sri Petaling (Kanyakumari 2020).
Since the Islamic gathering had over 16,000 attendees, the government tookurgent measures when the first case from this cluster was found on 11 March.
To contain the outbreak, the Malaysian government needed to efficiently
coordinate across various ministries and agencies.
Before COVID-19, Malaysia had experienced several other infectious
disease outbreaks and the authorities had demonstrated an effective capacity
to deal with the past smaller-scale outbreaks. In 1996, a major cholera
outbreak hit the northern state of Penang. The authorities reported a totalof 1182 cases and detected 231 carriers, but the outbreak resulted in zero
deaths. In 1997, the Malaysian state of Sarawak reported an outbreak ofHand, Foot and Mouth Disease (HFMD). This resulted in 31 deaths, a totalthat was relatively low in proportion to the number of deaths worldwide.
Two years later, Malaysia also saw an outbreak of Nipah Encephalitis that

The Coordination of COVID -19 Responses in Mal aysia

165

resulted in 283 recorded cases and 109 deaths. In 2001, Malaysia experienced
an Anthrax scare attributed to a bioterrorist attack. There were 136 reported
cases with no fatalities. Considering these events, the Malaysian government
and its Ministry of Health had a proven track record in handling infectious
diseases prior to the COVID-19 pandemic. The government had demonstrated
excellent coordination in containing diseases and preventing them fromreaching larger groups of Malaysian residents.
COVID-19 nevertheless has presented a different dynamic. The Minister of
Health, under the Prevention and Control of Infectious Diseases Act (PCID)
1988, declared that COVID-19 was a national outbreak. Under the PCID,
when a disease is classified in this way it requires the active intervention of
the authorities. That said, COVID-19’s characteristics show no similarity toprevious infectious diseases. The former has a fast-spiralling effect whereindividuals can be infected either through air-borne water droplets or
through physical contact with people or objects contaminated with thevirus. The rapid escalation of infection led to the Malaysian government
declaring COVID-19 a national disaster.1 This declaration took into accountthe exponential growth of infection globally. The labelling of COVID-19 as anational disaster for Malaysia meant that proactive government intervention
was required to stop the spread of the outbreak. Since 1969, the country
has not undergone any other catastrophe that has required government
intervention at the national level.
The Malaysian National Security Council (NSC) activated an emergency
structure to combat COVID-19. On 18 March 2020, Malaysia imposed anationwide Movement Control Order (MCO). The measure was intended
to limit citizens’ movements in order to break the chain of infections. Businesses were required to close except for essential services, and the generalpublic were only allowed limited travel. Interstate travel was prohibitedand any areas with more than 40 cases were considered red zone areas
and were cordoned (Tang 2020). Malaysia also enforced strict quarantine
measures for those travelling into the country and prohibited any formof mass gatherings. These measures were all strictly enforced, first by thepolice and later with the assistance of the military (Loh 2020).
The NSC, which is chaired by the Prime Minister, has convened frequently
to receive reports, analyse possible actions, and prepare a standard operatingprocedure for all citizens and other Malaysian residents. This standard
1 Under Directive No.20 of National Security Council (MKN 20), a disaster is defined as ‘an
incident that occurs without warning, complex in nature and results in loss of lives, property
and damage to the environment.’

166 Nurliana K AMARUDDIN and Zokhri IDRIS
Table 9.1

Daily reported cases from 25 September to 12 October 2020

Date (2020)

New cases

Total active cases

25 September
26 September
27 September
28 September
29 September
30 September
1 October
2 October
3 October
4 October
5 October
6 October
7 October
8 October
9 October
10 October
11 October
12 October

111
82
150
115
101
89
260
287
317
293
432
691
489
375
354
374
561
563

858
851
950
1,011
1,062
1,121
1,334
1,540
1,735
1,961
2,336
2,936
3351
3351
3863
4161
4587
5039

Source: Ministry of Health, Malaysia 2020c.

operating procedure has then been communicated to the public by the
Senior Minister of Defence through a televised briefing at 14:00 hrs eachday (during the first period of the Movement Control Order [MCO]). The
Ministry of Health, through its director-general, has also televised reports
about the number of new cases, existing cases, and deaths at 17:00 hrs eachday. According to the modelling and forecasting conducted by the National
Institute of Health, the MCO effectively controlled the transmission of
COVID-19 (Ministry of Health 2020b). The transmission rate decreased fromthe alarming three-digit figures seen in the early months to single-digit
figures in the months after that until the end of September. The success of the
MCO and the subsequent decline of infection rates allowed the government
to slowly ease the MCO. On 4 May 2020 it implemented the Conditional
Movement Control Order (CMCO) and then on 10 June it implemented theRecovery Movement Control Order (RMCO). These two orders saw thegradual loosening of prohibited activities. Businesses could operate as longas they followed the standard operating procedures (SOP).2
2 Some examples of these SOPs include businesses having only 30% of their essential operation
teams on the premises. Non-essential staff members were instructed to work from home. Stores

The Coordination of COVID -19 Responses in Mal aysia

167

Despite this success story, Malaysia began to experience another spikeof COVID-19 cases in late September 2020. On 25 September, the authorities reported a total of 111 cases. In the subsequent months, the country’s
daily reported cases consistently increased (see Table 9.1). The increase
sparked fears of a third wave. Currently, with stringent contact tracing andtargeted lockdown orders in place, the Malaysian government has expressed
confidence that the situation is under control (Loheswar 2020).
Aside from controlling and monitoring the number of cases, the Malaysian
government has also provided economic assistance for the affected populations as part of its COVID-19 measures. The government distributed Pakej
Prihatin (loosely translated as ‘Care Packages’) in different stages to aid
those Malaysians who had been economically affected by the outbreak. The
first package was released on 26 February, which gave financial allowanceto public healthcare workers, and also financial aid to households in the
middle and bottom 40% (known as B40 and M40 households). Households
and individual earners were awarded RM1000 to RM1600 (approximately
USD$250 to USD$400) and RM250 to RM500 (approximately USD$60 to
USD$125) respectively, according to their projected income (Prime Minister’s
Office 2020a).
Subsequently, the government released an additional Prihatin package on
6 April. These funds were intended to help small and medium enterprises(SMEs) to retain employees and avoid business closures. Following a seriesof consultations with financial institutions, the authorities announced
special packages to aid retrenched employees and locally-based SMEs. On
29 July, the government extended a previous loan moratorium for retrenchedcitizens by a further three months. Employed citizens who have received
pay cuts as a result of COVID-19 have also been able to negotiate with theirbanks on payment adjustments. Meanwhile, SMEs have been allowed to
pay interest to their banks at a later time, to extend their loan periods, aswell as to receive other payment exemptions that are reasonable to bothparties (Prime Minister’s Office 2020b).

Issues and Challenges
Handling a global pandemic can prove challenging even for the most advanced nations. The COVID-19 pandemic shows that economic strength does
were required to limit the number of customers on the premises at any given time. Temperaturechecks and a location log-in via the government application was made mandatory on all premises.

168 Nurliana K AMARUDDIN and Zokhri IDRIS

not equate to effective governance in dealing with the outbreak. Malaysia
has faced its share of challenges in its effort to combat the pandemic: thegovernment has to deal with domestic issues, such as a lack of complianceby some sectors as well as inconsistencies in policy announcement andenforcement. In Malaysia, one of the biggest challenges that the pandemic
has caused is linked to the issue of controlling the movement and migrationof people. This section will explore two major challenges that Malaysia faces.
The first is the way that cases involving foreigners have been linked to thelarger issue of illegal migration, raising questions about how migrants aretreated in Malaysia. The second concerns the implications stemming fromthe extended entry restrictions that Malaysia enacted.
On 18 September 2020, Malaysia recorded 21 new cases, of which only
one case involved a non-Malaysian. This positive turn of events however
was preceded by a tumultuous period where a large number of cases had
been found amongst groups of low-skilled migrant workers. Between April
and May 2020, clusters of infection were traced back to migrant workers
ranging from security guards to construction workers (Code Blue 2020). For
example, the Ministry of Health disclosed on 25 April 2020 that from 14,187
foreign workers who were tested, 676 had tested positive for COVID-19. Thiswas followed with the disclosure on 1 June 2020 that 2014 individuals out of
35,811 non-citizens tested were found to be COVID-19 positive (Tan, Mohd
Noor, and Khalidi 2020).
The organization Business and Human Rights Resource Centre (2020)
warned about the relatively high exposure of migrant workers to COVID-19,
in particular among those working in unhygienic environments, such as
those categorized as working in ‘3D’ employment, meaning that which isdangerous, dirty, and difficult (Sukumaran 2020). The low standards ofliving in the communities of migrant workers could also be problematic in
relation to their exposure to COVID-19. Residences are usually crowded inconstruction areas, which cram workers into small units. Poor sanitationand inadequate sewage systems impact the living condition of foreign
workers and thus increase their likelihood of infection.
To contain the spread of the virus, the Malaysian government has increased immigration raids, made testing mandatory for migrant workers,
and prohibited the hiring of new foreign workers (Babulal 2020). The news
organization Al Jazeera produced a documentary about the Malaysian
government’s treatment of migrants during the pandemic, criticizing
what it saw as draconian measures which included inhuman conditionsof detention and deportation (Al Jazeera 2020). In response, the Malaysian
authorities deported a Bangladeshi worker interviewed in the documentary

The Coordination of COVID -19 Responses in Mal aysia

169

and investigated the news agency for defamation and sedition (Rodzi 2020).
There has been a mixed reaction to the documentary and the government’s
response. Some news media have accused the Malaysian government ofbeing authoritarian and anti-freedom-of-speech (Peter 2020; Smith 2020).
Others have given the government their support. They state that the news
channel purposely misrepresented the government. They argued that claims
that the government’s actions were racist misconstrued these actions andthat the government’s measures have been based on containing the virus
and not on any racial discrimination (Yunus 2020; Malay Mail 2020).
Malaysia has covered the costs of COVID-19 testing for all the workers
whose employers contribute to the national social security organization(New Straits Times 2020). The Malaysian government has also continued
to provide medical care for all migrant workers infected with the virus,
regardless of their immigration status. The government likewise prepareda 600-bed quarantine facility specifically for migrant workers (Landau
2020). It declared that those workers who were found to be in the country
illegally would be deported after treatment (Kaos and Sivanandam 2020).
There have also been repeated calls from the Ministry of Health’s directorgeneral to ensure that there is no discrimination in the treatment provision(Hermesauto 2020).
Alongside the testing subsidies, financial aid from the government arguably has not reached the bulk of foreign workers as the aid has mostly beenchannelled to SMEs owned by Malaysians and employing Malaysian citizens.
The employment of migrant workers in Malaysia is largely concentrated
in large-scale construction firms and restaurants, with a group of migrant
workers also employed in individual households as domestic helpers. Migrant
workers who were employed on construction sites and in restaurants wereseriously affected by the MCO because of temporary closures. Most of thecompanies in these two industries are not SMEs but larger corporations
which have not been fully covered by the Prihatin economic assistance.
In all cases, the Malaysian government’s f inancial packages have notreached migrant workers directly. As such, migrant workers’ livelihoods
have largely depended on the performance of their employers in weathering
the pandemic.
Leaving aside the debate about whether Malaysia has been unfair in
its treatment of illegal migrant workers, the pandemic has revealed major
problems with the status quo in Malaysia. Malaysia’s dependency on foreign
workers for low skilled jobs means that the government has been inconsistentin handling the issue of undocumented workers in the country. Besides,
Malaysia has no separate official policy on refugees and asylum seekers,

170 Nurliana K AMARUDDIN and Zokhri IDRIS

leading to a sizable number of unregistered migrants in the country. The
conditions of immigration detention centres for arrested illegal migrants arepoor, with migrants kept in close and cramped quarters (Global Detention
Project 2020).
The COVID-19 pandemic has highlighted the fact that Malaysia needs
a major overhaul of its labour and migration laws in order to lessen its
dependency on cheap foreign labour and provide better protection for both
local and foreign workers in case another pandemic occurs. The International
Labour Organization has provided suggestions concerning migrant workers(Sandanasamy, Paavilainen, and Baruah 2020). This includes the observationthat one of the best ways to get undocumented migrants to voluntarily comefor testing and treatment during the outbreak is to ensure that there is nofear of detainment and that costs are subsidised or borne by the government.
At the same time, the enforcement of labour laws still needs to be upheld.
Malaysia’s decision to enact stricter border controls as a means to control
the pandemic has had economic and political implications for the country.
One economic implication is the impact on tourism. Tourism, which is a
big contributor to the Malaysian economy, has been one of the industries
hardest hit by the pandemic. At the time of writing (September 2020),
Malaysia had extended the travel ban on foreign tourists until the end of
December 2020. On 7 September, it also introduced an entry prohibition
for countries with over 150,000 cases. The list includes 23 countries, such as
the United States, Brazil, and India. The travel ban grants exemption only
to diplomatic travellers, while barring students and workers and spouses
with long term visas from entering the country for an indefinite period.
The decision has not been a popular one. The government has received
appeals from various sectors and especially from members of the business community such as the American Malaysian Chamber of Commerce(Bernama 2020; The Star 2020). It has also received appeals from local
investment promotion agencies (Lim 2020). These agencies point out thatthe entry restrictions not only impact immediate economic growth andemployment but could likewise have more far-reaching consequences, suchas a loss of trust in the reliability of Malaysia as a trade partner and placeof business. Malaysia’s government needs to consider the loss of overseas
expertise that companies based in Malaysia depend on.
Similarly, the travel ban may impact other sectors. Restricting international students coming into the country may also affect universities andthe attractiveness of Malaysia as a hub for higher education. In addition,
Malaysia is known as a medical tourism destination, and thus the travel
ban could have consequences in this industry. There are fears that theThe Coordination of COVID -19 Responses in Mal aysia

171

pandemic might mean that Malaysia would enforce tighter border controls.
As a country that is dependent on foreign workers, this could lead to anincrease in illegal migration instead. Such a phenomenon would potentiallycompound some of the problems that Malaysia is already facing and thathave been discussed earlier in this chapter
Overall, there are many sacrifices and trade-offs that the government
has made to enhance public health and safety. Malaysia should learn fromits current experience in order to handle future crises in a more consistentmanner. What remains to be seen are the long-term consequences of themeasures that have been taken during the pandemic. It is not yet known
whether the economic impacts of the MCO will be manageable. Although
the Malaysian government has continued to provide economic stimulus
and financial assistance packages, these solutions are not sustainable.
The government will thus need to consider what it can do to help sustain
economic growth, not only by maximizing its comparative advantage, butalso by ensuring that it remains actively engaged with international markets
and sustains international supply chains.

Conclusion
Malaysia provides an interesting case study of how a professional and wellestablished civil service can hold a country together during the COVID-19
outbreak, even in times of political crisis. Although ministerial posts werechanging hands and newly appointed ministers were tasked with facing
the national crisis, consultation and dependence on the civil service andexperts provided Malaysia with the means to tackle the pandemic. It is still
important to note that at the time of writing Malaysia remains under the
restrictions of a RMCO. Several new clusters of infections have been detected
and are being closely monitored by the government. The government has also
imposed quarantine requirements for all travellers coming into Malaysia
as well as those travelling between so-called ‘red-zone’ states.
The COVID-19 crisis shows that the issue of migrant workers in Malaysia
remains a challenge. Although these workers have received healthcare fromthe public hospitals, they will still face legal punishment, which includes
immediate deportation back to their home country. In terms of economic
assistance, the well-being of migrant workers is mostly dependent on whether
the company they work for has taken steps to ensure this. It is difficult toestimate the amount of government aid that reaches migrant workers. In
the midst of this, Malaysia’s political future also remains uncertain, since172 Nurliana K AMARUDDIN and Zokhri IDRIS

there is no clear-cut majority in parliament. It is likely that the politicaluncertainty will further impact and aggravate the damage that the pandemic
has wrought on Malaysia’s economy.

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Babulal, Veena. 2020. ‘Malaysia to Deport All Covid-19 Negative Undocumented Workers [NSTTV].’ New Straits Times, 26 May. Accessed 25 September 2020. https://www.nst.com.my/news/nation/2020/05/595449/
malaysia-deport-all-covid-19-negative-undocumented-workers.
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Spread under Control, CMCO and TEMCO way to go.’ Malay Mail, 21 December.
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for Immigration Detainees.’ Malay Mail, 3 June. Accessed 16 March 2021. https://www.malaymail.com/news/malaysia/2020/06/03/covid-19-foreign-missionsthank-govt-for-action-treatment-for-immigration-d/1872046.
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news/nation/2020/07/610396/explain-our-side-story-says-dr-m-al-jazeera-report.

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175

About the Authors
Nurliana KAMARUDDIN is Deputy Executive Director (Academic) at
the Asia-Europe Institute, Universiti Malaya. She obtained her PhD in
International Studies from Ewha Womans University, specializing in
Development Cooperation. Her area of research includes international
politics and development with a focus on ASEAN and East Asian relations.
Kamaruddin was a recipient of the Korea Foundation ASEAN Fellowship(2013-2015), the POSCO TJ Park Foundation Asia Fellowship (2009-2011)
and the Ewha Global Partnership Program scholarship (2006-2009). Prior
to her appointment as Senior Lecturer at the Asia-Europe Institute (AEI),
Nurliana was a Research Assistant at the AEI (2011-2013). Before that, she
was a lecturer at the English Language Centre, Stamford College, Selangor(2009). Nurliana is the co-editor of the book ASEAN Post 50: Emerging Issues
and Challenges (Palgrave Macmillan, 2019).
Zokhri IDRIS has held several academic positions in International Relations(IR) research and teaching, and now is the Deputy Dean of Student Affairs
at the Management and Science University (MSU) in Malaysia. He served
as a senior faculty member in the Faculty of Business Management andProfessional Studies (FBMP), MSU after completing his industrial attachment
at Puncak Niaga Management Services as an assistant manager serving theStrategic Resources and Public Relations Division. His research focuses on
the changing nature of diplomacy and sovereignty of developing nations,especially Malaysia. This led him to the establishment of the Eirene Research
website, to explore leadership and diplomacy in International Relations.
He co-founded ARUS, an avenue to nurture talent and empower Malaysian
youth. Currently, he serves the Institute of Democracy and Economic Affairs,
Malaysia (IDEAS) as Director of External Relations.

10

Analysis of South Korea’s Experience
with the COVID-19 Pandemicand its
Relations with the WHO
Eun Mee KIM and Jisun SONG

Abstract
This chapter analyses South Korea’s experience in combating the COVID-19
pandemic internationally in the context of the government’s global
outreach and development cooperation for developing countries, andthe public’s response to global health governance centring on the World
Health Organization (WHO). The findings indicate that the South Korean
government quickly embraced multilateralism in its COVID-19 response.
It did so by providing financial contributions to key global health initiatives for fair and equal access to COVID-19 vaccines, by creating global
platforms for dialogue, and by enhancing its participation in global healthinstitutions. However, analysis of South Korean media editorials indicates
that, in contrast with the government, the South Korean public showeddiscontent with the WHO.
Keywords: South Korea (Republic of Korea), World Health Organization,
global health governance, development cooperation, multilateralism,
COVID-19

Introduction
South Korea has stood out as an exemplary country in the battle against
COVID-19, handling the virus without going through a lockdown. Afterthe first cases of COVID-19 in China were reported in December 2019, theSouth Korean government was on high alert due to the geographic proximity

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_ch10

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Eun Mee KIM and Jisun SONG

between the two countries. It was on 20 January 2020 that the first COVID-19
case was confirmed in South Korea. Since then, South Korea has encountered
several hurdles in its fight against COVID-19. The number of COVID-19
patients gradually increased after this first case. On 18 February 2020, thecountry saw a sudden spike in the infection number due to a large clusterof cases associated with the Shincheonji Church of Jesus in Daegu, thefourth most populated city in the country. The spread of the coronavirus
related to this cluster was eventually contained. However, South Korea
witnessed a second major outbreak in late August and early September. On
15 August 2020, the National Liberation Day, a number of infected individuals
participated in a large-scale political protest organized by far-right church
members in Seoul. This resulted in the spread of the coronavirus across thecountry. However, South Korea was able to flatten the curve in a relatively
short time.
In responding to COVID-19 domestically, the South Korean government
has implemented an array of policies and strategies, including tracking, treatment, self-quarantine, immigration, and social distancing. It has adopted awhole-of-government approach, which implies a horizontally and verticallycoordinated approach from different government stakeholders. At the sametime, the South Korean government’s approach has closely followed therecommendations of the World Health Organization (WHO), particularly interms of limiting travel and trade to and from countries that are undergoing
COVID-19 outbreaks (WHO 2020a). The WHO’s recommendations emphasize
the need to refrain from imposing excessive entry restrictions. The South
Korean government even issued a statement with other United Nations (UN)member countries on the need for a global, coordinated response to avoid
unnecessary interference with international traffic and trade while taking
into account the movement of goods and people for humanitarian, scientific,
and essential business purposes, so long as this does not undermine acountry’s disease control (MOFA 2020c; 2020e).
South Korea has also focused on its responsibility towards other membersof the international community. As a member of the Development AssistanceCommittee (DAC) of the Organization of Economic Development and Cooperation (OECD), South Korea has a responsibility as a donor country
to assist its partner countries in developing regions, particularly during
the pandemic. South Korea has increased its financial contributions tointernational organizations as well as global initiatives on health. It has
also established platforms for dialogue on global health.
This chapter will analyse South Korea’s experience combating COVID-19,
in terms of the government’s domestic response and its international

Analysis of South Korea’s Experience with the COVID -19 Pandemic

179

contributions, and the South Korean public’s response to the role of the
WHO since the outbreak began. First, it will examine the South Korean
government’s global outreach with a focus on development cooperation forpartner countries during the COVID-19 outbreak. Second, it will look at the
responses to global health governance and the WHO of the South Korean
government and public. It will examine the government’s standpoint on
the role of the WHO as a global health institution and its contribution tostrengthening global health governance since the COVID-19 pandemic began.
The chapter will also pay attention to the South Korean public’s response
to, and debates about, the role of the WHO during the COVID-19 pandemic.
This chapter shows that there has been a concerted and coordinated effort
by the South Korean government to strengthen the role of multilateral
health institutions, including the WHO. However, public sentiment has
been contrary to this, particularly regarding the WHO’s management of
the situation and its position towards China.

