As COVID-19 burns its way through Latin America and southern Asia, the future of this accelerating pandemic remains unknown. Will it evolve into smaller waves of recurring outbreaks or reappear in the fall as a monster second wave? Or will it become a persistent threat ever circulating in the global community like its coronavirus cousins, which appear with cold-like regularity?
Whatever path the virus follows, experts warn that citizens should expect another 18 to 24 months of coronavirus activity at the very least.
But the world’s nations now have a better idea of what constitutes an effective public health response, and it’s not dithering.
Two months ago, The Tyee began a series to track and compare the fortunes of six different nations — New Zealand, South Africa, Brazil, Sweden, Germany and South Korea — as they grappled with the pandemic.
Clear winners and losers have emerged.
New Zealand eliminated the virus from its geography with teamwork. But the island nation now must watch its borders and seaports like a hawk.
In contrast Brazil, governed by a right-wing populist who denigrated the viral threat as a measly cold, may eventually bury more citizens than Russia, the United Kingdom and the United States, the current global leaders in deaths and infections. Brazil also faces economic ruin and widespread civil unrest.
Each of the six nations tracked by The Tyee has its own particular hard lessons to offer in terms of policy.
Nations such as South Korea and New Zealand that acted quickly and focused on containment or elimination have done better than those that moved slowly and only focused on slowing the virus, the strategy called mitigation.
Nations governed by women have fared much better than jurisdictions run by men. Germany and New Zealand top our list. (Taiwan and Iceland have also done exceptionally well with female leadership.)
Nations that tactically deployed testing, contact tracing and social isolation have experienced the greatest public health and economic successes, proving you can’t have one without the other.
But their choices don’t tell the whole story. The virus has hunted humans capriciously. It has hammered some communities while leaving others relatively unscathed, indicating factors other than public health policy at play in differing results (see sidebar).
In a bit we will break down the specific experiences of the six nations tracked by The Tyee.
First though, a broader overview: National responses around the world generally fall into one of six categories: Rapid Containers; Mitigators; Eliminators; Herders; Deniers and Copers.
The Rapid Containers. Based on previous experiences with outbreaks originating in China, a group of Asian nations acted early without resorting to lockdowns. Instead they focused all of their energies on early and rapid testing, tracing and isolation of the infected with the goal of stamping out the contagion.
These quick responders reversed the rate of epidemic growth and punched down the reproductive rate to below one. (That means one infected person infects fewer than one person.) Taiwan, Hong Kong, Singapore and South Korea achieved early success this way. Other countries including Finland, Greece and Iceland responded quickly, and have largely contained the virus. Yet Singapore and South Korea continue to battle and contain outbreaks.
The Mitigators. High-income nations in Europe and the Americas including Canada took a different approach. They initially focused on slowing but not stopping the spread of the virus, so hospitals would not get overwhelmed. Some nations such as Germany used their lockdowns to improve testing, tracking and isolation procedures. Others like Canada did not marshal a co-ordinated response, and continue to struggle as steady cases plague Ontario and Quebec.
The Herders. A couple of nations chose to risk herd immunity by exposing their populations to the virus. The Netherlands and England abandoned this experimental course when it became clear many members of the herd would die in the process. Sweden, however, offered voluntary public health measures but no lockdown. As a result this rich nation experienced one of the world’s highest death rates. It neither contained nor eliminated the virus. Nor did it achieve herd immunity.
The Eliminators. Next come those nations that aimed for elimination. After botching the initial outbreak for weeks, China came down hard on the virus with lockdowns, quarantines and isolation of the infected. It recently retested nine million people in Wuhan in an effort to eradicate the virus. Australia and New Zealand have taken similar courses. Elimination, as opposed to mitigation, gives nations much more freedom to manoeuvre provided they monitor their borders closely and maintain active surveillance. China, New Zealand and Iceland and a few other nations prove that the virus can be contained within a one to three-month period with the right combination of responses including the restriction of mobility and active case finding.
