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Millions of people out of work. Nationwide lockdowns keeping billions at home. Health care systems on the brink of collapse. And millions — plural — at risk of dying.

These are the consequences not only of the coronavirus outbreak but also what happens when world leaders deny its severity. Their actions, or rather inactions, have made the pandemic worse and all of us less safe.

From the United States to China to Iran to Italy, politicians facing life-or-death decisions early on in the outbreak minimized the global health crisis. They wasted precious time fighting reality, not the disease. And the results have been deadly.

“Denial results in a delayed response,” which usually leads to an exponential growth of infections, said Thomas Bollyky, a global health expert at the Council on Foreign Relations think tank. “Countries that were slow to respond have, so far, paid the price.”

China’s effort to suppress information about the virus when it first emerged helped it escape and spread around the world. And as Covid-19 spread, so did the denialism.

Last week alone, Mexican President Andrés Manuel López Obrador encouraged his people to eat out at restaurants, US President Donald Trump insisted most of America could start going back to work by Easter, and Brazilian President Jair Bolsonaro downplayed the coronavirus as “a little cold.”

Those leaders stand in stark contrast to their counterparts in places like South Korea and Germany who confronted the outbreak head-on, were honest with their publics, and saved lives as a result.

Their examples show that the added pain on multiple continents — the lack of tests, crowded hospitals, widespread fear, and mounting death tolls — wasn’t necessary. It was, in some ways, a choice. The coronavirus may currently be the world’s top threat, but a very close second is the political leader who doesn’t see it that way.

But why have so many leaders across the world responded like this? As Jeremy Shiffman, a health policy expert at Johns Hopkins University, told me, “You can’t clearly associate the denialism with a regime type or even a political ideology.”

So what explains it? Experts I spoke to suggested leaders might respond with denial for several reasons: concerns about harming their political fortunes or their nation’s public image; fear of harming the economy; individual leaders’ agendas; and belief that an outbreak won’t really be as bad as it sounds.

Whatever the reason, though, it’s now clear just how dangerous denial can be when it comes to handling a pandemic.

Politicians prioritize politics

As Vox’s Julia Belluz has written, China first announced the outbreak of a mysterious pneumonia on December 31. In the announcement, Chinese officials said that most of the patients had been to a food market in Wuhan; that there was “no clear evidence” of human-to-human transmission; and that the earliest case had shown symptoms only recently — on December 12.

It turns out that pretty much none of what Chinese officials said in that first announcement was true. As Belluz explains:

A study published on January 24 in The Lancet showed that in the first days China acknowledged the outbreak, by January 2, more than a third of patients had no connection with the Wuhan food market, including the outbreak’s index (or first) case. What’s more, that person became ill on December 1, nearly two weeks earlier than Wuhan health authorities had said of the first case.

But it gets worse. It’s not just that Chinese authorities got the details wrong. They were actively trying to suppress information about the burgeoning outbreak from both their own citizens and global public health experts. And they did so on the express orders of Chinese President Xi Jinping.

In the meantime, China let millions of people travel in and out of Wuhan, allowing the virus to spread. One recent study found that if China had acted to lock down Wuhan just three weeks earlier, it would have reduced the number of cases by 95 percent, thus “significantly limiting the geographical spread of the disease.”

The Chinese government is authoritarian, which helps explain its crackdown on embarrassing information from the start. But another important reason, experts say, is that China wants to be perceived as a stable world power. That’s hard to accomplish when new diseases keep originating in the country, like SARS did in 2003. To safeguard its global prestige, then, Xi and his underlings worked to keep news of the brewing crisis under wraps.

“There were definitely public image reasons why China did what it did,” Amanda Glassman, a health expert at the Center for Global Development, told me.

But while China may have been the first country to prioritize politics over public health in this pandemic, it wouldn’t be the last. Spain, and particularly Prime Minister Pedro Sánchez, had a tough choice to make. It was only in January that he formed a minority left-wing government, giving him a tenuous hold on power and making him one of the nation’s most historically weak leaders. Any move that might anger the population, especially his left-wing base, could see him lose control.