South Korea’s Health Multilateralism
The South Korean government’s global contribution to combating the
COVID-19 pandemic involves: (1) its financial contribution to global healthinitiatives that are dedicated to the eradication of global infectious diseases
including COVID-19; and (2) its creation of global platforms to create stronger
partnerships and dialogue on diseases.
First, South Korea has made contributions to several global healthinitiatives, including the Coalition for Epidemic Preparedness Innovations(hereafter, CEPI), Gavi, the Vaccine Alliance (hereafter, Gavi), the Global
Fund to Fight AIDS, Tuberculosis and Malaria (hereafter, Global Fund), andUnitaid, an innovative financing initiative to scale up access to medicines.
Different global health initiatives are playing pivotal roles in providing
global, rapid, and equitable access to COVID-19 vaccines at affordable prices,
especially for developing countries. For instance, CEPI acts as a global
mechanism for financing COVID-19 vaccine development, while Gavi helps
to provide vaccines at a more affordable price for developing countries(Yamey et al. 2020).
South Korea is currently participating in the decision-making body of all
three initiatives listed above. It is an independent member of the executive
board for Unitaid, a non-voting member of the ‘additional public donors’
group on the board of the Global Fund, and a member of the Gavi board
along with the United States, Australia, and Japan. For Gavi, the four-country

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Eun Mee KIM and Jisun SONG

group is currently represented by Australia, and Australia will hold thevice-chair seat until the end of 2021. In 2020, South Korea announced its
first contributions to CEPI. Although South Korea’s motives for funding
such initiatives have not been made explicit, its decision to contribute tothese initiatives may be influenced, amongst other things, by the way the
programmes align with South Korea’s Official Development Assistance(ODA) priorities, the effectiveness and impact of the initiatives, and theeconomic opportunities they offer for South Korean private companies(MOFA 2015).
Table 10.1 shows the size of the financial contributions that the South
Korean government has made to the four global health initiatives, as wellas its core funding to the WHO. South Korea’s funding to CEPI, Gavi, Global
Fund, and Unitaid is financed by the Global Disease Eradication Fund (GDEF).
This is an innovative finance mechanism based on the air-ticket solidarity
levy system in South Korea. The GDEF is managed by the Ministry of Foreign
Affairs, and the foreign minister has announced an increase of funding in
the coming years to help the global response to COVID-19. However, South
Korea has already increased its commitments to these initiatives since thestart of the COVID-19 crisis. For instance, South Korea’s contribution to Gavi
increased from an average of US$5 million per year to US$6 million per year,
providing a total of US$30 million in the period from 2021 to 2025 (MOFA
2020b). Last year, it also contributed to funding CEPI for the first time, giving
it an average of US$3 million per year (MOFA 2020a, 14). Despite an increasein financial contributions, the amounts that South Korea is giving to these
initiatives is relatively small when compared to other major donors. For
instance, South Korea’s pledge to CEPI was US$9 million, which is lower thanthe pledges of the US (US$20 million), Norway (US$25 million), and the UK(US$296 million), but higher than those of Austria (US$2.3 million), Denmark(US$1.4 million), and Finland (US$4.5 million) (The Economist 2021). South
Korea is also one of the five donors to Unitaid. In addition, it is a small donor
in the larger global health initiatives, such as the Global Fund, to which it
provided US$3.7 million in 2018, in contrast with the US and France which
provided US$959 million and US$424 million respectively (OECD 2021).
South Korea’s assessed contribution to the WHO, which is determinedby the country’s income level, is primarily managed by the Ministry of
Health and Welfare. The Ministry of Foreign Affairs and the Ministry ofEnvironment also fund WHO projects.1 Between 2020 and 2021, South Korea’s
1 Funding for the WHO is different from that of the other global health initiatives mentioned
above (e.g. CEPI, Gavi) as it is measured by the donor’s income level. While the Ministry ofAnalysis of South Korea’s Experience with the COVID -19 Pandemic

Table 10.1
Initiative

181

South Korea’s Contributions to the Global Health Initiatives
PledgeCEPI– (2020-2022) US$9 million

Gavi– (2019-2021) US$15 million– (2021-2025) US$30 million

Global Fund

– (2017-2019) US$12.5 million– (2020-2022) US$25 millionWHO– (2020) Core contribution of KRW10 billion (US$8.9 million)– (2021) Core contribution of KRW9.9 billion (US$8.8 million)

Unitaid– (2017-2019) US$8 million (US$4 million annually)– (2019-2021) US$15 million (US$5 million annually)

Note: Currency converted from Korean Won (KRW) to US Dollars based on the exchange rate from
Oanda.com website, converted on Oct 24, 2020.
Source: MOFA (2019a; 2019b; 2020a; 2020b); CIDC (2020a; 2020b).

assessed funding to the WHO remained constant at around US$9 million(CIDC 2020a, 28; 2020b, 36).
Another major way in which South Korea makes financial contributions
to global partnerships for responding to infectious diseases is through its
official development assistance (ODA). South Korea has been committed
to increasing its ODA budget since joining the OECD DAC in 2010. Although
South Korea’s ODA as a proportion of Gross National Income (GNI) was
only 0.15% in 2019, which is far below the global target of 0.7%, it aims toreach 0.3% ODA/GNI by 2030 (CIDC 2020a, 7). During the pandemic, theSouth Korean government announced that it would increase its total ODA
budget by 19% (i.e., by 652.3 billion Korean won or US$577 million), from
3427 billion won (US$3 billion) in 2020 to 4079 billion won (US$3.6 billion)
in 2021 (CIDC 2020b, 29). This announced increase was made despite thefact that the International Monetary Fund projected South Korea’s real GDP
growth rate to be -1.9% in 2020 (IMF 2020, 56).
More specifically, South Korea increased health-related ODA by 33.7%(93.4 billion won or US$83 million) from 277.3 billion won (US$245 million)
in 2020 to 370.7 billion won (US$328 million) in 2021. This increase wasmade to help its ODA recipient countries respond to COVID-19. At the sametime, the South Korean authorities are going to partner with Korean civilsociety organizations and the private sector to tap into diverse forms ofdevelopment finance. For instance, a group of South Korean non-government
Health provides the assessed contribution, additional funding also comes from other ministries
through project funding.

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Figure 10.1

Eun Mee KIM and Jisun SONG

South Korea’s ODA Trend for 2015-2021

organizations that focus on international development announced a plan
to allocate 60 billion won (US$53 million) to around 60 partner countries tomitigate the impact of COVID-19 (CIDC 2020b, 13). Moreover, at the WHO’s
World Health Assembly on 18 May 2020, the South Korean government
declared that it would contribute US$100 million in humanitarian assistanceto help developing countries tackle the outbreak (GoK 2020a). Increasing
humanitarian aid is in line with South Korea’s aim of carving out its role
as a middle power while responding to the growing demand in partnercountries (CIDC 2020b, 3).
In addition to the monetary contributions, South Korea is participatingin multilateral platforms that aim to provide fair and equitable access to
COVID-19 vaccines for all countries, regardless of the level of economic
development. For example, South Korea participates in the COVAX Facility, which is a global collaboration co-led by CEPI, Gavi, and the WHO toassure the development and equitable distribution of COVID-19 vaccines(Yonhap 2020). The South Korean government has urged other countries
to do the same. It also provided US$10 million to COVAX Advance Market
Commitment (AMC) for developing countries’ better access to COVID-19
vaccines (MOFA 2020e). South Korea is also a facilitation council member ofthe Access to COVID-19 Tools Accelerator (ACT-A), which was co-launchedby the WHO, European Commission, France, and the Bill & Melinda Gates
Foundation (KBS World 2020; WHO 2020b).

Analysis of South Korea’s Experience with the COVID -19 Pandemic

Table 10.2
Date

183

Global Solidarity Groups on COVID-19 Launched by South Korea
Name

May 12, 2020 UN Group of Friends of Solidarity for
Global Health Security

Participating Countries–	Co-chairs: South Korea, Canada,
Denmark, Qatar, Sierra Leone

May 20, 2020 WHO Support Group for Global–	Core-members: South Korea, Kenya,
Infectious Disease Response (G4IDR)
Mexico, Morocco, Peru, Singapore,
Turkey, United Arab Emirates
May 26, 2020 UNESCO Group of Friends for–	
Inaugural members: South Korea
Solidarity and Inclusion with Global(Chair), Armenia, Austria, BangCitizenship Education (GCED)
ladesh, Colombia, Italy, Jordan,
Kenya, Philippines, Serbia, Senegal
Source: MOFA (2020f; 2020g; 2020h) .

Furthermore, in May 2020 South Korea launched three global solidarity groups contributing to the COVID-19 response at the UN, WHO, and
UNESCO. The UN Group of Friends of Solidarity for Global Health Security
is dedicated to strengthening the UN’s response to health security issues, including COVID-19. The WHO group seeks to build an effective
global infectious disease response system. Meanwhile, the UNESCO groupaims to galvanize global cooperation and discussion on discriminationand other forms of inhumane acts provoked by COVID-19. South Korea
participates as a chair or core-member of all three platforms, which areopen to all countries. In addition to this, on 19 May 2020 South Korea waschosen to serve as a WHO executive member in the period from 2020 to2023, with the South Korean Vice Minister of Health and Welfare acting
as the representative. Participation in such multilateral platforms canconsolidate the country’s influence as a global agenda-setter. For instance,by proactively participating in board meetings where budgets, programmes,and strategies are discussed, South Korea is able to ensure that its own
agenda is reflected in these organizations’ decision-making processes(MOHW 2020).
As one of the countries severely affected by COVID-19, South Korea hasquickly and effectively reacted to the outbreak to prevent further spread ofthe disease domestically. At the same time, the above analysis has shown
how it has taken a proactive role in contributing to the global discussion
and cooperation in responding to COVID-19. It has done this by utilizing
existing global health initiatives and increasing its financial contributions
to these, as well as by establishing multilateral arenas for the discussion of
global health security.

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Eun Mee KIM and Jisun SONG

South Korea’s Reactions to the COVID-19 Measures of the WHO
As part of its strategy to tackle COVID-19 domestically, South Korea
has followed the WHO’s recommendations while making necessary
adjustments. However, the South Korean public has displayed negative
reactions to the WHO’s slow response and the position of the organization
towards China.
To assess the South Korean public’s attitudes towards the WHO, weanalysed editorials published by domestic news agencies between 20 January 2020, when the first case of COVID-19 was reported in South Korea, and18 October 2020. Although editorials are based on the authors’ opinions,
there is not only room for such pieces to influence public policy (Sommer
and Maycroft 2008), but these can also act as a mechanism in shaping theagenda and public opinion (Coppock, Ekins, and Kirby 2018). Our study
therefore assumes that the editorials represent public opinion to a certain
degree.
We obtained the editorials using the Big Kinds database run by the
Korea Press Foundation, which stores all the articles written in either
Korean or English that have been published by 54 different news agencies.
We searched for all editorials using the keywords ‘WHO’ or ‘World HealthOrganization’ in both Korean and English. The first search generated 324
editorials, which we cross-reviewed to determine if the respective editorials
were about COVID-19. Editorials that were irrelevant to COVID-19 andSouth Korea were omitted. This led to the removal of 44 articles. Then, we
reviewed the full text of each editorial and narrowed down the number
by removing any editorials that did not have an opinion on the WHO.
That is, editorials that simply quoted the WHO’s data or statements were
removed. A total of 262 editorials were omitted from this second screening
and the remaining eighteen editorials were analysed. All articles were
written in Korean and we translated the contents as literally as possible
to best convey the original message. The eighteen pieces are summarizedin Table 10.3 with the key events that influenced the tone and content of
the editorials.
Public reactions to the WHO were seen after the following events: theinitial outbreak of COVID-19, the South Korean government’s declaration of
COVID-19 as a Public Health Emergency of International Concern (PHEIC)
and subsequently as a pandemic, and also the suspension of funding to the
WHO by then US President Trump. The media and the public especiallycriticized the WHO’s position towards China when the first case was recorded. They were also critical, to a lesser extent, of the WHO’s approachSeoulShinmunChungbuk
Ilbo

Seoul
ShinmunSeoul
Shinmun

Chosun Ilbo

1

3

4

5

2

Publisher

Date

Title

Key Relevant Sentence(s)National
newspaper
Local newspaper(Jan 20, 2020) First case of COVID-19 infection in South Korea
Jan 28, 2020
Larger plan to prevent the regional It is very unfortunate that the WHO postponed declaring a
spread of COVID-19 is needed
public health emergency during these urgent times.
Jan 29, 2020
Must focus on blocking the second However, the WHO has not yet declared a public healthwave of ‘Wuhan pneumonia’
emergency. Restricting the spread of the virus is a race
against time. There is a need to run a global disease control
cooperation system. In this sense, the WHO’s actions areregrettable and unfortunate.
(Jan 30, 2020) The WHO declares COVID-19 a Public Health Emergency of International Concern (PHEIC)
National
Jan 31, 2020
Belated WHO declaration of global There is criticism that the WHO’s declaration of a global
health emergency was belated. The WHO Director-General
newspaper
health emergency. [The Korean]
Ghebreyesus showed his consideration for China in thegovernment must strongly recompress conference after the declaration by saying “this is not
mend refraining from travelling toa vote of no confidence in China.” It is difficult to understandChina
the WHO’s slow response after COVID-19 first broke out
last December. It is evident that the WHO has missed theopportunity by running about in confusion
National
Feb 3, 2020
Response to the spread of COVID-19 As the infectious disease spread globally, the WHO, that had
newspapermust be faster and stronger
continued to protect China, had no choice but to declare apublic health emergency of international concern (PHEIC).
The US Center for Disease Control and Prevention (CDC),
National
Feb 5, 2020
Chinese ambassador says it is “notwhich has higher scientific authority than the WHO,
newspaper
necessary to limit travel”. To whichemphasized the need to limit the entry of foreigners who(Korea’s) ruling party says it “musthad visited China and said: “science should come before
judge those who aggravate fear”
anything else”. The WHO, which China is using as a shield, isan institution that is under the influence of ‘China money’.
China announced that it will give the WHO US$10 billion in
funding in 2017. The current Director-General of the WHO
also received support from China during his election. It is an
institution that has lost objectivity concerning China.

Publisher Type

Editorials on the WHO in South Korean MediaNo.

Table 10.3
Analysis of South Korea’s Experience with the COVID -19 Pandemic

185

Publisher

Seoul
ShinmunFinancialNews

The Korea
Economic
Daily

Joong Ang
Ilbo

No.

6

7

8

9

National
newspaper

Financialnewspaper

Financialnewspaper

National
newspaper

Publisher Type
Seek international cooperation on
COVID-19 and strengthen airport
disease control
It is right to hurry the return of
Korean residents living in Wuhan

Title
While the WHO reacted in a lukewarm manner, COVID-19
spread faster than SARS or MERS had in the past […]Key Relevant Sentence(s)Although the WHO sees a low probability of a global
pandemic, it’s evident that at least in China the spread of
infections has not slowed down. … This is why it’s difficult torely on the optimistic long-term predictions of the Chinese
government or the WHO.
(Sentence on South Korean government saying it is unnecesFeb 19, 2020
Exploding ‘COVID-19’ … Do notsary to limit travel). This is contrary to 133 countries including
walk on eggshells, only focus on
the U.S., France, Germany, Canada, and Australia who havepeople’s safety
adopted widespread entry limitation measures, ignoring the
WHO that has shielded China.
(Mar 11, 2020) The WHO declares COVID-19 a global pandemic
Mar 11, 2020
Shaking trust in the WHO […] must International Organizations, either the WHO or the UN, are
not performing their role and have in fact lost their grip
create new norms for ‘COVID-19
on the problem. […] The WHO has been criticized sinceinternational cooperation’the outbreak of COVID-19 in China that it has reacted too
passively. It has made ambiguous remarks or even shielded
China, which provides around 10 trillion Korean Won. …
The WHO’s behavior has been very disappointing so far. …
Although the WHO does not have any legal force, it has tonow improve international norms and regulations to fit thechanged reality. [The author] urges the WHO to properly
fulfill its role now as a ‘doctor of humanity’ and promote
global cooperation.

Feb 10, 2020

Feb 6, 2020

Date

186 
Eun Mee KIM and Jisun SONGMar 12, 2020

Mar 13, 2020

Mar 13, 2020

Local newspaper

Local newspaper

National
newspaper

JoongbooIlbo

Gwangwon
Ilbo

Seoul
Shinmun

11

12

10

Date

Publisher Type

PublisherNo.

Key Relevant Sentence(s)The WHO finally announced a global pandemic on COVID-19.
However, it was criticized for its belated response, with
COVID-19 having spread over 110 countries. Also, the WHO’s
behavior so far has been inconsistent. It has received much
criticism for protecting China from the beginning of the
COVID-19 outbreak. Just before, it mentioned Italy, Iran, Japan,
and Korea as countries of concern regarding COVID-19. However, it omitted Japan from its materials the next day. Basedon the Japanese press’ investigation into the WHO’s suddenchange of behaviour, this was due to Japan’s protest. Japan
asked the WHO to not give the same treatment to Japan as it
had to Italy, Iran, and Korea. This is the reason for the criticism
that the WHO has lost fairness and is being swayed by certain
countries. This was predicted when the WHO excluded thenumber of COVID-19 patients from the cruise ship docked in
Yokohama from the number of patients in Japan. The nextday, the WHO thanked Japan for its contribution of US$10
million. This is one aspect of the WHO being controlled by
Japan whose strong economic power cannot be ignored.
Spread of ‘Infection from Call Center’ Although a belated response, the WHO declared COVID-19 a
global pandemic.
puts pressure on the managementof multi-occupancy buildings
The WHO, which was dragging its feet about saying
Belated WHO declaration of
global pandemic, must win the fight COVID-19 could be characterized as a pandemic two days
ago, finally announced that it was a pandemic yesterday. […]against global disaster
Although many experts had already warned that COVID-19
had reached the pandemic level, the WHO had been on thefence, adjusting the global risk assessment to ‘very high’.
WHO announces COVID-19 as apandemic

Title

Analysis of South Korea’s Experience with the COVID -19 Pandemic

187

Herald
EconomyKyunghyang
ShinmunSeoul
ShinmunJoong Ang
Ilbo

Moo Deung
Ilbo

13

14

15

16

17

Apr 2, 2020

Financialnewspaper
The WHO’s confusion over masks
worsened global COVID-19 disaster

Title

Key Relevant Sentence(s)The WHO finally stated the usefulness of wearing masks incurbing the spread of COVID-19. […] This is too late. Also,
the WHO is being inconsistent. It has not apologized for its
wrong judgment. It is almost shameless that it is changing
words after causing the global COVID-19 disaster due to thesenseless argument of masks being useless. …
(Apr 15, 2020) U.S. President Trump announces that the US will suspend funding to the WHO
Apr 15, 2020
National
Trump’s suspension of WHO funds
The WHO has contributed to curbing the spread of COVID-19
newspaper
goes against COVID-19 responseby providing guidelines on social distancing. It is wrong toblame the WHO for the spread of COVID-19 at this point.
Although the WHO’s COVID-19 response has been unreliable,
its role is more important than ever.
Apr 17, 2020
National
Trump’s narrow-minded suspension It is evident that the Director-General of the WHO has
newspaperof WHO funds is worrisome
been running about in confusion during the early stage of
COVID-19 by making remarks that side with China to oppose
restrictions of movement and trade. However, for the US,
which funds over one-fifth of the WHO budget, to cut its
funding only means that it will prevent the WHO from helping
developing countries with a weak disease control system. […]The US and China are playing a blame game and the WHO is
National
Jun 29, 2020
Global COVID-19 patients surpass
helpless
newspaper
10 million…must tighten disease
control measures
Local newspaper
Jul 19, 2020
Many countries wrongly responding With COVID-19 threatening the world at a fast pace, eachto COVID-19?
government and the WHO should put their heads together tofind a solution on what is wrong with the COVID-19 response.

