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What We Can Learn from Six Countries’ Pandemic Battle Plans

From Brazil’s complacency to New Zealand’s bid to wipe out COVID-19, a look at the options. First in a series.

Andrew Nikiforuk 13 Apr

Andrew Nikiforuk is an award-winning journalist who has been writing about the energy industry for three decades and is a contributing editor to The Tyee. He wrote two best-selling books on epidemics: The Fourth Horseman and Pandemonium, both published by Penguin Books. Find his previous stories here.

Laissez-faire. Lockdowns. Mitigation. Testing. Denial. Elimination.

The world has responded to the pandemic with a diversity of strategies.

Some appear to be working well, while others are just coping or failing altogether.

And history appears to have prepared some countries better than others.

Given that there is no drug or vaccine for COVID-19, public health officials have only medieval tools at their disposal: isolation, quarantine and contact tracing.

Few countries have applied these tools with right force in the right populations at the right time to combat a highly contagious and agile virus.

Every week for the next month, The Tyee will take the pulse of six different national pandemic responses including Brazil, South Korea, Germany, Sweden, South Africa and New Zealand.

These countries represent different science experiments tempered by culture, politics, economics and moral will. All have lessons for Canada.

And each offers the virus a different menu in terms of age, class, health and economic inequalities.

Please note that case numbers and fatalities provide only a vague and often inaccurate measurement about the prevalence of the virus.

Early results suggest that governments that test widely (and most of Canada has not done this), isolate effectively, trace all contacts and lock down early will have better outcomes both medically and economically.

We will revisit the experiments next week.

Sweden: 10,483 cases; 899 deaths; 10.2 million population

A woman returning from Wuhan City was the first confirmed case in Sweden on Feb. 4. Travellers from Italy and Iran generated more cases and community transmission is now widespread.

But Sweden has taken a laissez-faire attitude to the outbreak. Unlike its neighbours Norway and Denmark, the country did not impose a strict lockdown or close its borders. Cafes, shops and schools for those under the age of 16 stayed open. However, the government did recommend social distancing and limited gatherings to 50 people.

It also asked people over 70 to stay home.

Anders Tegnell, Sweden’s chief epidemiologist, has argued that the country’s “flexible” approach will slow the progress of the virus and protect hospitals from being overwhelmed.

Tegnell also thinks it is important for a good portion of the community to acquire immunity by contracting the virus. (England and the Netherlands initially considered this approach until models suggested that going for herd immunity would kill many members of the herd.)

The Swedish government’s approach assumes that it will impossible to contain the virus without a vaccine.

To date, this radical experiment has widely been condemned by many members of Sweden’s health community, which has called on the government to lock down Stockholm, the centre of the infections. “No one has tried this route, so why should we test it first in Sweden, without informed consent?” asked Cecilia Söderberg-Nauclér, a professor of microbial pathogenesis and one of about 2,300 academics to sign an open letter to the government calling for tougher measures to protect the health care system.

But Tegnell and others think a lockdown lasting a year to 18 months is unthinkable and would be socially destructive. Lockdowns lasting four months might flatten the curve, they argue, but the epidemic will come roaring back and force isolation again.

Sweden performs about 10,000 tests a week, focusing on hospital workers, the sick or those caring for the elderly.

Unlike other parts of Europe, Sweden is not densely populated. It has a high percentage of one-person households and only a small percentage of the elderly live with young adults or children.

Yet Sweden has now had more than twice as many deaths as Norway and Denmark combined, although together the two have a larger population. A third of the nation’s nursing homes have reported infections.

Meanwhile, the army has been building field hospitals to accommodate a surge in cases expected over the next two weeks in Stockholm and Gothenberg. And the government is seeking the authority to impose a lockdown if needed.

Brazil: 20,984 cases; 1,141 deaths; 210 million population

Researchers have traced the origins of Brazil’s fast-moving outbreak to 300 travellers from Italy who made Sao Paulo the epicentre of infection in mid-February. The first case was reported on Feb. 26.