That led him to a fateful decision, experts say. Earlier this month, even as confirmed cases of coronavirus rose in Spain, Sánchez allowed thousands to attend soccer games and even permitted a 120,000-strong feminist rally in Madrid to proceed. The Spanish capital has now become the epicenter of the country’s outbreak, the world’s fourth largest.

Some experts I spoke to said that allowing so many people to congregate almost surely spurred a larger outbreak in the country, while others insisted it was too early to tell. But now that the country is on lockdown until mid-April, some who attended the rally said it was a bad idea.

“I regret going,” said Ellen Hietsch, an American expat living in Madrid, fearing the demonstration may have accelerated the spread. “I’ve felt anxiety ever since that I could be a carrier of the disease.”

Political aspirations have also kept Brazilian President Jair Bolsonaro from accepting the crisis his nation faces.

“In my particular case,” the 65-year-old leader said during a national address on Tuesday, “with my history as an athlete, if I were infected by the virus, I wouldn’t need to worry. I wouldn’t feel anything or, if very affected, it would be like a little flu or a little cold.” Only a few days later, he falsely asserted that Brazilians, somehow, are immune to the disease. (As of March 27, Brazil had nearly 3,000 confirmed cases.)

Bolsonaro’s denials are especially shocking as several of his close aides contracted the disease and, for a moment, it looked like he had it, too. Experts say the Brazilian leader’s denial partly stems from his more general reluctance to accept scientific evidence, as seen in his dismissal of climate change. But there’s also a clear political reason, they add: He’d like to gain more power for himself at the expense of the country’s democracy.

“He’s trying to advance authoritarian solutions to the problem,” Paulo Sotero, a Brazil expert at the Wilson Center think tank in Washington, told me. He’s openly fighting with governors who want to do more to stem the crisis, which some claim gives Bolsonaro an excuse to say they can’t be trusted to handle the situation correctly.

Instead, Bolsonaro — who has shown an affinity for Brazil’s past as a military dictatorship — wants to dismiss these regional leaders and concentrate more power in the presidency. “He’s seeking confrontation to adopt and impose control,” Sotero said. “He has very little attachment to democratic principles.”

The irony here is that his actions may have actually had the reverse effect: There are now editorials in major Brazilian newspapers calling for him to resign, and his poll numbers are declining.

His resignation is unlikely to happen, which means the coronavirus struggle in Brazil won’t just be a fight for public health. It’ll be a fight for the future of Brazil’s democracy.

Putting those cases together, it’s clear that the main political projects of Xi, Sánchez, and Bolsonaro clashed with taking necessary action against the coronavirus. That caused significant delays, hurting thousands in their countries and elsewhere.

But politics is only part of the answer to the epidemic of denialism.

Choosing economic growth over public health

There are widespread fears of a coronavirus-induced global recession or even a depression. That’s especially problematic for leaders who have built their entire brand on boosting their nation’s economy or who worry about what might happen if millions are suddenly out of work. Which is why some of them — from Mexico to Italy to the United States — prioritize economic growth over the measures required to curb a rise in infections.

Take Mexican President Obrador, known by his nickname AMLO. In speech after speech, he tells Mexicans they shouldn’t fear Covid-19. Despite warnings from global health officials, he continues to hold political rallies, kiss supporters, and request that Mexicans go out shopping to prop up the country’s sputtering economy during a global slowdown.

“Live life as usual,” he said in a video posted to Facebook on March 22, showing him outside at a restaurant. “If you’re able and have the means to do so, continue taking your family out to eat … because that strengthens the economy.”

That’s not to say the economy isn’t in urgent need. Petróleos Mexicanos, the country’s state-owned oil company, is deeply in debt and in crisis, especially as global oil prices plummet. The country’s economy contracted by 0.5 percent in the fourth quarter of last year, and many indicators point to a years-long slump. As the world confronts the possibility of a pandemic-induced recession, it’s not unreasonable for AMLO to want to boost the economy.

