“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair…. “

A Tale of Two Cities (Dickens, 1859)

The past 12 months have been dark, with over 2.4 million deaths being recorded as a result of the first real global pandemic in over a century, and economic consequences that have reverberated across the world.¹ Despite the many challenges, there has been a silver lining. We have seen unprecedented global science collaboration, the development of novel vaccines in record time, and ongoing efforts to promote open data sharing. Yet we have also seen the previous leadership of the United States, during Donald Trump’s presidency, adopt a blatant anti-science stance, with ad-hoc decision making, vaccine nationalism, and a deplorable attempt to weaken the only global public health body—the World Health Organization—in the middle of a pandemic.

In the US, the roots of democracy and accountability were strong enough to replace the president at the ballot box, but this has not been the case elsewhere. In Brazil, President Bolsonaro has adopted a Trump-like stance by denying the threat posed by covid-19. Bolsonaro has ridiculed mitigation measures and obstructed vaccination trials. Despite the mayhem this has caused and a covid-19 death toll of over 240 000 people in Brazil, he is still in power.² In Tanzania President Magufuli declared that “God had eliminated covid-19 from Tanzania.”³ He promoted prayer and herbal therapy, and continues to deny the effectiveness and rollout of large scale preventive measures—including vaccines. These are not isolated examples as similar denial and responses have been seen among other leaders, usually autocratic rulers with blatantly false narratives and an anti-science agenda.⁴

In a recent impassioned editorial in The BMJ, Kamran Abbasi accused many of our political leaders of “social murder or social neglect” and called for accountability and retribution.⁵ The charges are serious and not rhetorical. The damage from covid-19 is huge. In the US, the world witnessed a vicious campaign against Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, with the aim of discrediting his advice. The US Centers for Disease Control and Prevention was systematically marginalised, and US leadership and advisers surrendered to Trump’s false claims and unsound advice. While such politicisation of the pandemic may have been deliberate in the US, the UK government has lurched from misstep to misstep and exhibited poor leadership in the wake of confusing and often conflicting medical advice. In Sweden a massive social experiment to induce herd immunity against an unknown virus resulted in a covid-19 death toll tenfolds higher than neighbouring Nordic countries, mostly among older populations.⁶ 

Should politicians pay for these missteps? The track record for accountability by politicians isn’t encouraging. The great Bengal famine of 1943 is a case in point. When large scale food shortages began to take their toll on the starving masses in the streets of Calcutta, Winston Churchill chose to ignore advice and refused permission for ships laden with grain in Calcutta harbour to offload some of their cargo. Instead, he sent the grain to bolster Allied food reserves in Europe.⁷ By the time supplies were finally sent, it was too late to avert the estimated 2.1 to 3.0 million deaths.⁷ Thabo Mbeki’s presidency of South Africa (1999-2008) was notable for its official disdain for the scientific basis for HIV/AIDS and for denying patients access to effective antiretrovirals, an act which is estimated to have led to between 343 000 to 365 000 preventable deaths from HIV/AIDS in the country.⁸ Neither Churchill nor Mbeki were ever publicly charged or convicted in the court of public opinion. Nor do we see any moves to hold any of the leaders in the Arab world accountable for the criminal blockages of food supplies to starving women and children in Yemen while the pandemic rages on. 

While it may be futile to affix the blame on individuals and find scapegoats for the covid-19 death toll and economic consequences of the pandemic, we need systemic processes to ensure that such an abdication of public duty is no less than a crime against humanity, answerable to the international community. The Independent Panel for Pandemic Preparedness and Response, was strangely silent on the failure of political leadership in its recent report, and on the damage done by misinformation.⁹ And despite the threat posed to neighbouring states by unmanaged cases of covid-19 in Tanzania, the Organization for African Union did not issue a single statement to this effect or send a fact finding delegation. With the emergence of significantly more virulent SARS-CoV-2 variants, this dereliction of duty could cost Africa dearly in lives and livelihood. Although the prime minister of India, Narendra Modi later had the grace to apologise for his sudden imposition of a stringent lockdown on 25 March 2020,¹⁰ it still led to hundreds of thousands of urban migrant workers embarking on a long march back to rural villages. The action speaks volumes as to the human costs of such precipitous decisions. 

