Lessons from the frontline: how to stop the spread of COVID-19

By on 26/03/2020
Countries like China, South Korea, Taiwan and Singapore have managed to slow the spread of infection and have either maintained, or are starting to get back to, normal life. (Photo by Nicolò Lazzati via flickr).

Countries have adopted very different approaches to combating coronavirus – and had wildly different results. Mia Hunt explains how some Far Eastern countries have successfully prevented its spread, and identifies the errors that led Italy to disaster

In 2015, former Microsoft chief Bill Gates gave a TED talk entitled ‘The next outbreak? We’re not ready’. In it, he predicted with sobering accuracy the world’s current predicament. And many western countries clearly weren’t remotely ready: in Italy, Spain and the UK infections and deaths are spiralling, while movement controls bring economies to a standstill. But some Far Eastern nations have managed to control the virus’s spread while maintaining people’s ability to travel and work. Countries that have yet to suffer widespread infections still have time to save their economies and people’s freedoms – but only if they act quickly to replicate the strategies that have proved so effective overseas.

At last count, 172 countries had confirmed coronavirus cases. The outbreak started in the city of Wuhan, China, in December. The Chinese government and Wuhan officials have been heavily criticised for initially covering up the virus, silencing medics and denying reports of a new virus. The delay has had huge costs: a study published in March indicated that if Chinese authorities had acted three weeks earlier to impose controls, the number of Chinese coronavirus cases could have been reduced by 95%. Had they acted just one week later, the study found, the number of victims would have tripled.

China: cover-up then shut-down

However, when China did act, it did so robustly. On 23 January, six weeks after the first cases were discovered, Wuhan and three other cities – with a combined population of 58 million – were put into lockdown and movement out of the area barred. By that date, the country had recorded 800 infections and 25 deaths.

Within the quarantine area, movement was tightly controlled while the government acted to trace and isolate infected people. Those identified in testing – some of it involving house to house searches – were ordered to remain in their homes, supplied by daily visits by heavily-protected workers. And their isolation was carefully policed, with measures including stationing guards outside apartment buildings; encouraging residents to monitor each other’s activities; having people scan QR codes to prove they had not broken isolation rules; using tracking apps and data from state-owned telecoms firms; and arresting people for minor infringements.

Not all of these measures could be comfortably replicated in democracies (though western governments are rapidly taking powers to replicate many of them), but the lockdown and isolation measures have proved successful in halting the virus’s spread. Three months after one of the earliest known patients began feeling ill on 10 December 2019, China reported that the number of new cases had dropped to almost zero. 

South Korea: stumble and recovery

South Korea is the only other badly hit country to have flattened the curve of new infections. On 29 February, the country recorded 909 new cases. But within a week, the number of new cases had halved. It halved again over the next four days, and then within a single day.  

As in China, mass testing to identify those infected – whether or not they displayed symptoms – was key to success. The country has conducted over 300,000 coronavirus tests: far more than any other country, and 40 times more than the US on a per-capita basis. Not only did this enable it to isolate and treat scores of people soon after they were infected – segregating mild cases in special centres, to prevent hospitals being overwhelmed – it also helped to impress the seriousness of the situation on the nation. Infected people were ordered to isolate themselves, downloading an app to track their movements; violations attract fines of up to US$2,500.

“South Korea banked on people changing their behaviour as a result of massive testing,” Michael Mina, assistant professor at the Center for Communicable Disease Dynamics at Harvard University told Wired. “And that has shown pretty extraordinary benefit to curbing an epidemic that was really roaring.”

The US and South Korea have opened drive-through testing hubs. (Photo by Airman 1st Class Brooke Moeder/US Air Force).

The government acted fast to increase its testing capacity. Just one week after the country’s first citizen was diagnosed in late January, government officials met with representatives from several medical companies. They urged the companies to begin developing coronavirus test kits for mass production: it is now manufacturing 10,000 kits a day and, according to The New York Times, officials say they are in talks with 17 foreign governments about exporting them.

In total, South Korea has opened 600 testing centres – 50 of them drive-throughs. In an interview with the BBC the country’s foreign minister, Kang Kyung-wha, said mass testing had played a crucial role in keeping its fatality rate down. And testing was supported with other measures, including the use of thermal cameras and remote thermometers in offices, hotels and restaurants to identify people with fevers. In combination, the measures allowed authorities to pinpoint and deal with pockets of infection without the need to limit people’s movement en masse.     

South Korea: clear public messaging

Equally importantly, South Korea has been relentless – and very clear – in its public messaging. Visitors from abroad are required to download an app that guides them through self-checks for symptoms; citizens’ mobile phones receive emergency alerts whenever new cases are discovered in their districts; and websites and apps provide detailed timelines of infected people’s movements, allowing others who may have been exposed to get tested.

Meanwhile, television broadcasts and train station announcements remind people to practice social distancing and disseminate other important information.