Since then, Brazil’s elites have been arguing about how to protect the country’s 210 million inhabitants. Far right populist leader Jair Bolsonaro repeatedly minimized the virus as “a little flu” and has declared that “Brazil can’t stop.” In contrast, the country’s popular health minister, Luiz Henrique Mandetta, warned that Brazil’s health-care system could collapse by the end of April. Every day, thousands of Brazilians have banged pots demanding Bolsonaro’s resignation.

While Bolsonaro still belittles the virus, many of his ministers and local politicians started to act in mid-March. Twenty-four of Brazil’s 27 states have instituted their own lockdown measures, including strict isolation rules, school closures, bans on gatherings and the shutdown of intercity bus traffic.

Many of Brazil’s poor — some 38 million work in the informal economy — have no access to running water and live in densely packed shanty towns or in the country’s impoverished northeast. Most of Brazil’s elderly live with family members, a factor that increased the severity of Italy’s outbreak.

Brazilian researchers have noted that social distancing will have its limits among the poor where “living conditions will make it difficult to adhere to hygiene and isolation protocols.”

South Africa: 2,028 cases; 25 deaths; 58 million population

South Africa’s first cases appeared in early March among wealthy residents returning from Italy. As a result, many Black South Africans initially referred to it as the “white virus.”

The epicentre of South Africa’s outbreak is in Gauteng province, which includes Pretoria and Johannesburg.

On March 27, President Cyril Ramaphosa imposed a total three-week lockdown for the nation’s 57 million people, often brutally enforced by 18,000 security officers.

On March 30, the government said it would begin a screening, testing, tracing and monitoring program employing 10,000 field workers. Workers were directed to visit homes around the country and scan people for symptoms. Only the sickest would be sent to hospitals.

Unlike like some African countries, South Africa knows how to respond to respiratory diseases, as shown by ongoing campaigns against HIV and tuberculosis. Nearly eight million people live with HIV in South Africa and hundreds of thousands suffer from tuberculosis. Both populations are highly dependent on drugs manufactured in China.

In addition, nearly seven million of the nation’s 58 million people work in the informal economy and live in shanty towns.

China has sent masks, testing kits and other supplies to South Africa and other parts of the continent, but many Africans perceive Chinese products as poor quality. They are also questioning their colonial dependence on its growing economic might on the continent.

851px version of covid-secondary.jpg
Soldiers of the German Army test people with possible COVID-19 symptoms. Photo from EPA/Ronald Wittek.

Germany: 125,452 cases; 2,871 deaths; 83 million population

Germany is one of the most densely populated places in Europe and one of world’s top 10 viral hot spots.

It recorded its first case in January, when a symptomless Shanghai business woman seeded the first cluster. Community transmission was amplified by young and affluent skiers on winter vacations. The average age of those infected is around 49, younger than in other European nations.

Like most European countries, Germany was not quick to act. It didn’t impose a lockdown and social distancing until late March, a week after France and Spain did.

Germany has tested widely, but at the current rate of 70,000 tests per day (Britain manages 8,000) it would still take more than three years to test the entire population.

Given a fear of running out of test kits or the needed chemical reagents, the Robert Koch Institute recently recommended the country not test people without symptoms. But early and widespread testing did allow authorities to dampen clusters of infections like an outbreak in Gangelt. All testing is free.

At the same time, Germany has experienced many of the same problems that have hobbled other countries, including Canada: delays in communicating test results; equipment shortages; overworked medical staff; and insufficient supplies of reagent for virus testing. Disease models have suggested that Germany must increase testing from 70,000 tests a day to 200,000 to keep deaths from exceeding 12,000 fatalities out of a possible one million infections.

Although it remains a global hot spot, Germany has managed to keep its death rate at around 1.5 per cent compared to Italy’s 12 per cent.

Observers offer a number of reasons: plain luck; the fact that it’s still early days in the epidemic; a well-organized health-care system; widespread testing; lots of hospital beds; and a competent government. Germany’s 16 states (like Canada’s provinces) have their own health-care systems, and they’re well coordinated with federal bodies and the Robert Koch Institute, which researches and advises on public health.