Date

Publisher Type

Source: Big Kinds (2020)
Note: All articles were retrieved from the Big Kinds database. The authors translated the articles from Korean to English as literally as possible to best convey the original
message.

Publisher

No.

188 
Eun Mee KIM and Jisun SONG

Analysis of South Korea’s Experience with the COVID -19 Pandemic

189

to Japan and the way it had downplayed the number of COVID-19 cases by
not including the number of infected patients on the Diamond Princess
cruise ship that departed from Yokohama in Japan.
Soon after the f irst case of infection was reported in China, the South
Korean media urged the WHO to announce a PHEIC. The media viewed
the delay in the announcement of this as the result of the close political
relationship between the WHO, especially the WHO Director-General,and the Chinese government. This view was found in most of the editorials published during February 2020 that were analysed. Due to its
geographical proximity to China, which meant a large number of people
travelled between the two countries, the media criticized the WHO for
not recommending strong travel restrictions. They also criticized theSouth Korean government for following the WHO’s recommendations
while other countries had done the opposite and had limited the entryof people from China. This latter view was reflected in editorials 3 and 8.
Most editorials, published in both conservative and liberal newspapers,
criticized the role of the WHO during the crisis. Several editorials (i.e.,
numbers 3, 6, and 7) even condemned the WHO for aggravating thesituation.
Even after the WHO declared COVID-19 a pandemic in March 2020,
the editorials published at the time unanimously criticized this as beinga belated response. The WHO’s conflicting guidelines on wearing masksalso confused the public. The WHO had stated that a ‘medical mask is not
required for people who are not sick as there is no evidence of its usefulness
in protecting them’ (WHO 2020a). In contrast, the South Korean government
strongly recommended wearing masks in public places.
A change in the tone of the editorials emerged when the then US President
Trump announced the suspension of funding to the WHO. After this, while
acknowledging the limitations of the actions taken by the WHO, the editorials also stated that for a major donor like the US to pull back its large funding
was unfair and would set back global COVID-19 responses. These editorials
argued that the contributions of the donor countries were important for
helping the international community, and particularly developing countries,
fight the pandemic (see editorials numbers 14-17).
The South Korean government has maintained its political support for
the WHO and voiced concerns over diminishing support for multilateralplatforms including the WHO. Table 10.4 shows that the messages comingfrom President Moon Jae-in have been consistent, expressing the government’s support for the WHO at both domestic and international events. Ina joint op-ed published with the heads of eight countries including Canada

190 

Eun Mee KIM and Jisun SONG

Table 10.4

Remarks from President Moon, Jae-in on the WHO

Date

Event

Mar 26,2020

Remarks at the G20 2020
Extraordinary Virtual
Leaders’ Summit
Phone call with the WHO
Director-General

Apr 6,
2020

Apr 9,
2020

Apr 24,2020
May 18,2020

Jul 16,2020

Relevant Remarks… in accordance with the WHO’s recommendation, we minimized restriction on cross-border
movements of people and goods…
… we are minimizing unnecessary restrictions on
the movement of people and goods in line with
the WHO’s recommendations. […] In the face of
this unprecedented global healthcare crisis, therole of the WHO is becoming more important.
I hope that the WHO will play a leading role ineradicating COVID-19 by taking active countermeasures through international unity…
Remarks at a joint meeting […] Korea will actively participate in theinternational community’s efforts to surmounton COVID-19 treatments
the COVID-19 outbreak through a cooperativeand vaccines held
system led by the WHO and the UN.
domestically
The two leaders agreed that it is necessary to
Phone call with the
President of South Korea
assist the WHO so that it can fulfill its role.
Address at the 73rd World Second, in order to develop vaccines and treatHealth Assembly
ments, we must cooperate beyond our borders.
[...] The Republic of Korea fully supports theefforts of the WHO to develop vaccines and treatments. … We must update the WHO International
Health Regulations and other relevant norms andaugment them with binding legal force.
Thankfully, great efforts, investment and coordiJoint op-ed in the
Washington Post with the nation, largely facilitated by the WHO, are being
heads of Canada, Ethiopia, directed at putting an end to the pandemic. […] A
New Zealand, South Africa/ fair and effective vaccine allocation mechanism,
guided by WHO advice and based on needs
AU, Spain, Sweden, andrather than means, should focus on saving lives
Tunisia
and protecting health systems. … We particularly
recognize the WHO’s role as the leading global
health agency …

Source: GoK (2020a; 2020b; 2020c; 2020d; 2020e); Trudeau et al. (2020).

and Ethiopia, leaders specifically pinpointed the WHO as the leading global
health agency in fighting the current pandemic.
Other ministers, including the Minister of Foreign Affairs and the Ministerof Health and Welfare, have echoed this support for the role of the WHO. For
instance, at the Annual Reunion of Romanian Diplomacy, which was heldon 8 September 2020, the South Korean Foreign Minister Kang Kyung-wha
expressed concerns over the divisive dynamics of WHO member states andemphasized the need to ‘prize, respect and enhance the WHO’s technicalAnalysis of South Korea’s Experience with the COVID -19 Pandemic

191

and scientific expertise’ (MOFA 2020b). This shows how the South Korean
government, unlike the media and the public, has not wavered in its positionon the WHO. Instead, throughout the outbreak it has called for a further
strengthening of the institution.
The difference in attitude between the South Korean government andsociety at large can be explained by the South Korean government’s aim
to solidify its role as a middle power country and augment its leadershipin multilateral platforms. In other words, although South Korea lacks
the influence of a major power such as the United States, the current
administration has aimed to reinforce international cooperation throughdiplomacy by utilizing various regional and global arenas (GoK 2017).
As such, despite the negative public sentiment, support for health multilateralism is aligned with the government’s diplomatic priorities. In
addition, the public sentiment towards the WHO has turned less criticaland more supportive as the pandemic has progressed. This means thatthe initial difference in the views of the government and the public isunlikely to have any consequential impact on South Korea’s relationshipwith the WHO.

Conclusion
Given the international community’s efforts to combat COVID-19, thischapter looked specifically at South Korea’s efforts to strengthen global
health security by offering foreign assistance and participating in multilateral platforms. South Korea has not only increased its bilateral andmultilateral assistance, but it has also created new venues for global
discussion and cooperation on global health issues. At the same time, thechapter examined the contrasting opinions of the South Korean government and the public about the WHO and its responses to COVID-19. The
analysis shows that while there had been severe criticism of the WHO’sleadership and its early responses, the public became more supportive of
the WHO’s role in the global response after the US suspended financial
contributions to the health organization. Contrary to the shifting public
opinion, the South Korean government has displayed consistent support
for the WHO and its guidelines, while at times being criticized by the
public for abiding by the WHO’s recommendations. This implies that
the South Korean government’s goal of fortifying its global leadership in
multilateral organizations took priority over appeasing domestic public
opinion.

192 

Eun Mee KIM and Jisun SONG

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195

About the Authors
Eun Mee KIM is the seventeenth President of Ewha Womans University.
She is Professor in the Graduate School of International Studies, Director of the Ewha Global Health Institute for Girls and Women, and former
Dean of the Graduate School of International Studies, and former Directorof the Institute for Development and Human Security at Ewha Womans
University. She was appointed by the UN Secretary General in December 2016
to serve as one of the fifteen Independent Group of Scientists working on
the Global Sustainable Development Report 2019, which was presented to
the UN Secretary General and heads of member states at the UN General
Assembly in September 2019.
Jisun SONG is Assistant Professor at the Institute of Foreign Affairs andNational Security of the Korea National Diplomatic Academy. Previously,
she worked as Research Professor at the Institute for Development andHuman Security of the Ewha Womans University. She received her PhD
in International Studies from Ewha Womans University. Her researchand publications focuses on international development cooperation, aid
effectiveness, foreign aid modalities, global health security, and genderand development.

11State-Society Relations as Cooperative
Partnershipand the COVID-19
Response in Vietnam
Mirjam LE and Franziska NICOLAISEN

Abstract
The Vietnamese government used symbolic nationalism to gain public
support for its containment strategies over the course of the COVID-19
pandemic. This included a transparent communication strategy that
portrayed citizens as part of the solution. This chapter argues that thisapproach is rooted in an emerging cooperative partnership between
state and society in Vietnam, and that these comprehensive governancestrategies have strengthened trust in the Communist Party of Vietnam,
bolstering its legitimacy. However, this approach has also led to questions
about the government’s lack of transparency during past crises. If the
public feels that the government is not protecting national interests against
others, particularly China, this will reduce the gains in legitimacy madeduring the COVID-19 pandemic.
Keywords: state-society relations, Vietnam, public health, COVID-19,
political legitimacy, symbolic nationalism

Introduction
Vietnam has been relatively successful in handling the COVID-19 crisis, witha low number of deaths (35 deaths until 7 March 2021) and a low number ofcases (2512 cases in a country of 97 million people [World Health Organization
2021, 1]). Regional experts and health officials have praised the Vietnamese
response to the COVID-19 pandemic as exemplary (Dabla-Norris, Gulde-Wolf,

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_ch11

198 Mirjam LE and Franzisk a NICOL AISEN

and Painchaud 2020). This chapter gives an overview of the underlying
factors producing this effective response: timeliness in implementation ofpolicies, experience with previous infectious diseases, transparency, andcommitment. It analyses the strategies which emerged from these factors,
with a focus on transparent communication, a broad social mobilization
based on national identity, and the central involvement of the Vietnameselabour movement. The relative success of these strategies provided legitimacy
for the Vietnamese state.
This chapter argues that the strategies employed by the government are
representative of an emerging cooperative partnership between state andsociety in Vietnam. This has allowed for the level of transparency and senseof accountability that have been essential for Vietnam’s communication andmobilization strategy during the pandemic. However, some of the contradictions inherent in these strategies might threaten the political leverage gained.

Health Governance in Vietnam and the COVID-19 Pandemic
Several factors have contributed to Vietnam’s success in combating thecoronavirus (Bui et al. 2020). The first factor leading to this success has been
the Vietnamese government’s timeliness in taking action. The Vietnamese
government often took action before the World Health Organization (WHO)issued related advice (Bui 2020). The virus was first detected in Vietnam on
23 January 2020 (Murray and Pham 2020). Then on 28 January the government developed an action plan based on a pandemic scenario (Bui 2020).
On 1 February, while case numbers were in the single digits, the government
cancelled all flights from China and stopped issuing tourist visas to citizens
of affected countries (Murray and Pham 2020). Vietnamese schools wereclosed and did not reopen after the Lunar New Year holiday but were ordered
to extend their holidays on a week-by-week basis (Murray and Pham 2020).
Vietnam completely closed its borders to foreign nationals on 22 March(Elegant 2020).
In July 2020 the virus emerged again in the city of Danang following 99
days without confirmed community transmission. After the detection of
two new cases, the authorities immediately imposed a lockdown in Danang,
implementing social distancing measures and preparing to evacuate 80,000
domestic tourists (Peer 2020). These tourists were ordered to quarantine
for fourteen days after returning home (Elegant 2020).
According to Murry and Pham (2020), the Vietnamese Communist Party
implemented this rapid response to COVID-19 because it understands theState-Societ y Rel ations as Cooperative Partnership

199

inner workings of policy- and decision-making in Beijing and distrusts
official Chinese communication. Because of this distrust, the Vietnamese
government sought its own information through informal channels tounderstand the situation in Wuhan (Thayer 2020; Stubbs and Satter 2020).
A second factor in Vietnam’s effective response to the COVID-19 pandemic has been its previous experience of handling infectious diseases,
including the SARS pandemic in 2003, as well as other infectious diseases
such as dengue fever (Bui 2020). Measures that were applied in 2020 had
already proven successful earlier (Bui 2020). Since the SARS pandemic in
2003, Vietnam has expanded its capacity to control emerging infectious
diseases (Le S.M. 2020). This meant that, when confronted with the COVID-19
pandemic at the start of 2020, the authorities immediately had effective
mass testing, contact tracing, and quarantine measures available (Duong,Le, and Bui 2000).
A third factor in Vietnam’s successful handling of the COVID-19 pandemic
has been the transparency of government actions. Close and effective
coordination and communication among different levels of government
ensured that information given out to the public was accurate throughout
the initial stages of the outbreak (Bui 2020). This affected public perceptionsof how serious the disease was. The way in which the government raised
awareness of COVID-19 early on was essential to ensure public complianceand mobilization (Bui et al. 2020, 2). Vietnam suffers from limited resources
and fragile health infrastructure. The healthcare system could therefore
have been overburdened if a high number of people had been infected.
This meant that, particularly during the early stages of the COVID-19 crisis,
there was an urgent need for the government to prioritize containment of
the virus.
Vietnam’s response has been described as aggressive and rooted inauthoritarianism (Bui 2020). Nevertheless, its success in minimizing community spread and infection numbers also shows that this level of commitment
has been effective in containing the pandemic (Duong, Le, and Bui 2000).
Policies have often been harsh in implementation. The government mobilized
the military and retired medical personnel to assist the implementationof its response strategy. The authorities issued strict quarantine measuresthat relied on military supervision. The Vietnamese leadership deemed
the use of the military as essential for ‘coordinating food, transport andaccommodation required to quarantine thousands of people’ (Bui 2020). The
government also mobilized all sectors of the economy to produce equipment
to help fight the virus. These measures have been justified as a means for
wiping out the virus entirely (Peer 2020).

200 Mirjam LE and Franzisk a NICOL AISEN

Strategies of Grassroots Mobilization in Vietnam
Communication Strategies
The Vietnamese government has proven creative and media savvy in communicating with the public. It framed the fight against the virus using the‘language of war’ (Bui 2020). In a clear reference to the 1968 Tet offensivethat took place during the war between Vietnam and the US (1955-1975),1
Prime Minister Nguyen Xuan Phuc called the fight against COVID-19 the‘Spring General Offensive of 2020’ (Murray and Pham 2020). This wartime
language was used with the aim of mobilizing all of Vietnam’s citizens as
active participants against COVID-19 (Truong 2020b).
Information has been communicated through an array of channels, including the use of social media platforms, as well as messages sent directly topeople’s mobile phones. Newspapers reported daily case numbers, COVID-19
deaths (or the absence of deaths until July), and the number of Vietnamese
repatriated from abroad (La et al. 2020, 12-14; Truong 2020b). When thevirus re-emerged in the city of Danang in late July, the state again used
the same methods of communication to prevent a public backlash against
the strict containment measures. The Vietnamese state presented itself as
a competent and caring actor that was promoting the common good. Thishas helped drive up support for the Vietnamese government’s message: thatthe people of Vietnam should feel national pride in the successful pandemic
response, and that success has been a result of cooperative efforts. A study
from 30 March 2020 showed that 62% of the survey respondents saw thegovernment’s response as adequate, which was the highest percentage in 45
countries assessed. Only 13% of respondents thought that the Vietnamese
government should do more and 12% thought that the government hadoverreacted (Dölitzsch 2020). International recognition of Vietnam, as amodel for low-income countries in how to handle the pandemic, has further
strengthened this message (Dabla-Norris, Gulde-Wolf, and Painchaud 2020).
The production of coronavirus messaging also involved the creative sector.
In late February, the National Institute of Occupational Safety and Healthfunded and released a music video by the singer Khac Hun on YouTube called‘Jealous Coronavirus’ (Ghen Cô Vy) that promoted basic preventive measures
1 We are aware that the term used in academic literature is ‘Vietnam War’. However, the useof this term reflects a US-centric narrative. This paper is written from a Vietnamese perspective,
and in the spirit of decolonising academia we decided to use the above description and willcontinue to use ‘Vietnam-US War’.

State-Societ y Rel ations as Cooperative Partnership

201(Saigoneer 2020). The video portrayed the coronavirus as a common enemy
against which the Vietnamese nation and every citizen should mobilize.
This video was very popular, including outside of Vietnam. It was spread by
global media outlets such as HBO and inspired a viral TikTok dance trendthat further engaged the public (La et al. 2020, 12-14; Last Week Tonightwith John Oliver 2020).
While this music video used cartoon animation, other imagery in the
public sphere primarily used a form of symbolic nationalism. The use ofhistoric imagery reminiscent of war propaganda on billboards nationwide
is a staple of political communication in Vietnam, reminding the public ofa shared history and identity (Humphrey 2020; Kirubakaran 2020; Nguyen
M. 2020).
Due to this direct, open, and clear messaging strategy from the state,
the pandemic has been successfully framed as a national emergency which
demands sacrifices and the participation of every citizen. This strategy has
stressed national unity and the role of each individual, and it has thus framed
every citizen as part of the crisis management. In this way the COVID-19
response has essentially been a campaign of national pride in accordancewith a longer tradition of the ‘war against imperialism’ that extends back to
the Vietnam-US War as well as the fight against French colonial rule (Truong
2020b; Hartley 2021, 159). War metaphors are a common rhetorical tool inpublic discourse. They relate to an emotional experience and an adversarial
threat which needs to be defeated as a common enemy. These metaphors areeasy to understand and can be very useful in mobilization. However, theymight create adversarial relations and reduce moral complexities (Flusberg
et al. 2018, 25). The war metaphors in the Vietnamese public discourse on
COVID-19 relate back to the Vietnam-US War, and the sacrifices demandedfrom Vietnamese citizens during that time. It establishes an emotional
continuity. The focus is on the need for sacrifices and behavioural changes
from everyone as well as the acceptance of state control to counter the
threat. This was successful in mobilizing large parts of the population tofollow rules and accept quarantine measures and limits to free movement.
However, it might also paint all those who are less willing to make sacrifices,
including those who are infected, as threatening the success. It might also
push a social narrative in which neighbours police each other.
Social Participation and Communication
The Vietnamese government portrayed every citizen as an integral partof the national solution to the COVID-19 pandemic. Its open manner of202 Mirjam LE and Franzisk a NICOL AISEN

communication has helped increase the willingness of the public to comply
with regulations, and there has been a high acceptance of measures such as
the quarantining of people and contact tracing (La et al. 2020, 18-20; Tran,
DiGregorio, and Nixon 2020). In addition, masks were already widely usedin urban spaces because of concerns about air quality (Onishi 2020; Duong
M.C. 2020). As a result, instructions to wear masks to help prevent the spreadof COVID-19 have met with little resistance (Le S.M. 2020). The government
published lists of locations with contact tracing dates, urging anyone who
visited these spots in the given timeframe to report to health officials, andsocial pressure reportedly also increased the willingness of the public to be
named as contacts by family members or friends (Bui 2020; Tran, DiGregorio,
and Nixon 2020). For example, in a much-reported case in May 2020, a man
was reprimanded by his aunt after illegally crossing the border from Cambodia
into Tay Ninh province to visit his family. Thereupon, he presented himself
to the nearest police station for quarantining (Le N. 2020).
The Vietnamese public’s solidarity in tackling the pandemic can also
be seen in several grassroots initiatives. In one widely publicized initiative, a Ho Chi Minh City entrepreneur set up rice ATMs to dispense rice to
low-income families. These ATMs found official support and can now befound nationwide (Duong and Yen 2020). This cooperation between stateand citizens for the public interest was central in official communication,
as it exemplified the official message of citizens contributing to the state’s
efforts (La et al. 2020). The enforcement of quarantine measures has also
been widely supported by the public. Social media, newspapers, photos, andpaintings, have presented positive narratives about quarantine experiences,
supporting the government’s strategy (Nhat Minh 2020; MacDonald 2020;
Ng 2020; Snell 2020; La et al. 2020, 12-14). For example, Gavin Wheeldon, aBritish citizen living in Vietnam, shared his positive experience of being
quarantined in a government facility on Facebook and wrote an online
article (Wheeldon 2020). His story was then picked up by the Vietnamesepress and he was interviewed for a documentary on national television (Talk
VietNam 2020). This episode showcases how the Vietnamese government
has actively presented a positive narrative regarding its response in its
communication to the public during the pandemic.
However, social pressure and uncertainties during the pandemic can also
have significant side-effects. In early March, a social media influencer anddaughter of a wealthy Vietnamese family in Hanoi returned from travelingin Europe and subsequently infected numerous people. The government
locked down her neighbourhood, shared private information, and invitedthe press to a live-stream meeting concerning the woman’s health. The