The Deniers. The populist leaders of the U.S., Russia, the U.K., Brazil and Mexico minimized the virus, reacted slowly to the threat and then responded in a poorly co-ordinated fashion. These nations have experienced the highest infection and death rates in the world. They all represent one singular tragedy: their largely narcissistic leaders could not imagine the power of the exponential function.
The Copers. Many poor nations in Latin America, Africa and Asia don’t have well-funded public health systems, let alone adequate health care. Yet they are used to coping and adapting to tragedies with scarce resources at hand. South Africa, for example, has built on its experiences with HIV and TB, to fight the coronavirus with more invention than many developed countries.
Here’s a by-the-numbers snapshot of where Canada’s performance stands today:
Canada: 97,779 cases; 7,910 deaths; 37 million population. Deaths per million: 213
Those figures put Canada in the top 20 countries in terms of infections and in the top 10 in terms of deaths. Its performance has been mediocre, and it is still struggling with testing and tracing in its most populous provinces.
Let’s move on now to comparing the performances of the six other nations we’ve looked in on three times previously.
Sweden: 45,924 cases; 4,717 deaths; 10.18 million population. Deaths per million: 457.52
State epidemiologist Anders Tegnell at the National Institute of Public Health hasn’t admitted total defeat yet, but he has suggested that the so-called Swedish or common-sense model has led to more deaths than neighbouring Nordic countries.
"If we were to encounter the same disease again, knowing exactly what we know about it today, I think we would settle on doing something in between what Sweden did and what the rest of the world has done,” he recently told Swedish public radio. The nation, he added, should have tested more and done a much better job of protecting citizens in long-term care.
Tegnell’s laissez-faire approach kept restaurants, schools and bars open while recommending social distancing with no lockdowns. Tegnell thought this lax approach would slow the virus with a minimum of fuss while preventing the prospect of a second wave by letting immunity slowly build in the population.
But the experiment failed on multiple fronts. It did not protect the economy, which has floundered. It did not protect 25 per cent of the population — new immigrants — who lived in high-density housing with several generations under one roof. It did not protect seniors who accounted for more than half of the nation’s nearly 5,000 deaths.
Sweden completely downplayed the importance of asymptomatic carriers — particularly wealthy skiers who imported the infection from the Italian Alps. And it failed to generate much herd immunity: fewer than 10 per cent of Stockholm’s population had developed antibodies by the end of April.
Björn Olsen, a professor of infectious medicine at Uppsala University, told the Guardian that herd immunity was a “dangerous and unrealistic” approach. “I think herd immunity is a long way off, if we ever reach it.”
The New York Times noted that almost 30 per cent more people in Sweden died during the pandemic than the normal rate there, an increase similar to death rates recently experienced in the U.S. “It’s not a very flattering comparison for Sweden, which has such a great public health system,” Andrew Noymer, demographer at the University of California at Irvine told the newspaper.
Sweden’s lax approach to the coronavirus has given it one of the world’s highest virus mortality rates, with 457 deaths per million inhabitants. That’s four times more than neighbouring Denmark, and 10 times more than Norway. Both nations imposed strict lockdowns.
The virologist William Haseltine said the Swedish model now stands as a stark warning to U.S. jurisdictions struggling with testing, tracing and social distancing.
“The data from Sweden tells us what is likely to happen next — an ever-accelerating increase in the rate of infection followed by a rising death toll. That, in turn, is very likely to be followed by continued restrictions on public gatherings, school openings and public confidence in our government’s ability to protect us.”
South Korea: 11,852 cases; 274 deaths; 51 million population. Deaths per million: 5.29
South Korea was one of the first Asian nations to rapidly reverse the virus’s inroads with testing, tracing and isolation. After it reduced new cases to about 10 a day, it eased restrictions last month, mandating “daily distancing” complete with a 68-page coronavirus etiquette guide. Constant monitoring and screening now dominate daily life as South Koreans once again line up at restaurants and attend museums. Students, for example, get their temperatures checked four times a day even though many cases never display a fever.