But his slow response, including a lack of widespread testing and provision of additional protective gear for medical professionals, has made Mexico less safe — thereby likely dooming its economy in the long run. “You need to prioritize people’s health and worry about how many might die before the economy’s health,” Alejandro Macías, who served as the Mexican government’s “czar” for the 2009 H1N1 influenza outbreak, told me last week.

Trump has a similar mindset to AMLO’s. After months of minimizing the problem, saying America had it under control, he eventually listened to medical experts who said the country needed to impose social distancing measures to slow the spread of the coronavirus. But after only a few weeks of that, the president wanted everything to go back to normal.

Trump said he wanted businesses open and people back to work by Easter, April 12. “What a great timeline that would be,” he said during a Fox News town hall this week. That went against the advice of experts who said the US needed to keep socially distancing for more weeks, perhaps even months.

But Trump continued to insist that the “cure” — shutting down the economy temporarily — can’t be worse than the disease. “America will again, and soon, be open for business,” Trump said last week. “Very soon. A lot sooner than three or four months that somebody was suggesting. A lot sooner. We cannot let the cure be worse than the problem itself.”

Now, however, Trump has reversed course once again, listening to his experts who said he should keep social distancing measures in place. He’s now extended the guidelines until April 30.

Trump isn’t entirely off base to want the country open for business again, though. Numbers from last week showed unemployment claims jumped to 3.3 million, which shattered the previous record of 700,000 in a single week. There is no looming economic disaster in America; the disaster is already here.

Related 9 charts showing what coronavirus is doing to the economy

Still, that’s not the entire picture. The debate isn’t “open for business” versus “closed for business,” but rather short-term pain versus long-term gain. Indeed, an economics paper released this week showed governments that take precautionary measures in a health crisis actually do better overall.

“We find that cities that intervened earlier and more aggressively do not perform worse and, if anything, grow faster after the pandemic is over,” the authors write. “Our findings thus indicate that [non-pharmaceutical interventions] not only lower mortality; they also mitigate the adverse economic consequences of a pandemic.”

The reason, according to Ashish Jha, director of the Harvard Global Health Institute, is that leaders need to take aggressive measures early on when the crisis doesn’t look so bad. “But when it gets bad if left unaddressed, it’s really late in the game, and the stuff you have to do is so much worse,” Jha told me.

It’s for these and other reasons that everyone I spoke to said that the leaders in denial need to get out of their heads and listen to the medical experts at a time like this. The experts are the ones who know what to do and aren’t burdened with the political responsibilities and calculations of world leaders.

But if the denialism continues, it’s not just political futures that are at stake, it’s people’s lives. “It’s in their political interest to address the pandemic,” says Johns Hopkins’s Shiffman, “but it’s also the right thing to do.”

The coronavirus doesn’t fit into many leaders’ agendas

Seminal work by political scientists Frank Baumgartner and Bryan Jones shows the importance of political agendas, and the impact they have on a leader’s time in power.

Simply put, a new political leader brings with him or her a new way of viewing the world. Anything that falls outside of that view tends to take a back seat to the leaders’ main concerns, regardless of how important that back-seat issue may prove to be.

“It’s not like epidemiology is at the forefront of any political leader’s knowledge,” said Baumgartner, now at the University of North Carolina Chapel Hill.

This is less of a partisan or ideological issue and more of a personal issue. The individual, more than the political leaning, explains one’s action in times of crisis.

Indeed, Georgetown Law’s global health and politics expert Matthew Kavanagh gave me the example of how Presidents Ronald Reagan and George W. Bush, both Republicans, handled the HIV/AIDS crisis.

Reagan didn’t want anything to do with it, Kavanagh said, since during his time it was seen as a problem primarily affecting gay men — not a key concern for the conservative president or his explicitly anti-gay-rights Moral Majority backers.