State-Societ y Rel ations as Cooperative Partnership

203

government used the case to make an example of her. After people figuredout her identity, she was harassed on social media, particularly on Instagram.
People circulated rumours about her being the cause of a new wave of
infections, as the first large outbreak in Vietnam in almost a month directly
followed her arrival (Max 2020). The government has leveraged this case toemphasize a moral responsibility towards the community, and those defying
this morality are perceived by the public in a negative light (La et al. 2020,
12-14). Referring back to the martial language used by the administration, theframing of the pandemic using wartime language thus turns the COVID-19
pandemic into an existential struggle, which can, in turn, heighten anxieties
and inspire self-righteous bullying and mobbing (Flusberg et al. 2018, 21-22).
However, public support went beyond observing preventive measuresand moral responsibility, as demonstrated by the public interest in the caseof a British pilot working for Vietnam Airlines. For months, national media
reported on his critical condition almost daily, as many feared he would be
the first COVID-19 death in Vietnam. Calls by the local administration forlung donors were answered with public support. The pilot’s recovery has
been one of the main focus points in the positive framing of the Vietnamesefight against COVID-19. The media attention given here shows the level ofcommunity solidarity and moral responsibility the government is trying toconvey to the public in its communication during the pandemic. To uphold
public morale the government aimed to maintain zero COVID-19 deaths atthat time (Vietnam Insider 2020).
However, this particular case also showcases a level of accountability
towards the international community (Barnes and Bui 2020). In this narrative, Vietnam takes up the role of saving a European national from death,as though they were a Vietnamese citizen (Truong 2020b). This successstory was, in turn, contrasted in the media with the relative failure of many
Western countries to effectively respond to the pandemic (Truong 2020b).
Set against these Western failings, the effective and level-minded responseat home is then emphasized as a point of national pride.
Labour Activism
Beyond this broad social mobilization, Vietnam was also the arena for narrower and more specific social activism advancing the pandemic response,
particularly in the field of labour rights and protections. Generally, theVietnam General Confederation of Labour (VGCL), Vietnam’s workers’
union, lobbies for national-level changes to improve working conditions.
Workers participate in self-organized struggles, so-called wildcat strike204 Mirjam LE and Franzisk a NICOL AISEN

actions,2 to deal with local issues of wages and working conditions. This
creates a dual structure that has frequently proven to be effective (Däubler
2018, 153). Local government officials often support local worker strikes andhelp negotiate solutions (Sui and Chan 2015; Kerkvliet 2011; Buckley 2020).
During the COVID-19 pandemic, labour activists have been demanding
accountability from the government and the corporate sector in accordancewith the idea of this cooperative partnership.
This well-established system has helped mitigate the economic and healthrisks for Vietnamese workers. The VGCL has followed an educative approach,disseminating information on prevention and distributing masks and handsanitizers. It has also used a policy approach to lobby the government tofind solutions to lessen the economic pressure on workers. At the time ofwriting, the global economy remained in a recession, and Vietnam’s GDP
growth was lower than previously predicted, making this kind of economic
support increasingly important (Buckley 2020).
Turning specifically to the issue of labour activism, workers held wildcat
strikes to demand personal protective equipment (PPE) and other measures
to prevent the spread of the virus in factories. Local union officials organized
information events with medical experts at companies. These actions byworkers have forced companies to implement at least some safety measuresat the local level (Buckley 2020). For example, in the case of the Pinetree
garment factory, workers stayed home at the end of January 2020 after two
employees fainted due to lack of oxygen. Although they turned out to nothave been infected with COVID-19, the workers in the factory demanded that
precautionary health measures be implemented in accordance with existing
regulations. The company agreed to provide free masks, temperature checks,
and disinfectant to over a thousand employees (LDO 2020b; Buckley 2020).
Wildcat strikes have also helped prevent companies from passing the
economic costs of COVID-19 onto their workers. Many companies, negatively
impacted by the economic downturn, have attempted to reduce their wage
burden by refusing to pay their workers or by putting them on furlough.
Strikes carried out with the support of local state officials have helped toensure that these companies continue to pay employees (Buckley 2020). For
example, the Seething shoe factory in Haiphong announced at the end of
May 2020 that it would not pay outstanding bonuses, overtime payments,
2 As Pham (2017) states: ‘a legal strike has to fulfil two criteria: firstly, it can only take place
after a procedure stipulated by the law which rules out rights-based strikes; and secondly, it has
to be led by a trade union. However, all strike incidents in Vietnam appear to be spontaneousand unorganized, and thus are illegal and referred to as wildcat strikes.’State-Societ y Rel ations as Cooperative Partnership

205

and social insurance contributions due to a lack of money. Consequently,
on 22 and 23 May 2020, a thousand workers went on strike. The company
then stated that they would pay the money in instalments but would also
put a number of workers on leave without pay. This led to more protests
on 25 May, leading to an intervention by authorities who declared that thecompany was breaking legal regulations and would have to continue paying
wages to its workers (LDO 2020a; Buckley 2020).
However, this was not a national standard. In other factories, workers still
lost their jobs, either temporarily or permanently. These newly unemployed are
now dependent on their social networks and on state assistance for financial
support (Buckley 2020). Despite the limits of labour activism, local workers andthe VGCL have played an important role in helping confront the pandemic at
different levels, both for local implementation and enforcement as well as forpolicy making (Buckley 2020). Once again, cooperative partnership strategies
have been adopted, this time by workers demanding accountability. In fact,by supporting these workers, local state institutions seem to have gained ahigher level of public support during the pandemic (Hartley 2021, 160-161).

State Legitimacy and Emerging Contradictions
The Vietnamese government has successfully embedded COVID-19 ina historical narrative that depicts the ‘f ight’ of the Vietnamese people
against external threats. This creates a sense of historic continuity andcan potentially provide further legitimacy for the current political system.
Legitimacy here can be understood as a ‘quality of a rule which derives froma perception on the part of those to whom it is addressed that it has comeinto being in accordance with right process’ (Franck 1988, 706). Legitimacy
leads to the acceptance of government rule as rightful, in this case based on
merit, and thus fosters public support. In the narrative about COVID-19 thatthe government has presented, Vietnam has not only successfully managed
the pandemic without outside help, but has painted itself as exemplary,offering help to others. Its effective and prudent response has been madeinto a focal point for national pride. At the same time, the COVID-19 response
has revealed a number of internal contradictions.
Nationalism
The Vietnamese government’s narrative has focused on COVID-19 enteringfrom abroad. Due to the complicated historic relations with China (Strangio

206 Mirjam LE and Franzisk a NICOL AISEN

2020b, 64-84), the Vietnamese public has been particularly critical of the government’s response towards China and Chinese nationals. Border-crossings
were seen in public discourse as responsible for COVID-19 re-entering Vietnam several times, which led to public outrage (La et al. 2020, 12-14; Bohane2020). In February, factory workers based near the border with China felt that
Chinese nationals returning from their hometowns after the Chinese New
Year celebrations were not quarantining and being tested properly. Workers
went on strike to protest this perceived lack of enforcement of COVID-19
regulations by local officials (Buckley 2020). When the number of infections
rose sharply in late July, the public was once again quick to blame China.
Some official sources echoed the public in blaming Chinese migrants for therising infections, while other sources did not (Elegant 2020). However, if theVietnamese public feels that the government is not effectively protecting
Vietnamese interests against China, this will reduce the gains in legitimacythat the Vietnamese government has made during the COVID-19 pandemic.
Participation and Transparency
The government’s handling of the COVID-19 pandemic has increased public
cooperation by including citizens in its efforts. However, public space tochallenge the state has not increased, and it has maintained an iron gripon public discourse. In recent years, the Vietnamese government has beenusing repressive means to stabilize the country (Kerkvliet 2014). During
the pandemic, this crackdown on dissidents has continued (HRW 2020;
Strangio 2020a). There was a particularly intensive crackdown as the party
prepared for the 13th National Congress of the Communist Party of Vietnam
in January 2021 (The Straits Times 2021).
Vietnam’s perceived success in containing the virus has proven thecapacity and competency of the Party to effectively address public healthcrises. However, it also produces questions about the government’s lackof transparency during past crises (Truong 2020a). Therefore, how thegovernment deals with political dissent raises questions about its long-term
commitment to more open and transparent state communication, whichmight eventually undermine state legitimacy.
Economic Question Marks
While the Vietnamese government has so far been able to contain the
COVID-19 pandemic, its economic recovery is being affected by the situation
among its main trading partners such as the United States, Japan, and China

State-Societ y Rel ations as Cooperative Partnership207(World Bank 2020, 23). A major recession has so far been prevented, and at theend of 2020 the government still maintained that Vietnam’s GDP had grownby 2.91% that year (Nguyen P. 2020). The State Bank of Vietnam expecteda full recovery of the economy in 2021, and it predicted a GDP growth of
6.5% (Anh Phuong 2020). However, unemployment and underemployment
remain severe problems (Nguyen et al. 2020). By September 2020, 31.8 million people, or more than a third of the Vietnamese population, had been
negatively affected by the pandemic (GSO 2020). In order to support its
citizens, the Vietnamese government announced a US$2.6 billion support
package (Buckley 2020). At the time of writing, it still remained to be seen
how this support package would be used.
Economic success and growing prosperity are important pillars of theVietnamese government’s merit-based legitimacy. A long-term economic
downturn might have political repercussions for the party-state. If Vietnam
experiences economic uncertainties in the wake of the health crisis, thismight undo the gains in political legitimacy the government has achieved
as a result of its effective response to COVID-19.

Conclusion
After managing the first year of COVID-19 in the country, Vietnam now
faces an uncertain future.3 Domestically, the general consensus is that the
low number of cases and fast return to normal everyday life have vindicatedVietnam’s strategy. This chapter has argued that transparent communicationand social mobilization have been the cornerstones of this successful strategy.
The Vietnamese response to the pandemic has been based on a cooperative
partnership formed between the state and its citizens (Le and Nicolaisen 2021).
Globally, Vietnam’s strict national response has frequently been seen
to be rooted in authoritarianism. However, the cooperative relationshipbetween the government and the public has allowed the level of transparency
necessary for Vietnam to communicate effectively during the pandemic
while still creating a sense of accountability and responsiveness (Koh 2006).
In the everyday political reality of Vietnam, these processes often produce
localized conflicts (Le and Nicolaisen 2021). Nevertheless, during the recent
COVID-19 pandemic, the Vietnamese state and society have been able to
3 Following April 2021, Vietnam faced another local outbreak with cases in 39 provinces. By
9 June 2021 this outbreak was responsible for 6.328 cases and 20 deaths. Vietnam is also lagging
in its vaccination efforts.

208 Mirjam LE and Franzisk a NICOL AISEN

transcend these conflicts by emphasizing a shared Vietnamese struggle,
identity, and shared responsibility – all themes that the government utilized
in its communication to induce cooperation among citizens.
Once the pandemic ends, a sudden reversal in the transparency of thiscommunication might lead to a loss of the legitimacy built during the pandemic. Economic uncertainties in the coming months might also threaten
the gains made in political legitimacy. Additionally, the party-state will needto balance its relations with China with its nationalist narrative. Therefore,
to keep the positive momentum going, the Vietnamese government needs
to reduce the risk of another local outbreak, find ways to assist citizens
suffering economically, and balance the public demand for transparency
and national strength with its desire for self-preservation.

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19 October. Accessed 10 February 2021. https://thediplomat.com/2020/10/
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Nguyen, Phuong. 2020. ‘Vietnam’s 2020 Economic Growth Slips to 30-year Low
Due to COVID-19.’ Reuters, 27 December. Accessed 10 February 2021. https://uk.reuters.com/article/us-vietnam-economy-gdp/vietnams-2020-economicgrowth-slips-to-30-year-low-due-to-covid-19-idUSKBN29107M.
Nguyen, Trang (Mae), and Edmund Malesky. 2020. ‘Reopening Vietnam: How theCountry’s Improving Governance Helped it Weather the COVID-19 Pandemic.’
Brookings, 20 May. Accessed 10 February 2021. https://www.brookings.edu/blog/
order-from-chaos/2020/05/20/reopening-vietnam-how-the-countrys-improvinggovernance-helped-it-weather-the-covid-19-pandemic/.
Nhat, Minh. 2020. ‘Paintings about Life in Quarantine Area Inspire Vietnamese
People.’ Hà Nội Times, 19 April. Accessed 10 February 2021. http://hanoitimes.vn/
paintings-about-life-in-quarantine-area-inspire-vietnamese-people-311802.html.
Onishi, Tomoya. 2020. ‘Pollution Masks Help Vietnam Ward Off Coronavirus.’ Nikkei
Asia, 9 October. Accessed 10 February 2021. https://asia.nikkei.com/Spotlight/
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Peer, Mathias. 2020. ‘Auslöschen statt Abf lachen.’ Die Zeit, 7 August. Accessed 10 February 2021. https://www.zeit.de/politik/ausland/2020-08/
coronavirus-vietnam-zweite-welle-lockdown.

212 Mirjam LE and Franzisk a NICOL AISEN

Pham, Thi Thu Lan. 2017. ‘Why Always Wildcat Strikes in Vietnam?’ Global Labour
Column, University of the Witwatersrand, Johannesburg, no. 290, October.
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State-Societ y Rel ations as Cooperative Partnership

213—. 2020b. ‘Vietnam’s Communist Party Finds a Silver Lining in COVID-19.’ The Diplomat, 28 March. Accessed 10 February 2021. https://thediplomat.com/2020/03/
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About the Authors
Mirjam LE works in the field of Southeast Asian Studies at the University of
Passau, Germany. Her PhD thesis focuses on small town urbanization andthe production of urban space in Vietnam. Her research interests involveurbanization and state-society relations in Vietnam, especially processesof self-organization and citizenship.
Franziska Susana NICOLAISEN works as a freelance consultant for political foundations on topics of urbanization and education in Vietnam andSoutheast Asia. Her Master thesis at the University of Passau, Germany,is on sustainable urban mobility in Vietnam. Her research interests are
citizenship, social movements, and urbanization in Vietnam.

PART IV
The Global Economy and Transnational MigrantLabour in Asia during COVID-19

12

The Coronavirus as the ‘Final Straw’ of
the CCP’s Performative Legitimacy?
A New Economic Model in the Post-COVID-19 Era
Catherine Yuk-ping LO

Abstract
While COVID-19 is still raging worldwide, the Chinese Premier Li Keqiang
confidently stated that China had pulled out of the pandemic faster andin better shape than much of the world because of the ‘hard work andsacrifice of [the] entire nation’. However, this ‘hard work and sacrifice’ incurbing the spread of COVID-19 came at a price. The global COVID-19 crisis
has further worsened the Chinese Communist Party (CCP)’s ‘shrinking’performative legitimacy because it has led to a slowdown of economic
growth. Considering the ongoing Sino-US trade disputes and the risingsuspicion of China and Chinese firms in western economies, the chapter
examines to what extent the CCP can save its performative legitimacy
through the new economic strategy dubbed the ‘dual circulation strategy’.
Keywords: dual circulation strategy, non-pharmaceutical interventions,
Wuhan lockdown, performative legitimacy

Introduction
We live in unprecedented times. COVID-19 has become a pandemic thatis having tremendous impacts on societies around the world. After theextent of the pandemic emerged, pharmaceutical companies began topour considerable efforts into finding a COVID-19 vaccine. While several
promising vaccines have been launched since early 2021, before vaccinating the majority of the population, countries have employed an array of

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_ch12

218 Catherine Yuk-ping LO

non-pharmaceutical interventions (NPIs) in attempts to flatten the infection
curves. These include school and workplace closures, bans on public events,
restrictions on mass gatherings, stay-at-home requirements, and internal
movement limits.
China is no exception. Three weeks after the first officially reported
cases in China, the Chinese authorities ordered a lockdown of Wuhan
and its neighbouring cities for a total of 76 days. Travel in and out, for any
reason, was prohibited. Authorities stopped public transport and banned
most private cars. The authorities suspended free movement and started
enforcing mandatory quarantine (BBC News 2021a). While it was a priority
to contain COVID-19 as efficiently and quickly as possible, the NPIs China
used are likely to have both short and long-term economic repercussions
on the Chinese economy. This chapter will first discuss these impacts. After
this, it will discuss the extent to which the Chinese Communist Party (CCP)
can sustain its performative legitimacy by adopting a new economic model,
which has been called a ‘dual circulation economy’. It will also discuss theimplications of Chinese economic development in the post-COVID-19 era.
In this discussion, the chapter will consider the ongoing Sino-US politicaldisputes and the rising suspicion of China and Chinese firms in Western
economies.

Shaking Performative Legitimacy: Economic Impacts of
COVID-19 NPI Measures
The legitimacy of a state can be defined as ‘the belief that in spite of shortcomings and failures, the political institutions are better than others thatmight be established and [that these institutions] therefore can demandobedience’ (Yang and Zhou 2015, 70). Weber (1978, 28) proposed threeideal-typical aspects of legitimacy as the basis of state power: First, a state
enjoys traditional legitimacy when the people see its power as inheritedor always existent. Second, a state has charismatic legitimacy when thestate’s leader or leaders are perceived as having exceptional quality as aresult of their experiences or personal attributes. Finally, a state possesses
legal legitimacy when the state’s power is derived from a set of judicial andadministrative principles that bind all members of society. Based on theWeberian classification, Yang and Zhou (2015, 70) developed three pillars oflegitimacy with which state power can be justified, including legal-electoral,
ideological, and performance legitimacy. A state’s justification of its poweris based on legal-electoral legitimacy when top leaders are elected by the

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219

public. Meanwhile, ideological legitimacy means that a state’s right to rule
is justified by a specific value system. Finally, performance legitimacy
implies that a state’s right to rule is justified by its economic and/or moral
performance (Yang and Zhou 2015, 70).
In the case of the CCP, the Party lacks legal-electoral legitimacy because it
is not democratically elected by the public, based on liberal understandingsof democracy and democratic election (Yang and Zhou 2015, 70).1 The role ofcommunism in giving ideological legitimacy to the CCP has been viewed to be
declining, because the party has implemented capitalist Open Door economic
policies since the 1980s (Yang and Zhou 2015, 73).2 The CCP’s ideologicallegitimacy was further destabilized in the aftermath of the crackdown of
the democratic movement during the 1989 Tiananmen Incident (Zheng
2008, 788).3 Therefore, in the absence of political legitimacy and with fading
ideological legitimacy, performative legitimacy serves as the main pillar thatjustifies the rule of the CCP (See Zhao 2017). However, the performative pillar
has been weakened since 2012 because the Chinese economy has reached thelimits of its quantitative growth, which had been driven by investment andexports over the past thirty years. China’s real GDP growth rate was on average
more than 10% for the period 1981 through 2010, but it dropped to 7.86% in2012 and to 6.11% in 2019 (The World Bank 2019). The Chinese authorities
refer to this gradually declining trend as the ‘new normal’. This concept
was first used by Chinese President Xi Jinping to describe China’s economic
development to an international audience when he delivered a keynote
speech at the opening ceremony of the Asia-Pacific Economic Cooperation
1 In a democratic country: (a) there is political pluralism; citizens are permitted to participate
in the political system, (b) legitimacy is obtained via a fair and free election, (c) the human rightsof the citizens are protected, and (d) the state is founded on the principle of the Rule of Law.
That is, the law applies equally to all citizens, including the president and those who make andenforce the law. Therefore, China lacks legal-electoral legitimacy, a point also argued by Yang
and Zhou (2015).
2 There was a shift from ideological to performative legitimacy during the 1980s. The open-door
policy attracted a large number of overseas Chinese from Taiwan, Hong Kong and other parts of
the world. These people not only brought into China new ways of life and ideas, but shocked theirmainland relatives by their affluence. The old state propaganda on the superiority of socialism overcapitalism, that many Chinese people had believed in, was invalidated (See Yang and Zhou 2015).
3 After the crackdown on demonstrations in Tiananmen Square in 1989, the Chinese government knew that continuous economic reform was key to remaining in power. Facing resistancefrom the leftists in the Party, Deng started his southern China tour in 1992, calling for moreradical economic reforms. Deng’s southern China tour was decisive. After the tour, top Chinese
leaders all stepped out to show support, leftist propaganda disappeared from mainstream
media, and the state seemed to have quietly abandoned communist ideology as the basis ofstate legitimacy (See Yang and Zhou 2015).