But one week after easing the restrictions, medical authorities have been battling one outbreak after another.
First there was a super-spreader event at nightclubs and bars in Seoul’s Itaewon gay district, prompting a flurry of homophobic reporting in the country. Authorities were only able to contact about one-third of nearly 5,000 people who visited the bars. The government immediately closed 2,100 nightclubs and discos.
Next came outbreaks at churches and table tennis clubs. Another outbreak involving more than 100 people occurred at an e-commerce centre.
Then a health product retailer, Richway, held a promotional reception for older people in a poorly ventilated building in Seoul that resulted in more than 50 infections. Other clusters have also shut down 541 schools that reopened in the Greater Seoul area.
When the country began to ease restrictions in early May, the government calculated that its medical system could comfortably handle 50 new cases a day, provided authorities could trace 95 per cent of the infections. One month later South Korea is nearing that threshold with more than 50 cases a day. The country expects a long summer of fighting COVID-19 wildfires in its population.
Germany: 186,309 cases; 8,729 deaths; 82 million population. Deaths per million: 104.78
In early May, Germany’s 16 autonomous states agreed to ease the national lockdown. The states, which follow their own paths, have agreed to one critical condition: whenever new cases rise above 50 in 100,000 inhabitants for a week in one locale, the local authorities must re-impose restrictions.
Like South Korea, Germany has since seen a flurry of outbreaks as the number of daily infections has doubled to nearly 500 in the last week. Clusters have appeared in meat-packing plants, nursing homes, churches and restaurants.
Chancellor Angela Merkel has argued the reproduction rate must be held below one (one person infects fewer than one) to prevent the health system from being overwhelmed.
To achieve that goal, the country has built up an extensive low-tech contact tracing system that doesn’t use invasive digital tools due to widespread privacy concerns. There are five contact tracers for every 25,000 people, or about 16,000 for Germany’s 83 million people. They primarily do their work the old-fashioned way: by phone.
One health official told the Washington Post that the country expects more clusters, but “now we have a way to handle it that works, that’s already proven to work, so we sleep a bit better than before.”
Germany’s unflappable leadership and the high quality of its well-funded health-care system has been credited with the nation’s low death rate compared to other European nations and the U.S.
Neuroscientist and COVID-19 modeller Karl Friston of University College London, who has compared Britain’s high coronavirus fatalities with Germany’s low rate, suggests unknown factors might be a playing role. He recently told the Guardian it is increasingly likely “that Germany has more immunological “dark matter” — people who are impervious to infection, perhaps because they are geographically isolated or have some kind of natural resistance.”
Meanwhile Germany’s new normal includes protests against the pace of the easing of public health restrictions. Many of the protests have been organized by the far-right populist Alternative for Germany party.
New Zealand: 1,504 cases; 22 deaths; 4.9 million population. Deaths per million: 4.5
After imposing one of the world’s strictest and earliest lockdowns for a month, New Zealand is now coronavirus free. For the moment, at least. For the first time since Feb. 28, the nation has no cases. The island’s last one was a 50-year-old woman in Auckland who tested positive 10 days ago. New Zealand has now eased other restrictions on gathering and economic activities. It is the world’s first nation with more than 1,000 cases to declare itself free of the virus.
Tom Baker, the University of Otago epidemiologist who helped craft New Zealand’s elimination strategy, attributes the nation’s success and that of Germany, Taiwan and Finland partly to a willingness among their political leaders to listen to scientists. He recommends that the government make the wearing of cloth masks mandatory on public transport, on aircraft and at border control and quarantine facilities.
Strict border controls are essential for securing the country’s future. Entry has been restricted to New Zealanders and their immediate families and everyone must spend 14 days in government-run quarantine.
Quarantine-free entry might soon be available to travellers from other COVID-free jurisdictions such as Taiwan and Australia.
Prime Minister Jacinda Ardern considers elimination a work of vigilance in progress. “We [will] almost certainly see cases here again,” she told the Guardian. “That is not a sign that we have failed; it is a reality of this virus.”