The New York Times reported that polls show majority approval for the government’s efforts and that confidence is high, panic low, and hoarding unusual. “Public trust has resulted in a very high level of civic awareness and voluntary cooperation that strengthens our collective effort,” Lee Tae-ho, South Korea’s vice minister of foreign affairs, told reporters earlier this month.

The head of the World Health Organization, Tedros Adhanom Ghebreyesus, has hailed South Korea as demonstrating that containing the virus “can be done”, and urged countries to “apply the lessons learned in Korea and elsewhere”.   

Taiwan: prevent entry

Taiwan, Hong Kong and Singapore also acted early and fast – and have managed to keep a lid on infections. In all three countries, cases have not exceeded more than a few hundred cases and deaths remain in single digits.

Taiwan – which is only 81 miles from mainland China – managed to delay its first case until just 10 days before the virus reached Italy. The government started tracing and testing passengers from Wuhan as soon as China warned of a new type of pneumonia in the city in December. “Suspected cases were screened for 26 viruses, including SARS and MERS,” according to a Stanford Health Policy report. “Passengers displaying symptoms were quarantined at home and assessed whether medical attention at a hospital was necessary.”

Governments which don’t act swiftly are in danger of overwhelming healthcare services. (Image courtesy: The Kremlin).

Determined to understand what they were up against, Taiwanese officials went on a fact-finding mission to China. By late January, the government had established the Central Epidemic Command Center, centralising policy measures to protect public health. Business Insider reported that 124 safety protocols were then introduced, including banning flights from Wuhan; introducing social distancing and contact-tracing protocols; and deploying public-health infrastructure, data analytics, affordable healthcare, and extensive educational outreach in the fight against the virus.

Singapore: detective work

As in other Far East countries, Singapore has kept coronavirus in check through aggressive testing methods, intensive tracing of carriers and clear public messaging. Throughout, schools have remained open and businesses operational.

As in Taiwan, Singapore increased security at its borders as soon as news of the virus emerged from China. Meanwhile it mobilised scientists to start developing testing kits, which were later deployed in a mass testing drive. And it set up a dedicated 6,000-strong team who use CCTV footage and interviews to meticulously track down the contacts of confirmed cases. More recently, the Singapore government launched the TraceTogether app: this tracks people’s movements, enabling the government to identify anyone who’s spent more than 30 minutes in the company of someone later diagnosed with the virus.

All those who may have been exposed are then contacted and told to self-isolate until they can be tested and cleared. Those in isolation are contacted several times a day, and required to send photographic evidence of their exact location. Stiff fines or even jail terms await those who break the rules.

Singapore has now identified 683 cases, and suffered just two deaths.

Italy: delay – then total lockdown

In stark contrast, Italy – which reported its first cases a week after Singapore – has now suffered more than 74,000 cases and 5,500 deaths. The country has now imposed some of the toughest measures in the world, allowing people out of their homes only for solitary exercise, grocery shopping or medical treatment; violators face fines of up to US$3,200 or three-month jail terms. But during February officials played down the seriousness of the situation, and failed to introduce widespread testing and tracing measures.

As the situation worsened, they took a piecemeal approach to lockdown – isolating towns, then regions, before barring movement throughout the country. Forewarned that northern cities would be entering lockdown, many people fled south – carrying the virus with them. And while the president of the Veneto region ordered blanket testing, central government said it was a drain on resources. By the time the whole country went into lockdown on 9 March, 7,375 people had tested positive and 366 had died.

“If we had shut everything in the beginning, for two weeks, probably now we would be celebrating victory,” Attilio Fontana, president of the worst-affected Lombardy region, is reported as saying.

“Now we are running after it,” Sandra Zampa, the under secretary at the country’s Ministry of Health, told the The New York Times. Her assessment is that the country looked at the example of China not as a practical warning, but as a “science fiction movie that had nothing to do with us”. And when the virus exploded, Europe, she said, “looked at us the same way we looked at China”.  

Italian PM Giuseppe Conte at an emergency coronavirus meeting on 23 February. (Image courtesy: Dipartimento Protezione Civile via flickr).

Although Italy was the first country in Europe to block flights coming in and out of China, prime minister Giuseppe Conte is understood to have ignored an earlier plea by officials to quarantine schoolchildren in the northern regions who, some being from Chinese immigrant families, were returning from holidays in China. Later, calls for tougher national measures by healthcare officials were also ignored. And senior politicians sent out mixed messages: the foreign minister was disparaging about media coverage highlighting the threat of contagion; Milan’s mayor publicised the ‘Milan Doesn’t Stop’ campaign, encouraging residents to continue living as normal; and Nicola Zingaretti, leader of the country’s governing Democratic Party and president of the Lazio region, posted a photo of himself clinking glasses for “an aperitivo in Milan” and urged people not to change their habits.

The mixed messages, lack of concerted testing and late, staged lock-down measures allowed the virus to overwhelm health services, leading to very high death rates among new patients.

