The Forum

How 9 countries responded to Covid-19—and what we can learn to prepare for the second wave

by Rebecca Soistmann and Paul Trigonoplos

As society moves past the first Covid-19 wave, leaders are left contemplating what the path back to "normal" will look like—for society and for health care. Decisions around how and when to exit lockdown are not made lightly, and are complicated by fact that every jurisdiction seems to have a different calculus for how to approach their off-ramp. To help make sense of the policies that governments are chasing, and inform how and where you should be comparing yourself against other jurisdictions, we analyzed national governments' pandemic responses and lockdown exit strategies.  

Your top resources for Covid-19 response and resilience

We looked at nine countries: three with mild outbreaks, three with moderate outbreaks, and three with severe outbreaks, where deaths per million people exceed 400. The grid below compares these countries across seven pandemic response domains—including how they have supported their health systems financially, and how they are reintroducing hospital volumes. This grid is a summary of a more detailed analysis of each country's response. To download the full research analysis, click here.

4 global insights—and what they mean for hospitals

As part of our analysis, we identified four initial global insights, and what they mean for hospitals and their leaders. We will be updating the analysis in two weeks.

1. How invasive and widely adopted your contact tracing methods are is the most important predictor of future Covid-19 waves.

It's been reported since March that widespread, government-mandated contact tracing and surveillance protocols kept the virus at bay in countries like Hong Kong and South Korea. These countries were able to identify Covid-19 cases immediately after diagnosis and quarantine infected persons and anyone recently in contact with them. As a result, these countries have been able to open society back up (at least partially) with the confidence that their "geofencing" methods are sufficient to stave off future waves.

In western countries, where there is bigger cultural resistance to the privacy implications that come with surveillance, we have seen two trends: a higher tendency to shift contact tracing app development onto states or private companies, and a reliance on citizens to "opt-in" to the technology. These countries not only have had a late start to the contact tracing game—notably, the Apple-Google app will only begin hitting phones this month—but also are falling far short of the 50-70% adoption threshold experts agree is necessary to adequately protect residents against future waves.

What it means for hospitals: Hospitals should prepare for a second wave that is proportional to how well (or poorly) their region monitors and isolates new cases. In jurisdictions where contact tracing methods are late or have low adoption, there is a high likelihood of subsequent waves that will rely on boots-on-the-ground contact tracing and a reintroduction of social distancing and quarantine measures.

2. Singapore's second wave demonstrates that even the best technological solutions fail to account for vulnerable populations if testing isn't available to them.

Initially, Singapore was praised for its containment strategy. Its total cases remained below 1,500 as of April 9, with only six deaths. Today, Singapore has more than 20,000 cases.

While the country's response initially stood out as global best practice—border closures, rapid testing, social distancing, and a strong contact tracing strategy—the plan was not without its holes. Once strict lockdown was lifted in March, residents were still told to remain inside. This had adverse effects on the country's migrant workers, a population which resides in crowded dormitories—sometimes a dozen people per room, making social distancing impossible—and has poor access to health care and testing outlets. Singapore's cases spiked once the workers were finally tested, and its infection rate is now the highest in Southeast Asia. Since then, Singapore has reintroduced stay-at-home orders and closed schools—you will notice this is the only country on the grid below which experienced heavier social distancing and quarantine measures later into their Covid-19 journey.

What it means for hospitals: Hospitals should proactively test communities that live in cramped conditions or don't have regular access to medical care, and they should do so immediately. Due to Covid-19's latency, it is possible that the disease has been spreading unnoticed, and could contribute significantly to a second wave as lockdowns lift.

3. Time is not on your side when responding to Covid-19 waves.

It cannot be stressed enough that the response time of any jurisdiction greatly affects how effective measures will adequately mitigate virus transmission. Hindsight, of course, is 20-20, but that does not mean lessons can't be learned about how critical speed proved to be. Among others, United Kingdom's story gives us specifics here.

The UK implemented fairly strict, police-enforced social distancing measures in late-March. But this was only two days before Italy hit its spike in daily new confirmed cases, and weeks after Italy began its own lockdown. With all of March as lead time (though, it would later be reported that the first cases in the UK were reported in late January), the government missed their window to prevent significant transmission of Covid-19. Today, the UK has the fourth largest case total and second largest death count after the US, which followed a similarly delayed timeline.

What it means for hospitals: Providers must follow the leads of Singapore and New York, who have used this recovery time to create their own a "circuit breaker" plan, ready to flip immediately upon seeing signs of a second wave. For hospitals, this circuit breaker has two key elements: a fast-tracked decision-making process that allows leaders to make a near immediate call  to flip the switch, and protocols to put back in place around—at minimum—patient pathways, communication channels, hospital and clinical capacity limits, staff deployment and ratios, and PPE policies.

4. Sweden's divisive approach shows us why cultural factors matter when making comparisons, and that every country is different.

Sweden's decision to avoid a strict lockdown has captured the news cycle almost daily since Covid-19 hit, and has not been without controversy. During the worst of their first wave, Sweden banned gatherings of 50+ people, but most businesses, bars, gyms, and restaurants remained open, as did some schools. Their hope was that they could ensure economic sustainability while trusting the public to act responsibly and self-prevent infection, knowing they could launch a shutdown if the health care system became overwhelmed (it so far has not hit capacity).

But what is talked about less are the societal factors that make their approach a bit hard to compare against. First, over 50% of households in Sweden are single-person, guaranteeing a moderate level of social distancing to begin with. There are also higher than average work from home rates too. And Swedes are more inclined to trust advice from the government to socially distance than residents in other countries might be—there have been reports that mobility in Stockholm is down 75% just with a government recommendation to stay inside. While their mortality rate is higher than neighboring countries that enforced lockdowns, it is sizeably lower than that of Spain, Italy, or France with far less government intervention.

What it means for hospitals: Sweden's experience reminds us that data is not the only signal to follow when determining what best practices are worth importing to your own context—or avoiding altogether. Hospitals should ensure that their analysis of any Covid-19 policies and practices—even if the practice is coming from a peer down the road—must include a cultural filter. 

Click the grid to expand.

Covid-19 penetration:

  • Number: Deaths per million people as of May 7, 2020, 6:15am EST. This value was chosen to demonstrate disease penetration as it accounts for both population and varied case fatality rates.

Shading key:

  • Dark grey: Extensive government action—government led contact tracing implementation, imposed strict social distancing and quarantine measures, offered strong economic support, and prohibited planned procedures.

  • Light grey: Moderate government action—government will lead contact tracing implementation after technology is developed, imposed moderate social distancing and quarantine measures, is gradually lifting of measures now, offered moderate economic support, and is gradually resuming planned procedures.

  • White: Limited government action—contact tracing efforts non-existent at federal level, lax social distancing and quarantine measures, low economic support, and planned procedures unaffected by government intervention.

Footnotes from grid:

  1. CCG: Clinical Commissioning Groups – responsible for the planning and commissioning of health care services for their local area in England

  2. PEPP-PT: Pan-European Privacy-Preserving Proximity Tracing

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