Brazil: 707,412 cases; 37,134 deaths; 210 million population. Deaths per million: 174.04
When Brazil’s death toll surpassed that of Italy’s last week, President Jair Bolsonaro ordered the government to stop reporting full cumulative data on the pandemic. Bolsonaro said the rising death toll “would no longer be a story” on the evening news.
But Bolsonaro really axed the figures because they made the president, a long-time COVID-19 denier, look like a murderously incompetent leader. A former health minister fired by Bolsonaro noted, “Not giving out the information makes the state more harmful than the disease.” A supreme court justice reportedly has ordered Bolsonaro to resume reporting the numbers.
Carlos Wizard, a billionaire Mormon businessman appointed as the new secretary of science, technology and strategic supplies, accused public health officials of inflating death figures in order to secure larger health budgets. Yet researchers uniformly agree that Brazil, like many nations, has consistently under-reported deaths and infections. About one-third of all deaths have occurred in people under 60 years of age.
Bolsonaro, an ally of Donald Trump and a right-wing evangelical Christian who is considered a fascist by many critics, has by putting his economic ambitions ahead of public health in a nation of 210 million, reaped chaos, death and civil upheaval.
At the beginning of the pandemic, the president battled state governors over quarantines and fired two health ministers because they refused to betray the science. Bolsonaro brazenly attended public gatherings with no regard for social distancing. He has dismissed the nation’s death toll — probably in excess of 40,000 — as nothing important because death is “everybody’s destiny.”
As a result, Brazil now ranks second after the U.S. with the most infections and third in overall deaths. Researchers calculate the death toll will reach 100,000 by the end of the summer. Hospitals have been overwhelmed and in some places a stack of five bodies shares a single grave. Meanwhile life goes on for many Brazilians while social distancing remains an impossibility in shanty towns.
As the pandemic unsettles the nation’s fabric and exposes longstanding injustices, Bolsonaro continues to push the economy to colonize what remains of the Amazon’s forests with mines, ranches and dams. At some point most Brazilians expect an explosive political reckoning.
South Africa: 50,879 cases; 1,080 deaths; 57.7 million population. Deaths per million: 17.27
Despite initial successes with mobile teams of health workers that sought out the infected, South Africa is now struggling with a shortage of resources. The nation is grappling with an immense testing backlog (tens of thousands of tests and many 14 days old) and a scarcity of test kits. Although infections are peaking in the nation, the government has eased restrictions for political and economic reasons. To the alarm of some doctors it has even allowed church gatherings of less than 50 people.
Two-thirds of the people dying in South Africa are under the age of 65. Many young patients killed by COVID-19 suffer from some or all of these factors: obesity, hypertension and diabetes.
Like many poorer nations, South Africa has also discovered that the emphasis on expensive ventilators as an essential tool was mistaken. The nation’s frontline doctors have learned that cheaper tools such as high-flow nasal oxygen machines get better results. The practice of flipping patients on their stomachs to improve oxygen supply has also been widely adopted.
Meanwhile several major South African hospitals have become potent amplifiers of infection due to poor hygiene practices. One infected patient visited the emergency department at St. Augustine’s in Durban. Eight weeks later, that visit lead to the infection of 39 patients and 80 staff as well as 15 deaths. The virus travelled around the hospital on staff’s clothing and medical equipment. Health officials now joke that the most dangerous place in many clinics and hospitals are unsanitary tea rooms where staff remove their masks and share cell phones.
To date the Western Cape has recorded nearly two-thirds of infections, but the rest of the country is now bracing for more infections including the nation’s mining district in the northwest.
Shabir Madhi, a prominent vaccine expert, predicted a rapid escalation in cases if South Africans stop wearing masks and practicing good hand hygiene and social distancing.
“And whatever gains there were from the level five lockdown will be wiped out completely, because our health-care system will still not be able to cope and we will still face the full might of this pandemic.”
Read the entire series 'Six Countries, Six COVID-19 Strategies' here.