220 Catherine Yuk-ping LO(APEC) CEO summit in November 2014 (Xinhua 2014). Apart from slowing
economic growth, the continuous rise in the debt-to-GDP ratio in China has
further jeopardized the CCP’s performative legitimacy. As of 2009, China’s
total corporate, household, and government debts amounted to 189% of its
GDP (China Power Team 2017). The debts reached 303% of GDP in the firstquarter of 2019 (Reuters 2019). Although a debt-to-GDP ratio exceeding 100%
is not unusual, China’s credit expansion over the past decade has been solarge and rapid that this could threaten the long-term stability of the CCP’s
performative legitimacy. The three pillars of legitimacy developed by Yang
and Zhou (2015, 71) suggest that a one-party government could collapse if theperformative pillar is no longer sustainable. As a result, some commentators
have speculated that a big crisis, like COVID-19, could be the ‘ultimate’ causeof the collapse of the one-party system in China (Zhou 2020).
The CCP, however, has attempted to boost its legitimacy in the way it contained the COVID-19 outbreak. On 20 January, President Xi gave ‘important
directions’ for responding to the coronavirus (Xinhua 2020). This was the firstpublic speech that Xi made after the first cases were reported in China in
December 2019 (Wang et al. 2020). In Chinese bureaucratic politics, officers
tend to care about self-preservation. Local officials fear to take actions thatwould anger their superiors; they would rather wait for their superiors tomake decisions and are only accountable to their superiors instead of to thepeople (Li 2020). As such, when the top leader openly admits to an outbreak,
all related departments and officials understand that they are granted thepermission to react to the outbreak. Following the speech given by Xi, two
State Council special meetings were held, the first on 20 January and thesecond between 23 and 24 January. On 26 January, the Chinese authorities
established a policymaking and coordination body in the State Council,
chaired by Premier Li Keqiang and named the Central Leading Small Groupfor Work to Counter the New Coronavirus Infection Pneumonia Epidemic,
also known as the Coronavirus Leading Small Group (China Daily 2020).
This proactive approach from the Chinese authorities resulted in a seriesof non-pharmaceutical interventions (NPIs) that some commentators havedescribed as being ‘draconian’ (Gunia 2020). One well-known measure that
the Chinese government implemented on 23 January was the lockdown of
Wuhan and two neighbouring cities. The restriction banned travel in and outof the three cities for any reason. Authorities suspended public transport andbanned most private cars. They eventually began house-to-house inspections
and enforced quarantine (BBC News 2021a). In terms of the number of people
being quarantined (which was around twenty million in three cities), thescale of lockdown was unprecedented in human history.

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221

Other cities in China were also placed under semi-lockdown. For
instance, many residential districts and housing estates put in place asystem of ‘enclosed management’. Under this system, non-residents were
not allowed to enter residential districts. One person in each household
was permitted to go out for grocery shopping every two to f ive days.
This person had to wear a surgical mask and present their identity card
upon entering and leaving. They were given a temperature check at thegate (Gunia 2020). The government has also used a system to monitor
the health status of individuals through digital barcodes on an app (theAlipay Health Code) that is installed on people’s smartphones (Burgers
and Sicinski 2020, 15).
To deal with the outbreak, the Chinese government also built two new
hospitals in Wuhan, with construction of these taking only ten days. These
hospitals can admit and treat around 2000 patients (Williams 2020). Anothersixteen makeshift hospitals were later set up in Wuhan to admit patientswith mild symptoms. In 2003, during the Severe Acute Respiratory Syndrome(SARS) outbreak, the Chinese government had similarly built a hospitalon the outskirts of Beijing, with construction taking seven days in total(BBC News 2020). This previous experience with the rapid construction of
emergency hospital facilities may have helped the Chinese government in
its response to the new COVID-19 pandemic seventeen years later.
China was the first country to implement large-scale lockdown measuresand also the first country to ease COVID-19 restrictions. At the opening of
the National People’s Congress (NPC) on 22 May, Premier Li confidently
stated that China had pulled out of the pandemic crisis faster and in better
shape than much of the world because of the ‘hard work and sacrifice of
our entire nation’ (Li 2020).
However, this claimed ‘hard work and sacrifice’ of the ‘entire nation’ incurbing the global spread of COVID-19, came at a price. Global supply chains
have been disrupted due to complete and partial lockdowns in various
industrial provinces of China. One prominent example of such disruption
has been the way in which COVID-19 has affected the China-based production of Apple’s iPhone. In February 2020, Apple warned of global ‘iPhone
supply shortages’ as a result of its Chinese factories being shut because of
the coronavirus outbreak. The Californian company told investors that it
would fail to meet its quarterly revenue target of US$63-67 billion becauseof both a ‘temporarily constrained’ supply of iPhones, as well as a dramatic
drop in Chinese shoppers during the health crisis (Neate 2020).
In February 2020, the manufacturing purchasing managers’ index (PMI)
registered 35.7%, which was the lowest it had ever been, indicating a serious

222 Catherine Yuk-ping LO

contraction of manufacturing activity. 4 However, the figure released inAugust 2020 showed that the index rebounded to its baseline of 50% (National Bureau of Statistics of China 2020). A private manufacturing survey
in China, the Caixin Manufacturing Purchasing Managers’ Index (PMI),
also indicated that manufacturing activity expanded in September withan index figure of 53% (Trading Economics 2020). Furthermore, China’s
economy has seen a strong rebound since July 2020, from a contraction of
6.8% in the first quarter of 2020 to a positive growth of 6.5% in the fourth
quarter of the same year (BBC News 2021b). Overall, China’s economy grew
2.3% in 2020, making it the only major economy that had a positive GDP
expansion during that year (BBC News 2021b). Nevertheless, despite these
positive figures, the prospects for economic development in China remain
uncertain. China’s key trading partners, including South Korea, Japan,
Europe, and the US, are still struggling with the impact of coronavirus. That
the Chinese government did not set a target for economic growth during
the 2020 National Congress might imply that the authorities are being
cautious about COVID-19’s impact on other economies and the possibility
that COVID-19 could resurge in China.

US-China Economic Decoupling amid the Sino-US Cold War
Before the COVID-19 outbreak, the CCP’s performative legitimacy had
already been challenged as a result of changes in the long-standing US
policy of engagement with China. The radical turn to a more critical US
posture towards China was first seen in the speech delivered by former Vice
President Mike Pence at the Hudson Institute in October 2018 (White House
2018). Another speech delivered by Pence in 2019 then further outlined theend of US engagement with China:
As history will surely note, in less than three years, President Donald
Trump has changed that narrative forever. No longer will America and its
leaders hope that economic engagement alone will transform Communist
China’s authoritarian state into a free and open society that respects
private property, the rule of law, and international rules of commerce(White House 2019).
4 PMI is a critical indicator of China’s manufacturing activity. An index value above 50%
indicates a positive development in the industrial sector, whereas a value below 50% indicatesa negative situation.

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The speeches by Pence have been materialized in a ‘trade war’ between China
and the US. The US delivered three rounds of tariffs on Chinese goods in
2018, then a fourth round in September 2019. Together, these mean that the
US has imposed tariffs on more than US$360 billion of Chinese goods (Yong2019). Meanwhile, in response to the US tariffs, China has imposed tariffs on
more than US$110 billion of US products (Yong 2019). Negotiations between
the two sides resulted in the ‘phase one’ deal signed on 15 January 2020.
China agreed to increase purchases of American products and services
by at least US$200 billion (The Straits Times 2020). The deal also includes
stronger Chinese legal protections for intellectual property rights, and tosome extent China also made concessions to financial services by agreeing
to speed up the offering of business licenses.
While the Sino-US trade war is still ongoing, the current pandemic has
accelerated the decoupling of the Chinese and American economies (Rachman 2020). The naming and origin of the new coronavirus is one sourceof diplomatic tensions between the two countries. The virus was called‘Wuhan Pneumonia’ (Wuhan feiyan) by the Chinese authorities when thefirst cases were reported in Wuhan. Later, the central authorities replaced
the name ‘Wuhan Pneumonia’ with ‘New Coronavirus’ (xin guangzhuang
bingdu) so that people in other parts of the world would not connect the virus
with China. To divert the anger of domestic and international audiences
regarding the initial slow response to the outbreak, in mid-March 2020,
Chinese Foreign Ministry spokesperson Zhao Lijian promoted the theory
that the virus had originated in the US and was brought to Wuhan by a US
delegate who attended the Military World Games (Westcott and Jiang 2020).
Responding to the Chinese accusations about the spread of the ‘Americancoronavirus’ to Wuhan, President Trump engaged in a war of words byframing the disease as the ‘Chinese virus’.
In May 2020, Trump also announced the termination of the US’s relationship with the WHO. This can be seen as another move by the US toshow dissatisfaction with the ostensibly growing Chinese influence in theinternational organization. Trump alleged that, by covering up the COVID-19
outbreak, the Chinese government had caused the loss of more than 100,000
lives in the US and over one million lives worldwide. He also alleged that the
WHO has been effectively controlled by Beijing. Based on the survey conducted by the Pew Research Centre in 2020, around two-thirds of Americans(64%) say ‘China has done a bad job dealing with the coronavirus outbreak’.
Around three-quarters (78%) ‘place a great deal or fair amount of the blame
for the global spread of the coronavirus on the Chinese government’s initialhandling of the COVID-19 outbreak in Wuhan’ (Silver et al. 2020).

224 Catherine Yuk-ping LO

The political rift between the US and China has deepened during the
COVID-19 pandemic, resulting in further economic decoupling between
Beijing and Washington. During 2020, the Chinese smartphone apps TikTok
and WeChat were singled out for attention by the Trump administration. In
mid-September 2020, the US Department of Commerce said that it would
ban both TikTok and WeChat from app stores and would bar the apps
from accessing critical Internet services in the US (Arbel et al. 2020). A US
federal judge later issued a temporary injunction blocking the WeChat ban.
However, TikTok faced having to shut down operations unless its Chinese
owner ByteDance could sell TikTok’s US operations to a domestic company
to satisfy US national security concerns (Arbel et al. 2020). The dispute was
supposed to be settled when Trump approved a deal in which Oracle andWalmart partnered with TikTok to form a new, US-controlled company, but
the final deal has been pushed back indefinitely by the Biden administration(Feiner 2021). That said, with the US Senate Foreign Relations Committee
passing the Strategic Competition Act in April 2021, it is speculated more
US decoupling actions might continue under the Biden administration(Hsu 2021).

Chinese Responses to the US Economic Decoupling: Dual
Circulation Strategy
To sustain its performative legitimacy, the CCP has implemented consistenteconomic reforms during the past four decades. One of these has been the‘supply-side structural reform’ (SSSR) policy implemented in 2015. This
has attempted to reduce overproduction in selected products such as coal,iron, and steel. Another such policy is the ‘Made in China 2025’ plan announced in 2018. This plan intended to shift China from being an ‘export
and investment-led’ economy to a ‘demand and innovation-driven’ economy
by using government subsidies, mobilizing state-owned enterprises, andpursuing intellectual property acquisition to catch up with – and thensurpass – Western technological prowess in advanced industries.
In response to the US’s recent economic decoupling, in October 2020
China unveiled its own decoupling strategy, named the ‘dual circulation
strategy’ (DCS). In this strategy, ‘circulation’ refers to the production andconsumption of goods and services. The first or international circulationin the ‘dual’ formulation concerns maintaining integration with the rest of
the world. The second or internal circulation focuses on increased relianceon domestic demand and reducing economic dependence on the rest of theThe Coronavirus as the ‘Final Straw’ of the CCP’s Performative Legitimacy?

225

world (Garcia-Herrero 2020). President Xi is demanding that China both
continues its commitment to global integration and exports, or international
circulation, and also emphasizes domestic production for home consumption, or internal circulation (Pettis 2020). The ‘dual’ formulation has becomea key priority in the Chinese government’s 14th five-year plan (2021-2025),
replacing the supply-side structural reform (SSSR) and ‘Made in China 2025’
designated in the previous five-year period (Huang 2021).
The concept of ‘internal circulation’ remains contested. Some analysts
believe that it is an attempt to present old wine in a new bottle. A similar
concept was proposed in 2011 by the then-premier Wen Jiabao in the country’s
12th Five-Year Plan, claiming that the Chinese government would prioritize
domestic consumption-led growth over export-led growth (China’s National People’s Congress 2011). Pettis (2020) argues that internal circulation
conflicts with international circulation. Boosting domestic consumption
requires policies that would increase wages and benefits for workers. This
would weaken international circulation, which requires low labour costs tomaintain export competitiveness. Blanchette and Polk (2020) state that thedual circulation strategy will be inward-looking and that if the authorities
focus on internal circulation, China will close its door to the outside world.
Young (2020) suggests that China will retreat into the kind of ‘self-reliance’
developmental policy begun by Mao Zedong during the Chinese Civil War(i.e., ‘regeneration through one’s own efforts,’ or zili gengsheng).
Given that the dual circulation strategy is the Chinese response to the US
decoupling, internal circulation entails greater technological self-reliance.
The vulnerability of Chinese companies to bans on sales of US computer
chips has intensified China’s drive to become self-sufficient in criticaltechnologies. In light of the US sanctions, Huawei announced that a chip
plant would be set up in Shanghai to secure supplies of semiconductors for
its core telecom infrastructure business (Hille et al. 2020). Xi has likewise
stepped up calls for China to achieve ‘self-sufficiency’ for crucial components.
During a meeting of the CCP’s Central Committee, Xi declared that China
would make enhanced technological self-reliance a priority over the next
fifteen years and would make it ‘a strategic pillar of national development’(Buckley and Myers 2020). From a technological development point of view,
China may benefit from the current situation because this could moveit to shake off its over-dependence on US chips. That said, the success ofinternational circulation depends on the openness of the existing liberal
world order established by the US. If the US decides to further decouple
from China, its allies might follow suit with similar policies. Recently, forexample, Australia has decided to diversify its export markets and supply

226 Catherine Yuk-ping LO

chains away from China. Some European countries have similarly begun toreconsider trade and investment ties with China (Johnson and Gramer 2020).
Again, the dual circulation strategy cannot be successful in the absence ofinternational circulation.

Concluding Remarks
In 2019, the CCP celebrated the 70th anniversary of the founding of New China
in 1949. Historically, one-party governments have rarely survived longer than
70 years. I would argue that because of a lack of ideological and politicalelectoral legitimacy, especially in recent years, economic performance has
been the key pillar legitimatizing the CCP’s rule. The slowdown of economic
growth since 2015 and the possible financial repercussions of the Sino-US
Trade War since 2018 have threatened to impact the Party’s legitimacy.
The COVID-19 crisis and the related NPIs that were implemented in China
further risk eroding the CCP’s performative legitimacy. Therefore, the CCP
recently put forth the dual circulation strategy as a new economic model
to respond to the US economic decoupling from China. While the internal
circulation contributes to the advancement of Chinese technology andinnovation, continuous US decoupling could have a detrimental effect on
the success of this strategy.
Acknowledgement
I want to thank Yow Shuning for helping me with the data collection. Anyerrors remain my own.

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About the Author
Catherine Yuk-ping LO is an Assistant Professor at University College Maastricht, Maastricht University. She specializes in international relations andglobal health. Her current research interests include HIV/AIDS in China
and India, infectious disease responses in Northeast and Southeast Asianstates, antimicrobial resistance (AMR) challenges in the Global South andNorth, and also global health diplomacy. She is the author of HIV/AIDS in
China and India: Governing Health Security (Palgrave Macmillan, 2015). Herbook won the 2017 International Studies Association (ISA) Global Health
Section Book Prize. Her works appear in such journals as the Australian
Journal of International Affairs, Health and Policy Planning, Globalizationand Health, and the Journal of Global Security Studies.

13

Health Governance during the
COVID-19 Pandemic
Reflections on Taiwan’s Guest Worker Policy
Mei-Chun LIU

Abstract
Taiwan’s government was quick to act against COVID-19 with a quarantine decree, mask mandates, detailed tracking of confirmed cases,
and the nearly 100% coverage rate of universal health insurance. Thisapproach proved successful during 2020. However, at the same time,
Taiwan’s ‘guest worker policy’ deprives migrant workers of the right topermanent residency/citizenship, freedom of employment, social security
benefits, and residency arrangements. They lack access to health careand f inancial support, and they have faced wage cuts and dismissals
during the COVID-19 pandemic, making them a vulnerable minority. This
chapter argues that Taiwan needs to reconsider its ‘divide and exclude’
guest worker policy, not only for the sake of migrant workers themselves
but also to safeguard public health.
Keywords: health governance, guest worker policy, Taiwan (Republic ofChina), health insurance, migrant labour, COVID-19

Introduction
The COVID-19 pandemic has brought the momentum of globalization toa near halt, causing unmeasurable ramifications in terms of economics,
human rights, and social inequality. Taiwan’s government was quick to act
in tackling this unprecedented global health crisis. During the first year

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_ch13

232 Mei- Chun LIUof the pandemic, its strategy proved successful, with only nine deaths and909 confirmed cases before 30 January 2021.
The low infection rate achieved in Taiwan during this period can be
attributed to various causes, such as widespread mask-wearing and an
effective quarantine decree. The early success handling COVID-19 is also
partly due to Taiwan’s universal health insurance that covers everyone,
including blue-collar migrant workers. In contrast to the benefits broughtby this universal healthcare system, however, Taiwan also has a ‘guest
worker policy’ that deprives migrant workers of the rights to permanent
residency/citizenship, freedom of employment, and social security benefits,
making them vulnerable during crises. This chapter both examines the
successes Taiwan had dealing with COVID-19 during the first year of thepandemic and also looks at the ways that the pandemic has exposed thevulnerabilities of migrants in Taiwan. COVID-19 has revealed that migrants
face disadvantages in access to health care and financial support, as seen
in wage cuts and dismissals. The chapter argues that it is therefore time toreconsider the ‘divide and exclude’ nature of Taiwan’s guest worker policy.

Globalization and its Challenge to Public HealthWith proponents of globalization optimistically proclaiming the ‘endof history’ (Fukuyama 1992) and the benefits of a ‘flat earth’ (Friedman
2005), globalization seemed to herald a promising new world. However, as
the so-called ‘globalization’ of the world has progressed, these prophesies
have been turning into a bleaker picture. This is especially the case forthose who have been denied a share in the new prosperity globalization
has brought, something which is exacerbated by rising inequality among
the northern and the southern hemispheres (Chomsky 2006, 2012; Stiglitz
2002, 2015). On the one hand, globalization has enhanced the free flow ofpeople and capital, boosting the global economy. On the other hand, it has
increasingly jeopardized state sovereignty, leaving nation-states subject
to the consequences of heightened interconnectivity. This is somethingthat has been made clear by the world’s vulnerability to global pandemics.
Under conditions of increasing globalization, conflicts and turmoil havebecome more pronounced since the start of the new millennium with different
regions hit by refugee crises and a series of new infectious diseases. Five newviruses have led to extensive human casualties over the past decade, namely
H1N1 (2009), Polio (2014), Ebola in West Africa (2014), and Zika (2016) and Ebola
in the Democratic Republic of Congo (2019). Each of these viruses was declared

Health Governance during the COVID -19 Pandemic

233

a Public Health Emergency of International Concern (PHEIC) by the World
Health Organization (WHO). The devastating effect of virulent viruses has
made global health governance an urgent issue on the international agenda
in recent years, with calls for making it a joint global endeavour (Kickbusch
2016; Friedman and Lawrence 2017; Gostin, Moon, and Meier, 2020).
The COVID-19 pandemic, an unprecedented global crisis, has brought
to the fore a pressing concern for the protection of fundamental humanrights. In different countries, human rights have been jeopardized during
the pandemic by the restriction of people’s movement for health reasons,as well as a shortage of health care provisions. COVID-19 has devastatedeconomies, livelihoods, and the way people interact with each other, meaning that concerted public health actions, both globally and locally, are now
imperative.