Germany’s wealth and superior resources have also played a role. It produced the first reliable diagnostic test kit by Jan. 16. And German researchers were the first to establish that the virus can multiply not just in the lungs but the throat and digestive tract. They also were the first to flag silent carriers with no symptoms as critical drivers of infection in the community.

Angela Merkel has called the crisis a “symmetric shock” to the body politic and said that it is too early to lift restrictions.

South Korea: 10,512 cases; 214 deaths; 52 million population

In early January and February, South Korea thought it had COVID-19 under control, finding just 30 cases, mostly in travellers. But case 31, a woman who belonged to a secretive church in Daegu, became a super spreader. Within a week there were 2,300 cases, with the outbreak concentrated in young recruits of the Shincheonji religious cult.

In response, the government created a task force composed of regional and city government representatives. Regions with few cases sent equipment and staff to those areas overwhelmed by the virus.

Unlike other countries, South Korea didn’t lock down; instead it focused on extensive testing and painstaking contact tracing of the infected followed by isolation of their contacts for up to three weeks. However it did close its schools until early April.

An earlier coronavirus outbreak prepared the country. In 2015, a traveller introduced the Middle Eastern Respiratory Syndrome to a Korean hospital. It infected 185 people and killed 38. That experience convinced the government that it needed to support rapid analysis and testing of infectious diseases. Unlike Canada, South Korea was prepared for COVID-19.

As a result, in late January the government granted emergency approval to four firms to produce up to 14,000 testing kits a week. The government also set up 612 testing centres, including the now famous drive-through centres. Testing is free for people with lung problems or doctor referrals; everyone else pays $185.

The country boasts a modern and efficient universal health-care system with about 12 hospital beds per 1,000 inhabitants. (Canada has about three beds per 1,000 people.)

According to an analysis by the Asia Pacific Foundation of Canada, South Korea has tested one in 108 citizens. British Columbia and Alberta both have higher testing rates — one in 101 and one in 67 respectively. Ontario lags behind with one in 181 residents tested.

South Korea’s success to date is all the more impressive given that almost 20 per cent of young adults live with older parents in South Korea, increasing the risk of transmission to vulnerable older people.

New daily cases peaked at 813 in February and now average around 50 a day.

“Normal after the virus is going to look very different,” warned South Korean Foreign Minister Kang Kyung-wha. “This will be with us for a long time.”

New Zealand: 1,330 cases; four deaths; 4.9 million population

Unlike most Western countries, New Zealand has no interest in “flattening the curve” or slowing the virus’s progress. Instead it has chosen to eliminate the virus within its borders.

New Zealand recorded its first cases in late February due to travellers returning from Italy and Iran.

In early March, the popular tourist destination, which has a large Indigenous population, instructed all international visitors to self isolate for 14 days. On March 19, the country closed its borders to all international travellers. On March 23, Prime Minister Jacinda Ardern ordered a national lockdown within 48 hours. “We currently have 102 cases,” she said. “But so did Italy once.”

She closed all but essential services for four weeks and implemented a strong social distancing regime along with economic support for citizens. She banned going to the beach and hunting in the bush. Ardern even dressed down her health minister for breaking the rules. She is now considering mandatory quarantine for citizens returning after the lockdown.

To eliminate the virus the nation has ramped up its testing, contract tracing and quarantine programs.

New Zealand has heightened awareness of a pandemic’s impact on the poor. During the Spanish Flu pandemic it governed Western Samoa as a protectorate. The government failed to warn or protect the territory from the arrival of a ship carrying the flu. As a result, 22 per cent of the population died. New Zealand didn’t apologize until 2002.

Epidemiologists writing in the New Zealand Medical Journal say the elimination strategy’s success is “far from certain” but champion its many benefits over so-called mitigation efforts to slow the pandemic — Canada’s approach.

“If started early it will result in fewer cases of illness and death,” they write. “If successful it also offers a clear exit path with a careful return to regular activities with resulting social and economic benefits for New Zealand.”

Elimination requires a high degree of border security and extensive testing and contact tracing.

In the last 15 days, the number of new cases reported daily in New Zealand has fallen from 80 to 29.  [Tyee]

Read more: Health, Coronavirus

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