The UK: following Italy’s path?

In the UK, the government’s messages were initially confused – apparently due to tensions between prime minister Boris Johnson’s aides and the government’s scientific and medical advisers. While Johnson advised people to begin ‘social distancing’, working from home and avoiding social events, newspapers were being briefed that the government might allow enough people to become infected to create a ‘herd immunity’. And Johnson himself was plainly uncomfortable with heavy-handed measures, acknowledging that ordering pubs and restaurants to close was an infringement on the “inalienable free-born right of people born in England to go to the pub”.

UK PM Boris Johnson announces tougher restrictions as he addresses the nation from Downing Street on 23 March. (Photo by Andrew Parsons/No 10 Downing Street via flickr).

But as the number of infections rose and further evidence emerged of the likely death rates if hospital services were overwhelmed, the advice was strengthened. On 16 March, Johnson advised against going to the pub; a week later, he introduced lockdown. By then, 6,650 had tested positive for coronavirus and 335 people had died – numbers that are close to Italy’s at the point lockdown was imposed.

Neither Italy nor the UK adopted mass testing or made concrete efforts to trace people who might have been infected. And the UK still looks very slow on the medical front: even NHS workers are not being routinely tested, and health services are short of protective equipment, respirators and hospital beds. Already, some parts of the NHS are being overwhelmed: when one London hospital trust ran out of intensive care beds, it saw 21 deaths in four days. It has been reported that intensive care doctors and nurses are receiving training on who to prioritise – and therefore, effectively, who to allow to die – in cases where hospital beds and life-saving equipment are not available for all patients. The next few days will decide whether the UK acted quickly enough to avoid Italy’s fate.

Learn the lessons

Italy’s experience represents a warning to countries that still have time to contain the contagion. Though some measures – such as the tracking apps which have helped identify infected people in the Far East – would raise concerns about freedom and privacy in many countries, the lockdowns in place across vast swathes of Europe leave people with far less personal freedom than that enjoyed by Taiwanese and Singaporeans today. And there are less controversial measures that can be put in place everywhere: the preparation and expansion of health services; widespread testing and tracing; social distancing and personal quarantine measures; and clear messaging. Together, these actions have prevented infections spiralling out of control in Far Eastern nations, avoiding both high death rates and general lockdowns.

As Bill Gates warned, much of the world was not ready for the arrival of COVID-19. But some countries responded rapidly and effectively to protect their citizens – and others, where infection rates remain low, still have the chance to do so. The governments which have failed to react well, leading to huge personal and economic harm, will soon have to explain to their citizens why they got it so wrong. It is not too late for those as yet relatively unharmed to ensure that, when the time comes, they have a happier story to tell.

About Mia Hunt

Mia is a journalist and editor with a background in covering commercial property, having been market reports and supplements editor at trade title Property Week and deputy editor of Shopping Centre magazine, now known as Retail Destination. She has also undertaken freelance work for several publications including the preview magazine of international trade show, MAPIC, and TES Global (formerly the Times Educational Supplement) and has produced a white paper on energy efficiency in business for E.ON. Between 2014 and 2016, she was a member of the Revo Customer Experience Committee and an ACE Awards judge. Mia graduated from Kingston University with a first-class degree in journalism and was part of the team that produced The River newspaper, which won Publication of the Year at the Guardian Student Media Awards in 2010.

5 Comments

  1. Kam

    26/03/2020 at

    A well informed post but you haven’t mentioned much about Hong Kong. In particular, Hong Kong has a larger population with a border next to China but has fewer cases than Singapore. The world has much to learn from Hong Kong is dealing with the Coronavirus crisis.

  2. Lynda

    27/03/2020 at

    Very concise and informative article, but at the other commentator, Kam posted, there is a curiously absence of the Hong Gong data. It would be of great interest to include considering its location.

  3. Maria Filios

    27/03/2020 at

    And now Mr. Boris Johnson has tested positive. Perhaps he should have heeded the scientists….

  4. Esther Wong

    27/03/2020 at

    Lessons learned? Close the borders and restrict travels in the FIRST place for god sake. Ignore the politics from other countries for criticizing border closure (like what Europe did). Look at them now? Infection widespread and out of control. They were stupid. This is about protecting your own citizens. Don’t be like Italy. Infection was spread by infected travellers. Countries that had the borders closed and ban travels early from the start showed excellent control of spread of infection. Canada and USA had the chance stop the infection from spreading. Canada and USA could thrive as they were literally overseas. But politics delayed their response. USA and Canada had stupid people for government playing politics and for keeping the doors open during the outbreak.

  5. Paul Baines

    30/03/2020 at

    Perhaps Bill Gates should have looked closer to home in his TED talk. Countries with affordable health care, like Taiwan, contained the spread of the virus and mitigated deaths. Gates just has to look at his “homeland” where citizens are all “equal” to see how unequal they really are.

Leave a Reply

Your email address will not be published. Required fields are marked *