Despite this bleak picture, one can still take heart from some of the bright spots. A lot has been made of exemplar countries where strong, accountable—and often female—leadership was associated with effective public health policies and control. While the world focused on island states and economic powerhouses such as Taiwan, New Zealand, and Singapore, the exemplary performance of countries like Cuba, Sri Lanka, Rwanda, and the State of Kerala in India has often been neglected.

These positive examples include several common elements such as effective leadership, transparent communication and community engagement, social safety targeting the poorest populations, and strong equitable primary care programmes.¹¹ In a recent analysis of early covid-19 responses among 44 Muslim majority countries, a clear relationship between successful early flattening of the pandemic curve and countries’ ranking on the democracy index was noted, underscoring the importance of community engagement, compliance, and evidence informed decision making.¹² 

The covid-19 pandemic should refocus our attention on the importance of social determinants of health in poorer countries and the complexities of accountability in those settings. While abject poverty is a major driver, other factors such as ethnicity, gender, conflict, and displacement are also important. What can and should be done to ensure that the next pandemic isn’t characterized by the mayhem and dysfunction witnessed today? No matter how difficult, politicians and leaders who deliberately abuse their responsibility to their people should be potentially liable for human rights abuse outside of their jurisdictional boundaries.

The current disparities in covid-19 case burden, deaths, indirect effects, and now vaccine access, should be a wake-up call to return to the fundamental principles of equity and justice that underpin the sustainable development goals and multisectoral implementation. It isn’t surprising that comparable mindsets pervade covid-19 denial as well as climate change, and other ecological drivers of microbial threats and pandemics.¹³ We will hopefully find our way through the current crisis, but without fixing responsibility and accountability, the next pandemic could be much worse. 

Zulfiqar A Bhutta, Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada.

Competing interests: none declared.

References 

1. Johns Hopkins University. Coronavirus numbers and dashboard. February 14 2021. https://coronavirus.jhu.edu/map.html
2. Human Rights Watch. https://www.hrw.org/news/2021/01/28/brazil-crackdown-critics-covid-19-response 
3. Anna C. A nation refuses to follow its leader’s denial of COVID-19. Christian Science Monitor. January 29, 2021. https://www.csmonitor.com/World/Africa/2021/0129/A-nation-refuses-to-follow-its-leader-s-denial-of-COVID-19 
4. York G, Mackinnon M, Vanderklippe N, Morrow A. The notorious nine: these world leaders responded to the coronavirus with denial, duplicity and ineptitude. The Globe and Mail. 21 April 2020. https://www.theglobeandmail.com/world/article-the-notorious-nine-these-world-leaders-responded-to-the-coronavirus/
5. Abbasi K. Covid-19: Social murder, they wrote-elected, unaccountable, and unrepentant. BMJ 2021;372:n314. doi:10.1136/bmj.n314. 
6. Cumulative number of coronavirus deaths in the Nordic countries. https://www.statista.com/statistics/1113834/cumulative-coronavirus-deaths-in-the-nordics/
7. Keneally T. Three famines: starvation and politics. Public Affairs. New York. 2009
8. Boseley S. Mbeki Aids policy “led to 330,000 deaths”. The Guardian. 27 Nov 2008. https://www.theguardian.com/world/2008/nov/27/south-africa-aids-mbeki
9. Second Report on Progress. The independent panel for pandemic preparedness and response for the WHO Executive Board. January 2021. https://theindependentpanel.org/wp-content/uploads/2021/01/Independent-Panel_Second-Report-on-Progress_Final-15-Jan-2021.pdf
10. Schmall E, Husain A. Associated Press. Modi apologizes to Indians for 21-day lockdown hardships. March 29, 2020. https://abcnews.go.com/International/wireStory/modi-apologizes-indians-21-day-lockdown-hardships-69859501
11. Purkayastha S, Salvatore M, Mukherjee B. Are women leaders significantly better at controlling the contagion during the COVID-19 pandemic? J Health Soc Sci. 2020 Jun;5(2):231-240.
12. Jardine R, Wright J, Samad Z, Bhutta ZA. Analysis of COVID-19 burden, epidemiology and mitigation strategies in Muslim majority countries. East Mediterr Health J. 2020 Oct 13;26(10):1173-1183. doi: 10.26719/emhj.20.120. 
13. Joshi M, Caceres J, Ko S, Epps SM, Bartter T. Unprecedented: the toxic synergism of Covid-19 and climate change. Curr Opin Pulm Med. 2021 Mar 1;27(2):66-72. doi: 10.1097/MCP.0000000000000756.