Migration and its Challenge to Global Health Governance
The international community has been overwhelmed by the virulence
and mutating adaptability of the COVID-19 virus, posing a real challenge
to delivering effective, as well as coordinated, measures to ensure healthsafety for all. In one attempt to do so, the WHO launched the COVID-19
Solidarity Response Fund in partnership with the UN Foundation. This
Fund is intended to collect donations and financially support public healthinitiatives seeking to contain the pandemic across the globe (WHO 2020).
However, one question about the Fund, is whether it will recognize theplight of migrant workers in different countries. These migrant workers havebeen particularly hard-hit by the COVID-19 pandemic, often suffering mass
lay-offs or wage cuts and thus facing hardships due to the global economic
slow-down as well as lack of health protection.
The fact that migration is a significant public health issue and has pervasive global health implications has not yet received enough attention.
Studies have shown that the abusive and exploitative treatment that many
migrants encounter has led to a wide range of public health issues (Ottisova
et al. 2016). COVID-19 has offered a watershed moment, prompting societies
to re-examine the public health institutions and policy loopholes that haveleft those most marginalized even more destitute during the pandemic,
especially with regard to access to health resources and information.
Amongst the Sustainable Development Goals of the UN, there is thegoal of ensuring ‘healthy lives’ and promoting ‘well-being for all at all ages’(United Nations 2020). However, even if this goal is largely being realized,

234 Mei- Chun LIU

disadvantaged populations still suffer from insufficient access to healthservices and lack the needed materials for personal protection as a result of
discrimination, lack of access to health care services, and denial of welfare
benefits (Kickbusch 2016). This is a reminder that even if a nation has excellent universal health insurance, this does not automatically guarantee
equal health provision and safety for all unless marginalized segments ofthe population have received due attention.
In order to tackle the issues related to unequal health provision, a numberof measures should be taken. As Zimmerman and Kiss (2017) suggest, preventive measures that address structural determinants (such as discriminationand constrained access to health care services) should be prioritized becauseof their enormous impact on migrants’ health. It is crucial to have an inclusive
decision-making mechanism through which migrants can have their voices
heard. Looking at the case of Taiwan, the COVID-19 pandemic might beviewed as a disaster that can be turned into an opportunity by helping toexpose the deficiencies in Taiwan’s guest worker policy which follows the ruleof ‘dividing and excluding’ that emerged from nationalism and discrimination
against migrants. The use of this rule can be seen as detrimental not only
to the migrants themselves, but to everyone living in Taiwanese society.

Taiwan’s ‘Guest Worker Policy’ in Danger of Breaching Human
RightsIn Taiwan today, the population of blue-collar migrants already outnumbers
the population of Taiwan’s officially recognized sixteen indigenous peoples.1
This is followed in size by marriage migrants totalling 565,299 persons, 2
a significant sum considering Taiwan’s population stands at 23,561,236
persons.3
1 Migrant workers include white-collar and blue-collar workers. Both are regulated through the
Employment Service Law (1992), but receive differential treatment. White-collar migrant workers,
mainly specialized/technical workers and language teachers, enjoy freedom of movement,
choice of employers, and a duration of stay as long as their work permit is valid. All those rights
are denied to the 713,454 blue-collar migrant workers (as compared to the 39,439 white-collar
migrant workers, as reported by the end of April 2021).
2 Indicating migrants who enter Taiwan through marriage. Since the 1980s, men from lower
social strata turned to Southeast Asian countries, mainly Vietnam, Indonesia, Thailand, andPhilippines, in search for marriage partners. The annual number of marriage migrants has
declined since 2004.
3 Taiwan used to have four major ethnic groups with Fukienese as the largest, followed bymainlanders, Hakkanese and indigenous peoples, before the 1980s. Taiwan’s census bureau

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235

Migrant workers are covered by Taiwan’s highly renowned universal
health insurance, which features low premiums, low co-pay, free access, anda nearly 100% coverage rate. However, the utilization rate of this insurance
by migrants is minimal. This is due to several impeding features produced by
Taiwan’s guest worker policy. Instituted through the Employment Services
Law of 1992, the migrant worker policy, often referred to as guest worker
policy, guides the employment and management of migrant workers in
Taiwan. This policy strictly confines blue collar migrant workers to predesignated employers and places of work even before entering Taiwan. Ifthey leave their employers and start work elsewhere, they become illegal
and undocumented, regardless of whether their reasons for leaving arelegitimate or not. This policy allows employers to dismiss workers at will,often by sending migrants back to the brokers without worrying about legal
consequences (Aspinwall 2020).
Although Taiwan has a high demand for migrant workers, its society has
not been ready to accept them as part of the population (Wang 2011). Migrant
workers are officially designated as complementary workers, not substituteworkers. As a result, they can only sign fix-term temporary contracts which
deprive them of the right to attain permanent residency, let alone citizenship(Tseng and Wang 2011). This is regardless of how long they have been working
in Taiwan, with live-in domestic migrants allowed to work for a maximumof fourteen years and migrants working in factories and nursing homes for
up to twelve years (Ministry of Labour 2018).
Migrant workers are, in practice, denied social welfare benefits, even if
most are workers covered by health insurance and labour insurance, withthe exception of live-in domestic migrant workers who only enjoy healthinsurance. Nevertheless, the benefits that migrant workers have from both
insurances are not comparable with those that are enjoyed by locals, suchas maternity benefits, unemployment benefits, and wage compensation
for hospitalization due to occupational injuries as well as disease. 4 This isremoved the question on ethnicity in 1990. Therefore, we can only estimate ethnic populations
through sources such as the Council of Indigenous Peoples, the Hakka Affairs Council, theNational Immigration Agency and the National Development Council, which all have their own
surveys to monitor the population. An accurate estimate is beyond the scope of this chapter.
The National Immigration Agency produces an annual statistical report on marriage migrants
and work migrants, and the Council of Indigenous Peoples has their own survey.
4 Migrant workers are legally covered by both Universal Health Insurance and Labour Insurance, with the exception of domestic migrant workers who are covered by the former but not thelatter. However, when it comes to the realization of those benefits promised by both insurances,blue-collar migrant workers have been disadvantaged due to their lack of information, andthe complicated procedures required for f iling claims, making it diff icult to enjoy some of236 Mei- Chun LIU

especially the case when they are claiming benefits for severe occupational
injuries that require hospitalization and rehabilitation. In these cases, some
employers have brokers who ‘take back’ injured migrants that have not
medically recovered. These brokers will then send back the injured workers
even before they are able to receive compensation from employers or theirinsurance benefits.
Living arrangements are another factor affecting the health of migrant
workers. Migrant workers in Taiwan are often forced to accept dormitories
prepared by brokers/agencies or employers. Employers set dormitory rules
in order to effectively monitor and control workers, thus limiting migrants’
freedom of movement outside factories and dormitories (Turton 2021). Living in the dormitories also means that migrants have to share fully packed
rooms, bathrooms, and toilets (Everington 2018). These kinds of dwellingarrangements are dangerous to live in and make workers more susceptible
to infectious diseases (Timmerman 2020). The outbreak of COVID-19 among
migrant workers in Singapore in similar conditions exemplifies the health risks
associated with close-quarter living conditions (Reuters 2020; Yi et al. 2020).
Another health risk for migrant workers lies in their reluctance to takesick leave for fear of wage loss and the risk of endangering possible contract
renewal in the future. This unwillingness of migrant workers puts them atgreater health risk, and can lead to unknown outbreaks (Wang et al. 2020;
Aspinwall 2020). Moreover, it is difficult for undocumented migrant workers
to seek medical help for fear of exposure and deportation. Another reason
for their reluctance to seek medical help is financial, as they have to bear
the full cost of medical expenses once they become undocumented, which
also means losing their health insurance coverage.5
Migrant workers leave their employment and become undocumented
for a number of different reasons. Migrant workers might seek to get
the benefits. In reality, for example, if female migrant workers get pregnant, it is unlikely thatthey are able to work until their due date without being dismissed by employers. Therefore, if
pregnancy does occur, most of them choose to return to their home country, file a claim fromtheir country of origin, or flee and work as an undocumented migrant in Taiwan.
5 According to Taiwan’s migrant worker policy, employers have to provide National Health
Insurance to migrant workers working in factories and households. However, once they flee,
they lose their insurance. Taiwan’s national health insurance is renowned for its fairly low
premium (5.17% of monthly income of which employers are obliged to pay 60%, workers pay
30%, and the government pays 10%). It is also known for its extremely low fixed co-pay (about
US$1.7 for every clinic visit, US$3.3 for every visit to a regional hospital, and US$5.7 for a visit toa medical centre). Medical expenses will be fully covered by National Health Insurance Bureau.
If something happens to them after they have become undocumented, workers may be liable
for sizeable medical costs depending on the level of treatment required.

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237

away from unbearable working conditions, sexual assault, or inhumane
treatment. Debt-ridden migrant workers have previously fled to avoid
repatriation when their contracts were prematurely terminated due tothe death of care recipients, plant closure, or mass redundancy. This formof contract termination invited a wave of criticism. As a result, the guest
worker policy has recently undergone changes to allow migrants to seek
new employment within a limited period. This is under the condition
that the termination of their contract is not their fault. However, in suchcases brokers are often inactive due to a lack of f inancial incentives tohelp migrants in their job search. Brokers frequently resort to regulatory
violations by sending workers back home (Lan 2006; Hsia 2005, 343-344;
Gu 2013, 96).
Migrant workers also tend to owe large amounts of debt to brokers inorder to land jobs in Taiwan. This means that they have to work longer hours
to earn enough to pay back these loans. This debt burden has been anotherreason that migrants flee from their employment positions and become
undocumented (Olive 2020; Fleeing Migrants 2012).6 Once this happens,
the government loses track of the migrants and is unable to receive theirperiodic health reports. A special immigration task force is then charged
with hunting them down. This can force the workers to go into hiding.
Critics from academia and human rights organizations have been vocal
about the inadequacy of current regulations (Hsiao 2020).
In summary, the current guest worker policy restricts the mobility of
migrants and their freedom of occupation. It therefore renders the power
relations between migrants and employers extremely imbalanced, to thedetriment of the migrants. This is what Tan (2014) describes as a ‘governmentality of exclusion’. In his study of Singaporean society, he explainsthat it is the whole institutional apparatus that discriminates against thosedeemed ‘less worthy’ and unsuitable for inclusion. This applies to Taiwan aswell. The stringent residency policy, denial of the freedom of occupation, as
well as limited mobility, together function to drive migrant workers to leave
their legal but much constrained employment, and become undocumented.
When migrants are forced to become undocumented, the health risks borneby migrant workers increase. The exclusion of undocumented migrant
workers from the universal health insurance system thus endangers thewhole population.
6 Fleeing Migrants is a collection of 25 stories told by undocumented migrants in Taiwan.
As has been discussed here, there are various reasons for them fleeing their employment, withdebt burden being the most pressing. The original publication is in Chinese.

238 Mei- Chun LIU

Tackling COVID-19 – Protective Measures and Remedies for
Migrants
The Taiwanese government was quick to take action when the COVID-19
pandemic emerged at the start of 2020. It immediately implemented thermal
imaging at the border. It mobilized factories for the production of masks
and coordinated health-insurance-contracted pharmacies and convenience
stores to facilitate access to masks. It banned mass gatherings and suspended
businesses such as nightclubs where social distancing was not possible. It
also implemented mandatory wearing of masks in cinemas, department
stores, hospitals, post offices, banks, and on public transportation (Yip 2020).
Schools and offices also took preventive measures, such as restricted entry
and placing thermal imaging cameras at entrances. Flights were reduced, or
suspended, in accordance with the development of the pandemic in different
countries or regions (Ministry of Foreign Affairs 2021). The government
also implemented a fourteen-day quarantine measure for everyone comingfrom abroad.
These measures can partly explain why, during the f irst year of the
COVID-19 pandemic, Taiwan saw very low infection rates when comparedto other countries around the world. However, Taiwan’s success in 2020 is
not a guarantee for sustained success. Since April 2021 new variants of the
COVID-19 virus have started spreading, resulting in 14,157 new confirmed
cases and 575 deaths by 23 June 2021. The new virus outbreak has hit eighttechnology plants, leading to cluster infections among migrant workers,
400 being confirmed by 21 June 2021 (Huang 2021).
Although the clustered spread of COVID-19 among hundreds of migrant
workers in Singapore at the end of March 2020 forced the Taiwanese government to reconsider their policies in order to offer assistance to migrant
workers,7 the issue of clustered living conditions did not receive ample
attention, eventually leading to the aforementioned outbreak in 2021.
In order to reduce cross-border movement, migrant workers were also
encouraged to stay in Taiwan and renew their contracts or take new placements. They were given a transportation subsidy to compensate for the delay
or cancelation of their annual leave. Employers were also encouraged to apply
for the extension of permits for migrants who had reached the maximum
7 This includes providing information about the pandemic at migrant service centres stationed
at the airport, installing a hotline, establishing a multi-lingual website aimed at migrants, andusing social media, pamphlets, as well as flyers to disseminate information in a bid to reachTaiwan’s migrant populations (Workforce Development Agency 2020).

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239

duration of stay (Ministry of Labor 2020). They were asked to apply for shortterm employment permits of three months or six months for those migrant
workers with contracts due to end. They were also encouraged to releasemigrant workers to other employers if there was a slowdown in business.
The government also put in place a measure to cover the hospital expenses
incurred by infected migrant workers to encourage these workers to seek
medical attention without worrying about the possible financial burden.
Wage loss due to quarantine measures has been compensated by the government at NT$1000 per day (approximately US$35) when employers have notpaid this (Yang 2020). Meanwhile, the government has also instructed thatquarantine fees have to be paid by employers or agencies. It is forbidden forthese fees to be transferred to migrant workers, with employers/agencies
being fined if they attempt to do so (Everington 2020).
The government migrant worker policy has undergone several changes
throughout the COVID-19 pandemic. Home quarantine applied to all incoming migrant workers as early as 19 March 2020. However, as the pandemic
escalated, newly arrived live-in domestic migrant workers and factorymigrant workers with re-entry permits were required to undergo centralized
quarantine, while newly arrived factory migrant workers were subject toemployer-provided home quarantines starting from 27 March 2020.
As the pandemic continued to escalate in Indonesia by the end of 2020,
the government’s policy was adjusted to include a temporary ban on all
Indonesian workers (Lee 2020; Taiwan Centres for Disease Control 2020).
Due to a growing number of confirmed cases and a rising death toll, a more
stringent policy was issued on 19 May 2021 to ban all visa applications inaccordance with stricter border control (Bureau of Consular Affairs 2021).
In order to encourage undocumented migrant workers to come out of
hiding and abide by the preventative health measures, the National Immigration Bureau has adopted a three-month amnesty policy that exempts
them from the confinement, re-entry ban, and fine that normally would
apply when workers are arrested. In addition, the government has offeredundocumented migrant workers a free anti-virus taxi service to and fromCOVID-19 testing centres, quarantine checks, and medication in order toprevent new infections from spreading.8 During this three-month amnesty
period, nearly 8000 workers reported to the government (Lo 2020; National
Immigration Agency 2020).
8 The government recruits and contracts the so-called ‘anti-virus taxi’ to offer migrant workers
a free service that allows them to use a safe method of transport, in contrast to using regulartransportation methods through which the virus might spread.

240 Mei- Chun LIU

The Taiwanese government also initially demanded that migrant workers
on fishing vessels underwent a fourteen-day quarantine on their vessels.
This rule also applied to those who have a low risk of contracting thevirus, such as workers who have not anchored in other nations, have notinteracted with other ships, have not changed crew members, and have notbeen inspected by foreign officials in the 30 days prior to their return to
Taiwan. These rules were later tightened, requiring compulsory on-board
health management of crew members who did not go ashore, if the ship
was to set sail again within fourteen days. However, if crew members leave
their ship and enter the community, the rules require either a ‘one crew
member one room’ version of quarantine on the ship, or a hotel quarantine
for fourteen days.
Eleven security posts were set up in three different cities to provide
help and to monitor deep sea fishing vessels. The government has also
provided masks to fishing associations and organizations of ship owners,
through which crews can purchase them. Those undergoing the ‘one crew
member one room’ quarantine also receive a pandemic protection bag
that contains masks, a temperature recording card, sanitizer, towels, and atoothbrush. Ship owners receive a subsidy of NT$1500 per crew member per
day (approximately US$39) if they are quarantined on this basis (Fisheries
Agency 2020).
During the first stage of the COVID-19 pandemic these measures aimed
at migrant workers in Taiwan proved relatively successful, resulting in a low
rate of infections and confirmed cases related to migrant workers.

Taiwan’s Guest Worker Policy: Ready for an Overhaul?
After the first stage of the COVID-19 pandemic appeared to subside, Taiwan
was quick in seeing business resume, schools open, and people getting backto their daily routines. Nevertheless, the number of employers who have put
their employees on unpaid leave or have dismissed these employees in large
numbers has hit a record high. Migrants are covered by labour insurance but
are denied unemployment benefits, unlike their Taiwanese counterparts
who are entitled to these benefits. Furthermore, migrant workers are also
not entitled to severance pay because their labour contracts exclude thisright. This means that, for some migrant workers, even though they havebeen able to survive the pandemic, they are likely to be in great debt as aresult of having been placed on unpaid leave or having been dismissed. Manyof these migrant workers might be described as being virtually invisible toHealth Governance during the COVID -19 Pandemic

241

policy makers, who continue to ignore the predicament of migrant workers
due to the ‘divide and exclude’ principle that characterises Taiwan’s guest
worker policy.
Although Taiwan is a signatory of five major human rights conventions,these conditions have persisted. Taiwan has notably not signed the International Convention on the Protection of the Rights of All Migrant Workers
and Members of Their Families. It can be argued that the key to improving
Taiwan’s human rights record lies in the way workers’ basic human rights
are protected, such as the freedom of occupation, freedom of movement,a right to family reunion, equal rights to employment and justice, andpermanent residency. It is therefore time for Taiwan to transform its guest
worker policy, a policy that is still used to structurally exploit migrant
workers’ vulnerability by depriving them of their labour rights.

Looking Ahead: Inclusiveness and Solidarity
The unprecedented global health crisis sparked by the COVID-19 pandemic
has exposed the exclusionary shortcomings of Taiwan’s guest worker policy.
The COVID-19 pandemic has hit those most marginalized the hardest andhas disenfranchised migrant workers, who have already long been excluded
from the Taiwanese government’s worker protections. The way in which
Taiwan’s guest worker policy deprives migrant workers of certain rights
exemplifies how, in different countries, an ‘us vs. others’ mentality can
prevent fair policy and impede global public health challenges in an eraof globalization.
As Kickbusch (2016) argues, a paradigm shift is necessary in global healthgovernance, as health governance has deepened rising inequalities. Any
country that withholds health as a basic human right, especially to migrants,
will be trapped in an ever-worsening health dilemma. Global health governance therefore requires international solidarity.
This pandemic offers a rare opportunity to re-examine what has beenachieved in global health governance up until now, and what is left tobe amended after the pandemic is over. Normative principles need to beestablished that require the international community to recognize theimportance of committing to inclusiveness, and to incentivize governments
to take concerted action so as to include non-state actors that deserve
more attention. Ulrich Beck (2011) used the concept of the ‘cosmopolitan
imperative’ to describe the urgency that modern societies face in addressing
emerging global risks that cannot be confined in space or time. The same

242 Mei- Chun LIU

reflection also applies to any society where discrimination, prejudice, andexclusionary policies do no justice to those most vulnerable. The safetyof those most marginalized matters significantly when public health isconcerned. Therefore, the existing structural inequity of health governancedemands a close review in order to safeguard all.