Bush, by contrast, came to power on the back of his “compassionate conservatism” push. “Compassionate means you care about people and the policies you enunciate help people,” he told the Catalyst magazine in 2018.

When he announced a major, well-funded program to combat the epidemic on the African continent in 2002, he told a Rose Garden audience that “the global devastation of HIV/AIDS staggers the imagination and shocks the conscience.”

He saw it as his duty, as president of the United States, to help solve the problem. The program was, and remains, one of the greatest global health initiatives in history. It proved so successful that pundits continue to note how popular Bush actually is in Africa.

All told, despite coming from the same political party, each politician had different priorities, which in turn led them to prioritize in vastly different ways.

In the case of the Covid-19 pandemic, world leaders such as Trump and Bolsonaro who denied the disease’s severity had their attention broadly tuned to gaining political power or growing their economy. That, in one sense, is normal. “Countries have political and economic incentives to underplay what’s happening” during an outbreak, the Council on Foreign Relations’ Bollyky told me.

But in another sense, combating the virus forcefully — risking other aspects of their time in power — would counter certain leaders’ agendas and biases. “Politicians need to fit what’s happening into their line of thinking,” Kavanagh said. “There’s a narrative that every leader and politician is constructing about who they are and how they govern. It’s very hard to shake them out of that, even when a crisis confronts them.”

For Trump, that narrative was that he had single-handedly Made America Great Again. The notion that with the coronavirus pandemic America might be facing a challenge unlike any it had faced in recent history — and, even worse, that it might not be prepared to handle it — ran counter to that narrative. If Trump has already made America great, surely it would be able to handle a few hundred sick people.

Trump’s failure to see beyond the mythology he’d created around his presidency led to a sense of overconfidence when it came to the coronavirus response early on — a deadly miscalculation.

“The boy who cried wolf” syndrome

It’s important to remember that the coronavirus isn’t the first big pandemic scare the world has faced in recent years.

In 2003, there was SARS. In 2009, there was the H1N1 influenza. In 2012, there was MERS. In 2014, there was Ebola. And in 2015, there was Zika. Each of these diseases spread around the world and killed thousands. But they didn’t produce the large-scale disruption that Covid-19 has in 2020. Instead, they were mostly contained to specific regions, like MERS was in the Middle East.

It’s therefore not terribly surprising that some leaders and their populations might not have taken the novel coronavirus scourge seriously. “I’m sympathetic to the fact that some leaders looked at this situation and thought, ‘We’ll be the one lucky country that this passes by,’” said Harvard’s Jha, “but that’s not how the world works.”

The other diseases were incredibly dangerous, but what makes Covid-19 so problematic is that it can take a long time for symptoms to show up. That means people can transmit it to one another even when they’re not showing symptoms. People who are infected can also be completely asymptomatic yet still transmit the virus.

All of that means the novel coronavirus is a lot more dangerous than those previous outbreaks. As Vox’s Daniel Markus notes, SARS and MERS (both of which are coronaviruses) together killed fewer people overall than this virus did in less than two months.

But in the early days of the outbreak, much of this information about the disease was not well known — in part because, as discussed above, Chinese officials actively covered up critical details about the virus.

A world leader seeing an outbreak in a specific region of China might understandably assume it would play out the same way previous coronavirus outbreaks have and not take drastic steps early on like closing borders and instituting stay-at-home orders.

“These are unprecedented steps that are called for, and so there would be a desire to engage in wishful thinking that it’s not as bad as the experts are saying,” UNC’s Baumgartner said.

And, interestingly, it seems that the leaders who didn’t engage in wishful thinking were, for the most part, in countries that had experience with previous disease outbreaks. South Korea was familiar with SARS and Saudi Arabia remembered MERS. Before the outbreak got much worse, they took the necessary actions — like closing borders early and testing often — to slow the spread.

That’s the kind of rapid, aggressive action that is still needed now. Denialism will only make it worse.