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About the Author
Mei-Chun LIU is a Professor at the Institute for Labor Research, School ofSocial Science, National Chengchi University, Taipei, Taiwan. She earned
her PhD in Sociology at the University of Southern California, US. She iscurrently chairperson of the Taiwan Public Health Promotion Association, aformer chairperson of the Taiwan Higher Education Union and the Taiwan
Health Reform Foundation, and a committee member of the New Immigrants
Development Fund. Between 2016 and 2020, she served as a member of the
Human Rights Committee of the Presidential Office.

14

Public Health and Capitalism in JapanThe Impact of Labour Market Challenges and Welfare on
Public Health
Saori SHIBATA
Abstract
Attempts by the World Health Organization (WHO) and national governments to provide direction on public health have been affected by thesocio-economic institutions present in different countries. The different
national models of capitalism that are in place in different countries have
had an impact upon the capacities of these countries to deal with publichealth during the COVID-19 pandemic. This chapter introduces the relationship between public health and national models of capitalism by looking at
the case of Japan, and argues that the problems faced by people as a resultof Japan’s neoliberalized labour market and welfare system have createda number of obstacles to the successful management of the pandemic.
Keywords: public health, Japan, capitalism, labour market, neoliberalism,
COVID-19

The World Health Organization (WHO) has received much criticism withregard to the legitimacy and effectiveness of its handling of the COVID-19
pandemic, with many political leaders being especially critical. This has
made more evident than ever the challenges that international organizations,such as the WHO, face as they seek to coordinate international communities(NHK 2020). The attempts by the WHO, as well as by national governments,
to provide direction on public health have been affected by the socioeconomic institutions present in different countries. The national models
of capitalism in place have had an impact upon the capacities of different
countries to deal with public health.

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_ch14248 

Saori SHIBATA

This chapter first introduces the relationship between public health andnational models of capitalism. Here, it highlights the impact of different
socio-economic institutions (especially the labour market and welfare
system) upon public health. After this, the chapter demonstrates how
workers’ problems are intertwined with their health. The chapter thendemonstrates how challenging it has been for the WHO to address the
pandemic and public health in different nations. This has been challenging because of how its attempts to deal with the pandemic have been
influenced by the socio-economic institutions that are present in different
nations.
In some nations, these socio-economic institutions include deep-rooted
labour market problems that have been produced through an ongoingprocess of neoliberalization. This is the case, for instance, in Japan. The
chapter then goes on to show that Japan’s neoliberalized welfare system
also impacts public health and increases social and health risks for manymembers of the public. Finally, it argues that the problems people face in thelabour market and the welfare system have created a number of obstacles
to the successful management of the pandemic and the implementation ofnecessary public health measures.

WHO, Capitalism, and Public Health
The national model of capitalism in place in any one country and global
capitalism as a whole both significantly influence how public health isachieved (Sell and Williams 2020; Hernández-Álvarez et al. 2020; Hunterand Murray 2019). Many national models of capitalism function in stateswith a substantial welfare system. However, this system has proven unable
to remove the market logic from public health in general, as well as interms of access to healthcare services and essential medicines (Sell andWilliams 2020, 4). Neoliberalism, and the associated preoccupation withmarket fundamentalism, has seen a prioritization of profit-seeking andausterity. It has also made work more precarious, resulting in growing
economic insecurity for workers. This market logic, and particularly thedrive for austerity, has led to widespread cutbacks in health services as wellas market-driven reforms that have limited the availability of healthcare.
During the ongoing COVID-19 pandemic, these conditions have created thepotential for devastating consequences to public health (Sparke 2020, 1).
Health is not an accidental outcome, but is ‘shaped by people’s location interms of generational wealth, poverty and income inequalities within a wider

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national and global structure of accumulation’ (Sell and Williams 2020, 4).
As An and Tang (2020, 793-796) highlight, both institutional infrastructureand system capacity influence pandemic crisis management. Crucial factors
for pandemic management include the capacity of public health institutions,healthcare facilities, medical services, information management technology,
and regulatory systems.
This chapter argues that in order to understand the impact of the
COVID-19 pandemic upon public health in Japan, we need to consider
the country’s institutionalized structures of inequality. In Japan, themedical and healthcare system, welfare system, health insurance system,and the labour market system are key socio-economic institutions thattogether have largely determined the extent to which the pandemic andpublic health have been handled. In other words, the model of capitalism
present in Japan, as well as the existing patterns of social inequalities
in public health, have had a crucial influence on how the pandemic has
been managed.
The impact of the pandemic has depended on wealth, poverty, andincome inequalities, within a wider national structure of capital accumulation. For instance, in some nations markets fail to deliver accessto healthcare to all of the population when this access is dependent
upon the ability to pay health insurance contributions, or when people
are denied access to basic healthcare. Labour market conditions canalso impact how the pandemic affects people. If people lose their jobs
and become unemployed during a public health crisis, this can present
signif icant risks to them and their families. Where national welfare
systems provide insuff icient coverage, this can mean that vulnerable
people bear considerable risks during a pandemic (see also Nguyen’s
contribution in this volume).
The WHO has sought to advise national governments about responding
to the pandemic by issuing a range of guidelines and measures relating
to public health, local communities, domestic violence, quarantine, foodsafety, and safe workplaces (WHO 2020a). However, these guidelines
and measures have so far had limited effects. For example, the advice
given by the WHO has had a limited effect on securing public health inJapan. This is in large part due to the WHO’s limited ability to deal withquestions such as job security and welfare provisions, which play anessential role in addressing public health. In particular, socio-economic
institutions have had a considerable effect on health governance and theunequal ways in which people in Japan have experienced the COVID-19
public health crisis.

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Labour Market Challenges and Public HealthA number of labour market reforms have sought to address problems faced
by workers in Japan. These include the structural reforms and Work Style
Reform (hatarakikata kaikaku) that were part of the so-called ‘Abenomics’
policies adopted by former Prime Minister Shinzo Abe. These reforms
involved an increase in the minimum wage, an attempt to move workers
on non-regular contracts to regular contracts, and efforts to encourage ashortening of working hours (Shibata 2020). However, the Abe government’s
priority has been the pursuit of labour market flexibility. This means thatthe proportion of non-regular workers, or those who do not have long-term
employment security, within Japan’s labour market has remained high,amounting for nearly 40% of the total workforce. The precarious situation
faced by many non-regular workers has not improved under Abenomics(Shibata 2020).
The increase in the number of non-regular workers does not necessarilymean an increase in inequality; not all non-regular workers are precarious,and the employment situation surrounding non-regular workers has becomecomplicated (Imano 2020). Nevertheless, it is under the current labour market
conditions that non-regular workers were the first group of workers to facedismissals as a result of the COVID-19 pandemic. Such dismissals were termed‘corona dismissals’ by the media, who announced a ‘significant unemployment
era’ (Toyo Keizai Online 2020). These dismissals have seen the number of
unemployed grow from 1.5 million at the end of 2019 to almost 2 million in
May 2020 (Nihon Keizai Shimbum 2020). This also resulted in a rise in theunemployment rate, from 2.4% in 2019 to 3.1% in October 2020 (MHLW 2020).
In addition, workers were denied access to, or received reductions in, the‘absence allowance’ that they were supposed to receive from employers.
This ‘absence allowance’ was a government scheme that promised 80% of
wages to staff who were unable to work because COVID-19 had forced thetemporary closure of the companies where they worked. The government
also provided other financial support, but the absence allowance was themost comprehensive financial support available, covering the majority ofworkers who were not able to work as a result of COVID-19. The allowancepromised to guarantee workers’ wages during the pandemic. Despite thisguarantee, 24% of non-regular workers reported that their employers refused
to provide the allowance (Nishinihon Shimbum 2020). Not receiving thisallowance can impede workers’ access to medical and healthcare services,because this access is dependent on their ability to pay healthcare insurance
contributions. It can particularly lead to difficulties accessing medical

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healthcare services for foreign workers, female workers, and precariously
employed non-regular workers. In particular, foreign workers faced a higher
risk of losing their jobs and were more likely to receive low wages, bothof which represent obstacles to public health. These workers are often
ineligible for Japan’s health insurance system while also lacking the informalfamily networks that offer an alternative means for securing healthcare andsocial support (Sawada 2018). While these problems existed before this, thepandemic has magnified them.
In different nations including in Japan, gender-based discrimination has
intensified during the pandemic. The WHO has used its briefing papers toaddress the potential for increased domestic violence against women during
the pandemic (WHO 2020b). Although this has represented an importantsource of advice, it is the Japanese government that has had to take theinitiative and address nationally specific issues in terms of gender inequality.
In Japan, there is a large disparity between male and female workers’ wages
and employment status. Female workers have tended to be most burdenedwith home-making and domestic care for family members. This has led
to a decline in female workers’ participation in the labour market and acorresponding increase in the degree to which women are dependent upon
their husbands or partners for health and medical care. This has put single
female workers at a considerably higher public health risk.
Female workers appear to have borne the brunt of pandemic-related
job losses (Ishibashi and Nakafuji 2020). The number of jobs lost by female
workers is significantly higher than that of male workers. For example, 11.4%of female workers lost their jobs between December 2019 and August 2020,
compared to 0.8% of male workers during the same period (Statistics Bureau
of Japan 2020). This may have contributed to a reported recent rise in suicide
among women. According to an August 2020 report on suicide by Japan’s
National Police Agency, the number of women who committed suicide roseby 51% between April 2020 and August 2020, from 442 to 669, whereas thenumber of men committing suicide rose by 17% (National Police Agency2020). The WHO needs to recognize such nation-specific inequalities as
crucial for public health policies.

The Transformation of the Japanese Welfare System andChallenges to Public HealthSome observers have highlighted that during the initial stages of the COVID-19 pandemic Japan handled the coronavirus relatively well, maintaining

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a low number of infections and deaths in comparison to other countries.
It did this despite being a densely populated country with a large elderly
population (Iwasaki and Grubaugh 2020; Tashiro and Shaw 2020). In seeking
to identify reasons for this relative success, commentators have pointed toJapan’s culture, its medical and healthcare systems, the level of sanitation,
citizens’ behaviour, and the ‘cluster approach’ used (Tashiro and Shaw
2020, 3).
However, it is not universally agreed that Japan has handled the pandemic
entirely effectively, or that it has done so for these reasons. Crump andTanimoto, for instance, have argued that Japan’s situation worsened due toa mismanagement of the pandemic, lack of adequate personal protection
equipment, and incompetence among hospital personnel (2020, 2). Similarly,
An and Tang argue that Japan has mismanaged the pandemic, highlighting
the country’s lack of pre-established institutional infrastructure, the lack oflegal means to impose substantive penalties, and its limited testing capacity
in comparison to other East Asian polities (2020, 795-797). In contributing
to this debate, this chapter leans towards the more critical interpretations,but in doing so it seeks to draw attention to the declining quality of welfare
provision in Japan, arguing that this has been a decisive factor in explaining
how the pandemic has been managed.
The Japanese welfare system introduced a universal medical insurance
system in 1961. There was a stable labour market during the 1960s, 1970s,
and 1980s. This was characterized by high levels of long-term employment(especially among men) and meant that Japan witnessed an increasing
number of workers and increasing insurance contributions. This enabled thestate to create a stable welfare system, including a well-functioning publichealth system. Migrant workers are also covered in this public health system.
However, from the 1990s onwards, the neoliberalization of Japan’s socioeconomic institutions has progressed steadily. This has been accompanied
by a greater emphasis upon individual responsibility for health, including
through the privatization (or partial privatization) of health, medical, andelderly care. The government raised insurance premiums from 20% to 30%
in 2002. In 2011, it reduced the breadth of insurance coverage as part of a
gradual increase in the privatization of public hospitals (Ogasawara 2018,127). Moreover, since the bursting of Japan’s so-called ‘bubble economy’ in
1991, it has experienced low economic growth and economic recessions. Thishas had a knock-on effect, posing problems for those who have difficulties
paying, or are unable to pay, insurance contributions.
As a result, the number of people who are covered by the health insurance scheme has declined from 126,907,000 people in 2010, to 125,877,000

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253

persons in 2017 (MHLW 2018). In particular, there has been a significant
decline in the number of people who are covered by the national healthinsurance, which also tends to cover non-regular workers. The numberof people covered by this has fallen from 38,769,000 people in 2010 to
31,475,000 people in 2017 (MHLW 2018). This is also closely related to theincreased number of non-regular workers in the labour market in Japanbecause the monthly contribution for national health insurance can bea heavy burden for people with low monthly incomes, taking nearly 20%of their wages (Sato 2014). The rising numbers of non-regular workers,
including migrant workers who receive lower wages, face difficulties inpaying their health insurance contributions. Moreover, according to Kin(2015), many employers have gradually shifted to non-regular workers who
work for shorter hours. This way, employers can avoid paying the costly
employers’ contributions towards the health insurance of their employees.
This trend for increasing non-regular employment will translate into
public health deficiencies. During the COVID-19 pandemic, these risks
have become more visible.
As part of the state of emergency introduced in Japan in early 2020, thegovernment announced that it would provide 100,000 yen (or around US$920) for every person in the country, including migrant workers and foreign
students. However, this money has only been made available for those
who had their address registered with their municipal government (Tokyo
Shimbum 2020a; 2020b). This stipulation has meant that the government
has effectively denied access to financial support for those most vulnerable,
especially the homeless. In Japan, support for homeless people has been left
to voluntary citizens’ groups, reflecting the inadequate nature of publichealth provision for the homeless (Inaba 2014).
As this chapter has argued, the WHO’s one-size-fits-all approach to giving
advice risks being ineffective. For example, in spite of the pandemic theJapanese government has decided to continue cuts to the ‘public assistancesystem’ (seikatsu hogo seido) that have been ongoing since 2018. This public
assistance system guarantees the minimum standard of living for those whohave difficulties in making a living. This system provides financial support
to enable people to have minimum living expenses (Ministry of Health,Labour and Welfare 2021). The next round of cuts has been announced
for October 2020, despite the clear risks to public health these reductions
will bring about during the pandemic (Kyodo 2020). The effect will be that
67% of households who receive the benefits will experience a reduction
in financial support, which will worsen accessibility to medical care forthose on benefits.

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While foreign residents with permanent residency or a settlement visa
are also covered by this benefit scheme, it excludes migrant workers who
are only permitted to live in Japan for a fixed term. As such, the availabilityof these benefits is neither sufficient nor comprehensive, something whichfurther endangers impoverished households that are already vulnerable
during public health crises such as the COVID-19 pandemic. In particular,
migrant workers who have lost their jobs during the COVID-19 pandemic,
and who are not entitled to these benefits, can suffer significantly as aresult of their income loss.
Obstacles also exist for those who are entitled to access public healthschemes. A number of companies – known as ‘black companies’ (burakku
kigyō) – have a practice of registering employees as self-employed in orderto deprive workers of their rights to minimum wage entitlements, overtime
payments, the national insurance scheme, health insurance contributions,and medical care. Many migrant workers tend to suffer from this kindof exclusion, even though they are entitled to health insurance. This iscompounded by the fact that workers on low pay and with insecure employment contracts have already faced considerable obstacles since before thepandemic began.

Conclusion
The guidance that has been issued by the WHO represents an important
step in making public health recommendations for national governments.
A key limitation of this guidance, however, is its scope. The WHO does
not address nation-specific socio-economic institutions that have a large
impact on public health. This chapter suggests that, in the context of Japan,
we have to consider the effects of the ongoing neoliberal reforms acrossJapan’s labour market and public health system. Japan has maintained a
relatively low rate of infection, especially in comparison to Western Europe
and the United States. However, more adequate employment protections
and a comprehensive insurance system would have led to more effective
management of the pandemic and long-term maintenance of public health.
As the risk of infection has continued into 2021, a rise in unemployment
and the fact that a substantial portion of the working population remains
in low paid jobs hamper measures to secure public health. As this chapter
has shown, the labour market, welfare provision, and public health aremutually dependent upon each other. Social inequality is a public healthmatter.

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255

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item/n/646635/.
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kobe_centre/sites/default/files/G43_20200514_JA_Gender.pdf.

About the Author
Saori SHIBATA, PhD, is an Assistant Professor at Leiden University. Her
research focuses on Japan’s political economy, including the changing
nature of work, the digital economy, and how Japan’s model of capitalism istransforming. This draws on institutionalist approaches to capitalism andcritical political economy. She has published on these topics in journals
such as New Political Economy and British Journal of Political Science. She is
the author of Contesting Precarity in Japan: The Rise of Nonregular Workers
and the New Policy Dissensus (Cornell University Press, 2020).

15

Indonesia’s Response to Global
Recommendations on Labour
Migration during a Pandemic: Muddling through Priorities
and Needs
Sylvia YAZID

Abstract
Policies made to address the global COVID-19 pandemic have significantly
affected people’s mobility between countries. For migrant labour sending
countries, such as Indonesia, the government has had to deal with the
pandemic domestically while simultaneously managing the social andeconomic impacts and safety of citizens abroad or in transit. This chapter
assesses the Indonesian government’s policy responses related to labour
migration. It shows that they have been in line with the recommendations
made by relevant international organizations, such as the International
Labour Organization (ILO), but that such recommendations often fail toaddress nation-specific issues. In doing so, this chapter contributes tothe understanding of transnational migrant labour governance in Asia.
Keywords: Indonesia, labour migration, International Labour Organization, global health governance, labour mobility, COVID-19

Introduction
COVID-19, with its rapid transmission rate, has required countries to takestrong emergency actions to limit its impact. While SARS and MERS wererelatively containable, COVID-19 has seen governments implementing
policies specifically targeting highly affected areas and has forced countries

Van der Veere, Anoma P., Florian Schneider, and Catherine Yuk-ping Lo (eds), Public Health in
Asia during the COVID-19 Pandemic: Global Health Governance, Migrant Labour, and International
Health Crises. Amsterdam, Amsterdam University Press 2022
doi: 10.5117/9789463720977_ch15

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to temporarily close their borders. The pandemic has caused stagnant
economic growth, pushing different countries into recessions.
A striking feature of the pandemic has been the effect it has had on themobility of migrant workers. It has disrupted workers’ mobility as countries
have implemented protectionist policies such as border and travel restrictions, as well as entry bans for migrants from certain countries. For countries
such as Indonesia that send many workers abroad (referred to as ‘sending
countries’), this has led to postponed departures and the unplanned returnof migrant workers. For example, Indonesia’s National Board of the Placement and Protection of Indonesian Overseas Workers (BP2MI), reported
in early 2020 that 37,379 Indonesian migrant workers had postponed theirdeparture, and 129,202 workers were repatriated (BP2MI 2020). As a resultof this, concerns have surfaced about the protection of the rights of theseworkers. If restrictions continue, labour migration might go underground,with migrant workers departing through unofficial channels.
When it comes to migration governance in Southeast Asia, nations alreadyhave limited capabilities (Kneebone 2010, 392), signifying the importanceof external parties such as international organizations. Epidemics andpandemics have further highlighted how global health governance requires
rigorous coordination between various stakeholders at different levels andthe commitment of global, national, and local authorities. This chapter
examines Indonesia’s policy responses to the pandemic, assessing whether
they are in line with recommendations made by international organizations
such as the International Labour Organization (ILO). While the COVID-19
pandemic requires collaborative actions led by global authorities, criticism
concerning the performance of international organizations and the commitments of member countries grew during the pandemic. This chapter
shows how attempts at global governance should take into account the
specific characteristics and needs of each country, in this case of Indonesia.

MethodThe 1990 International Convention on the Protection of the Rights of All MigrantWorkers and Members of Their Families recognizes the need for states toensure the protection of the rights of migrant workers (Nanda 1993, 161-177).
However, the signing and ratification of this convention do not automaticallyguarantee that these rights will be fulfilled. Two decades later, there remains
a gap between the global recommendations and countries’ specific needs
for protection of migrants’ rights.

Indonesia’s Response to Global Recommendations on Labour

261This chapter analyses whether, in the case of Indonesia’s response to the
COVID-19 pandemic, these measures are actually closing the gap. It doesso by combining a literature study with interviews to analyse Indonesia’s
response to the pandemic and its conformity to ILO recommendations
regarding labour migration during a pandemic. The research relies on
publicly available data and information gathered from interviews. Theinterviews were with Judha Nugraha, Director of Protection for Indonesian
Citizen and Legal Entities of the Ministry of Foreign Affairs of Indonesia,
Brian Sriprahastuti, Senior Advisor at the Executive Office of the Presidentof Republic of Indonesia, and Anis Hidayah, Head of Migrant Study Centerof Migrant CARE, all of whom kindly agreed to be identified for the purposeof this study.

Protecting Migrant Workers during the Pandemic: ILO
Recommendations
The ILO has released several policy recommendations regarding migrant
workers and the fulfilment of their rights during a pandemic. This chapter
refers to the earlier policy brief titled Protecting Migrant Workers during the
COVID-19 Pandemic (ILO 2020). It was released in April 2020 and highlights
three key areas of action: ‘migrant workers’ inclusion in national COVID-19
responses, bilateral cooperation between countries of origin and destination, and social dialogue and full involvement of employers’ and workers’organizations in the development of COVID-19 responses’ (ibid.). For the
purpose of analysing Indonesia’s responses, this chapter focuses on thefirst area of action, consisting of six recommendations. Although theserecommendations may seem directed toward countries receiving migrants(‘receiving countries’), they are actually quite general and are also of concern
for sending countries.
The ILO’s recommendations on the inclusion of migrant workers innational COVID-19 responses suggest different kinds of support for theseworkers. The first kind of support is economic. The ILO encourages countries
to provide financial support for migrant workers, based on reliable data. It
also stresses accessible healthcare and social protection for migrant workers
of all statuses. Additionally, making sure that these migrant workers are
well-informed regarding health and safety information is considered crucial.
Alongside this, the ILO also recommends that countries provide workers withaccess to essential migration services. This is to ensure that migrant workers
do not fall into irregular status. The ILO also states that countries should

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provide appropriate communal accommodation and quarantine areas, sothat migrant workers are free from hazards in their communal or worksite
housing. Finally, the ILO recommends that governments provide migrant
workers with legal counsel to prevent them from being undocumented orirregular.
The ILO made these six recommendations at the beginning of the
COVID-19 pandemic, giving them to governments to address the main
challenges that migrant workers face during the pandemic. The next section
looks into Indonesia’s policy responses to the pandemic and identifies
whether these responses fit into the framework that the ILO set out.1

Protecting Migrant Workers during the Pandemic: Indonesia’s
Policy Initiatives
Indonesia confirmed its first positive case of COVID-19 on 2 March 2020.
Since then, the government has taken various steps to address the pandemic
at the national, provincial, city/municipality, and village levels. There havealso been attempts to coordinate between levels and across neighbouring
areas. Indonesia’s two main policies related to labour migration are: theMinistry of Manpower Decree No. 151 of 2020 concerning the Temporary Cessation of Placement of Indonesian Migrant Workers (PMI), and the Ministry of
Manpower Decree No. 294 of 2020 concerning the Implementation of Placementof Indonesian Migrant Workers during the New Normal Adaptation.
With the first policy, Indonesia sought to slow the spread of COVID-19
by temporarily stopping the placement of Indonesian migrant workers.
Indonesia’s National Board of the Placement and Protection of IndonesianOverseas Workers, or BP2MI, 2 coordinated with a number of related
ministries in supporting migrant workers who were delayed in departure,
stuck in the country of placement, or who had to return to Indonesia. The
enactment of this regulation also temporarily halted the departure of those
who wished to leave for placement. However, this was not a full-fledged
moratorium or repatriation of Indonesian migrant workers abroad. After
1 The discussion in this chapter has been based on the situation in Indonesia, as well as theinformation and data that were produced, during the early stages of the pandemic. This situationand information determined many of the related policies made at later stages.
2 Indonesia’s National Board of the Placement and Protection of Indonesian Overseas Workers(Badan Pelindungan Pekerja Migran Indonesia), or BP2MI, is a non-departmental government
agency that oversees the implementation of policies in the placement and protection of Indonesian
workers abroad.

Indonesia’s Response to Global Recommendations on Labour

263

the regulation was put in place, those with valid work-visas have still beenable to depart if their country of destination allowed arrivals. Those in the
country of placement have still been able to reside there in accordance with
their work contract (Kemnaker RI 2020a).
To order a complete halt of the placement of migrant workers would havebeen a difficult choice for Indonesia to take amidst the economic slowdown
faced during the pandemic. Therefore, five months after the temporary
halt, the placement of migrant workers restarted again, with the sendingof migrant workers to thirteen countries. The government adopted thisas a new policy, the Minister of Manpower Decree No. 294 concerning the
Implementation of Placement of Indonesian Migrant Workers, that aimed
to regenerate remittances from abroad during what was labelled as a ‘New
Normal Adaptation’.
The Indonesian government has been trying to balance protecting publichealth and safeguarding the economy. This balancing was discussed inseveral of the interviews conducted for this chapter. According to Sriprahastuti, the government’s balancing act explains President Joko Widodo’s
use of an approach that shifted between acceleration and braking.3 Thebalancing act was also discussed by Nugraha, who posited that migration is
not only about economic development, but also about human development.4
However, critics also argued that this approach has not prioritized migrant
workers. In her interview, for example, Hidayah argued that the current
policy was aimed at generating income for the country rather than protecting
the welfare of migrant workers.5 She warned of the possible increase of
migration when the pandemic eventually eases and therefore insisted on
the preparation of a concrete welfare protection protocol.
Through the enactment of the aforementioned policies, Indonesia has
shown its concerns about economic and human development, social protection, healthcare and safety, information, and documentation schemes. It
is apparent that while the safety and health of migrant workers have been
considered important, the (re)sending of migrant workers has also been
made a part of Indonesia’s economic recovery strategy.
In terms of economic and human development policies, Indonesia has madeefforts to refocus activities and reallocate budgets to accelerate support for
migrant workers affected by COVID-19 (BP2MI 2020). Consider, for example,
the distribution of Pre-Employment Cards (Kartu Prakerja) to job-seekers,
3
4
5

Brian Sriprahastuti, interview by author, 3 October 2020.
Judha Nugraha, interview by author, 6 October 2020.
Anis Hidayah, interview by author, 6 October 2020.

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including workers who were laid off due to the pandemic. The holders ofthese cards are eligible to access skill development training and receive
paid post-training incentives. As was explained by Nugraha, this initiativeis intended to include migrant workers who lost their jobs.6 Therefore, theMinistry of Manpower (MoM) collected data on prospective migrant workers(PMW) and current migrant workers (CMW). It has submitted this data to the
Coordinating Ministry for Economic Affairs, so that these migrant workers
can be registered for the Pre-Employment Card programme. The National
Board of the Placement and Protection of Indonesian Overseas Workers(BP2MI) has also coordinated with local offices of the Ministry of Manpower
and the Indonesian Migrant Worker Placement Company (P3MI) to assist
in the registration process. This data is also being used for the allocationof the work opportunity expansion programme that aims to encouragelabour productivity (BP2MI 2020). Through the programme, it is expectedthat current and prospective migrant workers will improve their skills andboost productivity, which is hoped to reduce the number of unemployed.
In order to provide social protection for migrant workers, BP2MI has
made suggestions to the Employment Social Security Administration (BPJS
Ketenagakerjaan). It has made suggestions specifically regarding the filingof benefit claims for current and prospective migrant workers, as well as forutilizing the Social and Environmental Responsibility (TJSL) programmeof BPJS Ketenagakerjaan as an effort to ensure the welfare of Indonesianmigrant workers (BP2MI 2020). It can be said that by these means, current
and prospective migrant workers have been included in the national policies
aimed at addressing pandemic-triggered economic issues. This generalapproach is confirmed by Sriprahastuti, who explained how economic
recovery policies such as cash assistance for small and medium enterprises
have been given to everyone, including migrant workers.7
To ensure access to health services during this pandemic, in March 2020
the Indonesian Task Force for COVID-19 (Gugus Tugas Percepatan Penanganan COVID-19) issued the Guidelines for Rapid Medical Response and Public
Health Aspects of COVID-19. During the early months of the pandemic, when
the repatriation wave was high, the government made efforts to ensure
the safety of returning migrant workers by imposing measures such asquarantines and provision of facilities, measures in which migrant workers
received priority. For example, an emergency hospital was established on
Galang Island that specifically prioritized the care of infected migrant
6
7

Judha Nugraha, interview by author.
Brian Sriprihastuti, interview by author.

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workers. According to Sriprahastuti, at the beginning of the pandemic when
Indonesia was still considered to be safe, more specific attention was given
to migrant workers. This specific attention given to migrant workers was
based on the idea that they were coming from affected countries.8
As the pandemic has continued, the greater attention given to migrant
workers has decreased. The direction of efforts has been reversed, fromdealing with migrant workers coming back to Indonesia to facilitating theiremployment abroad. As Nugraha pointed out, the government is now trying
to make sure that the immigration services for migrant workers follow the
COVID-19 protocols of the destination country both upon their departureand arrival.9 Therefore, specific measures regarding health services andsocial protection have become associated with the mobility of migrant
workers. However, once they receive official clearance for entry, workers
are again considered part of their local community and are not specificallytargeted as migrant workers in official policy. While this approach can beconsidered fair, migrant workers’ advocates have argued for the specificidentification and treatment of migrant workers while they are at home inIndonesia. They claim this is necessary because these migrant workers do
not face exactly the same problems as the local unemployed.
In ensuring accessible information, the government has made attempts
to increase the effectiveness of communication on health and safety withworkers and related organizations. BP2MI and the MoM have coordinatedwith the Representatives of the Republic of Indonesia (KBRI) in migrant
workers’ countries of placement to provide for logistical needs and repatriation. A 24-hours complaint service for Indonesian migrant workers abroadhas been established (Kemnaker RI 2020a). To help overseas workers manage
the risks of COVID-19, they have provided protective equipment (such asmasks and sanitizers) and risk assessment for individuals with higher risksof being infected (WHO 2020a).
In addition, the government has communicated with employers in placement countries to enable workers to get more flexibility in working hours,
while still receiving wages. The government has coordinated with figuresin the placement countries to ensure the implementation of the WHO
COVID-19 risk management protocols both at work and in the workers’
housing facilities. Efforts have also been made to provide information
through organizations, public figures, social media platforms, and various
other media (Kemnaker RI 2020a).
89Brian Sriprahastuti, interview by author.
Judha Nugraha, interview by author.

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Sylvia YAZID

Nugraha stated that, although efforts have been made to ensure thedissemination of complete and accurate information, there is still room
for improvement, such as extending the coverage of public awarenesscampaigns to villages.10 Hidayah also suggested that the information
available has tended to be generic, leaving workers to struggle with more
specific conditions that are not included in this available information.11
With the reopening of Indonesian borders for workers, the availability ofcomprehensive information is crucial.
The MoM and the KBRI have taken measures in the placement countries of
migrant workers to ensure the proper documentation of Indonesian migrant
workers. At the beginning of the pandemic, these focused on returning
migrant workers. As the pandemic continued, the measures then sought
to ensure the sustainability of the placement programme for prospective
workers after the COVID-19 pandemic ends, to synchronize labour migration
policy with the policies of the country of placement, and to make sure that
all workers are documented and receive training according to existingprocedures (Kemnaker RI 2020b).
In the ‘new normal’ adaptation period which Indonesia has moved into
now, the sending of migrant workers abroad is being resumed. The MoM
has issued a policy directive to regulate the verification and legalizationof Request Letters for migrant workers that overseas employers provide.
It has also issued a directive to regulate the quota approvals submitted
by employers or business partners through the KBRI or the Indonesian
Economic and Trade Office (IETO) abroad. Before departure, the MoM
will verify and legalize the Requests for Indonesian Migrant Workers andthe quota approvals that employers have submitted (Kemnaker RI 2020b).
The employer and/or the government of the placement country are expected to take responsibility for matters such as workplace safety, working
conditions, the cost of implementing the health protocols in the country,
and other costs incurred if a worker is infected while abroad. They are also
expected to provide a guarantee for the well-being of Indonesian migrant
workers. Also, at the time of arrival in their country of placement, workers
are required to report their arrival to the KBRI, either offline or online
through the SafeTravel application and the Portal Peduli WNI. The Portal
Peduli WNI is a digital platform which Indonesian citizens can use to reporttheir own arrivals, transfers, and returns.

10 Judha Nugraha, interview by author.
11 Anis Hidayah, interview by author.

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These measures the Indonesian government has taken have been focusedon repatriation and facilitating mobility. They are based on previously
existing mechanisms, only now with the added health protocol and requirements that the WHO provided. Unfortunately, as Hidayah pointed out, some
immigration services in Indonesian embassies have been disrupted as aresult of the change to online services made necessary by COVID-19. This
has resulted in administrative problems such as challenges to the collectionof data about migrant workers’ mobility. It has also meant disruption tosome consular services.12 Moreover, as Nugraha stated, protection efforts
depend on the procedural or non-procedural nature of workers’ mobility,
which may be influenced by other countries’ policies.13
The government has taken steps to ensure the provision of healthy living
conditions at communal or worksite housing. In Indonesia, it has madeefforts to minimize the amount of communal living during the pandemic
by sending home those waiting for departure and vacating shelters andthe Overseas Training Centre (Balai Latihan Kerja Luar Negeri) (BP2MI
2020). However, the government has not been able to do so much to impact
the communal living of Indonesian migrant workers overseas. In terms ofcommunal living arrangements in the country of placement, the BP2MI and
the MoM established the aforementioned 24-hours service for complaints ofIndonesian labour migrants in placement countries. They also coordinatedwith relevant stakeholders to monitor the repatriation of prospective workers
to their areas of origin (BP2MI 2020).
There have been no reports from migrant workers of serious legal issues
resulting from the pandemic. So far, the legal process in place for theseworkers has been a continuation of what was already in place before thepandemic (Kurniati 2020). Nevertheless, to ensure access to legal remedies
for all migrant workers, the MoM continues to monitor condition reports,
placement country policies, handling efforts, and potential problems that
may occur in fulfilling migrant workers’ rights (Kemnaker RI 2020b). The
MoM also coordinates with all relevant stakeholders to continue reporting,monitoring, and evaluating the placement of Indonesian migrant workers. In doing this, it focuses on matters such as complaint services, healthconditions, numbers of prospective Indonesian migrant workers, and thecurrent condition of the country of placement (Kemnaker RI 2020b). In
short, efforts made to ensure access to legal remedies have been similar topre-pandemic policies.
12 Anis Hidayah, interview by author.
13 Judha Nugraha, interview by author.

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Migration Governance in Indonesia during the COVID-19
Pandemic: A Response Aligning with Global Recommendations?
This outline of the situation regarding migrant workers during the earlystages of pandemic, and the steps that the Indonesian government has
taken on this issue, shows that the government policies and initiatives
are essentially in line with the ILO’s recommendations. The government’s
economic and social policies have included migrant workers as beneficiaries, treating them like other citizens of Indonesia. The government ofIndonesia has made an effort to give migrant workers access to services
and information. There have still been challenges in the implementation ofthese policies, however, some of which are the result of the need to balance
the safety and health of the people and economic recovery. It is difficult
to determine whether or not the policies the Indonesian government has
taken were made based on the ILO’s recommendations. This is particularly
as the recommendations made by the ILO are not legally binding and theirpower depends on the willingness of governments to adopt them. Therefore,
to establish correlation between Indonesia’s national policies and the ILO’s
recommendations, the shape of Indonesia’s pandemic response needs tobe explored in relation to the role that has been played by internationalorganizations during COVID-19.
According to Nugraha, the relevance of international organizations
has increased during the COVID-19 pandemic. This is because countries
frequently lacked the resources to address problems individually, particularly
in terms of labour migration.14 Nugraha emphasized the importance of
joint efforts through initiatives such as the Travel Corridor Arrangement(TCA).15 The TCA is a bilateral agreement between Indonesia and countries
including the United Arab Emirates (UAE), South Korea, Malaysia, andSingapore. The agreement was made in order to boost economic relations
through travel permits for business essentials and diplomatic visits. Nugrahasaid he was hopeful that this arrangement would soon be implemented
multilaterally.16 The TCA is evidence of the way in which solutions so far havetended to be sought on a bilateral basis with the countries involved. Since
recommendations from international organizations such as the ILO havebeen quite general, countries have tended to work out their own solutions
and arrangements based on their own specific needs.
14 Judha Nugraha, interview by author.
15 Judha Nugraha, interview by author.
16 Judha Nugraha, interview by author.

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Sriprahastuti argued that, in making health policy, the Indonesian government has acted in accordance with WHO recommendations. She said, forexample, that Indonesia had followed the WHO guidelines in the activationof the initial emergency response.17 She claimed that Indonesia has adopted
two out of the three WHO recommendations: prevention and response. Recovery is yet to be implemented, but social distancing and testing have been
adopted. In general, practical and direct recommendations have been easier
to adopt. However, there are complex factors that need to be considered.
As a sending country, with a large population and approximately 135 entry
points, Indonesia is currently facing two major emergencies: the handlingof health matters, and the challenge of ensuring economic development.18
Nugraha explained how Indonesia has implemented the ILO recommendations with local adjustments based on domestic needs.19 The current
challenge is establishing coordination between stakeholders. In this respect,
Sriprihastuti argued that, if the policies it has put in place are to have their
desired effect, Indonesia needs a more binding structure to ensure theenforcement of new regulations while also considering the economy.20 It isnotable that the leadership of the task force responsible for the pandemic
response in Indonesia has changed several times. It has moved from the
President’s Staff Office, to the Head of The National Agency for Disaster
Countermeasure, and then finally to the Minister of State Owned Enterprises. This corresponds to a changing policy focus. As the pandemic has
continued, the targets have shifted to economic recovery. This also indicatesa change in how the issue is perceived, with it moving from being solely ahealth issue, to a health and economic issue.
Regarding the functioning of international organizations, however,Sriprahastuti also argued that more leadership is needed to improve global
governance systems. She argued that the recommendations made bythese organizations still treat the economy and health as separate which
is detrimental for a comprehensive understanding of labour issues during
a pandemic. Sriprihastuti described how, rather than the organizations
leading the way, some countries have come up with their own innovations,to which the WHO then responded. On a similar note, Hidayah statedthat the ILO’s recommendations provided a necessary policy framework.
However, whether these recommendations are known and understood by
17
18
19
20

Brian Sriprahastuti, interview by author.
Judha Nugraha, interview by author.
Judha Nugraha, interview by author.
Brian Sriprihastuti, interview by author.

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those making policy in Indonesia, and whether they are accommodated innational and local policies, remains unclear.

Conclusion
In managing the issues of Indonesian migrant workers, the government has
taken several measures and initiatives to protect and ensure their welfare.
These measures have been implemented through the enactment of the Ministerial Decrees No. 151 and No. 294. The government translated this decision into
policies in economics and human development, social protection, healthcare
and safety, information, and documentation. Meanwhile, on the global scale,the ILO has published policy recommendations for nations to implement inassuring the fulfilment of migrant workers’ rights. This chapter has shown
that, in general, the policies and programmes carried out in Indonesia havecorresponded with the ILO recommendations. However, in the implementationof these policies, challenges prevail both domestically and internationally.
There are two key takeaways that can be drawn from Indonesia’s case.
First, issues concerning migrant workers during a pandemic should not
be perceived only as issues faced by receiving countries. There are also
problems when workers are forced to go back to their country of origin.
This then requires policies from the sending countries’ government. This
government may consider the migrant workers returned from abroadas either a regular part of society, or as a particular group that requires
specific policies. Second, the general solutions to handling the pandemic
proposed by international organizations will eventually reach their limits.
Each country has its own issues that require specific, localized solutions.
Therefore, recommendations made by international organizations as partof an attempt at global governance should take into account the dynamic
and specific characteristics and needs of each country.

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Migran Indonesia Pada Masa dan Pasca Pandemi Covid-19.’ In Webinar hosted
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Gugus Tugas COVID-19. 2020. ‘Pedoman Penanganan Cepat Medis dan Kesehatan
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About the Author
Sylvia YAZID is currently an Associate Professor at the International
Relations Department of Parahyangan Catholic University, Indonesia. She
wrote about how Indonesian NGOs have influenced Indonesia’s domestic
and foreign policies on migrant workers to obtain her PhD from Monash

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University, Australia. Following this, Sylvia has continued to work on theissue of labour migration policies. Recently she has expanded her researchinterests to include the issues of democratization and human rights bothin domestic and international contexts.