When New Zealand had only eight confirmed cases of COVID-19 in mid-March, the country banned gatherings of 100 people or more. A few days later, it shut its borders. The island nation had one of the strictest and earliest responses to the pandemic and it was able to drive new infections to zero within about 80 days.
Sweden and Japan, on the other hand, took a more lenient approach, enacting few restrictions, yet were nonetheless able to keep flat curves (although Sweden reported more deaths per capita than its Scandinavian neighbours).
Yet other countries, such as India and Argentina, announced strict measures early on but weren’t able to contain the virus.
What gives? Why were some countries better able than others to control their outbreaks despite having similar measures?
To get an idea, CBC News compared countries’ daily COVID-19 numbers with how strict their containment policies were, as measured by the Oxford COVID-19 Government Response Tracker, which rates countries on a host of factors such as workplace closures, travel controls, restrictions on gatherings, and testing regimens.
With the help of experts, CBC News found that successful countries were not only swift to respond, but also applied the three Ts of disease control: testing, tracing and trust.
CBC News grouped countries into six categories based on how they responded and how well they managed the pandemic and visualized them in the charts below. Darker blues mean fewer restrictions, darker reds mean stricter lockdowns.
The first hard-hit countries
These were the countries that were first slammed by the novel coronavirus. They didn’t see it coming. In the case of China and Iran, much has been written about their slowness to respond and doubts about the honesty of their tallies of reported cases.
In Italy’s case, the population’s lack of trust in government, the third T, which tends to be lower than in neighbouring countries, made containing the outbreak more difficult, said Colin Furness, an infection control epidemiologist at the University of Toronto.
Trust, he says, affects how much the public complies with confinement orders, especially at a time when the severity of the virus was still a bit of a mystery.
“Italy tried being stringent, but the population ignored it,” Furness said. “Italians are cynical about the government. The army had to be called in, and by then it was too late.”
Italy and China also have many large, multigenerational households that likely helped exacerbate their outbreaks, he said.
“The young people went out to party, got a mild case of COVID, then went home and infected their elderly parents and grandparents, many of whom developed severe or fatal illness,” he said.
Italy recorded 570 deaths per million people, one of the highest rates in the world. At its worst, the pandemic was so brutal that some hospitals in Italy had to impose wartime triage, prioritizing care for patients with a better chance of survival.
The quick responders
The most successful places in dealing with the pandemic were in East Asia, where public health systems are robust and proficient in the three Ts, said Saverio Stranges, an epidemiologist at Western University in London, Ont., who has researched the response in Asia.
Thanks to the 2003 SARS outbreak, Hong Kong, Singapore and South Korea had plans and staff in place to do massive testing and contact tracing.
“The centrally planned public health infrastructure is well trained,” Stranges said.
With the exception of Singapore, each was able to drive new daily cases to the single digits and lift some restrictions (and as the charts show, they later reported a surge in new cases).
But some non-Asian countries were equally effective. New Zealand is held up as a model for its swift response to the pandemic, but also for the way its prime minister, Jacinda Ardern, addressed the country.
“New Zealand was strategic in getting people to conform by appealing to a sense of community,” said Jeffrey Hopkins, a cultural geographer at Western University.
This is precisely the kind of messaging that motivates people to trust and comply, said Simon Bacon, a behavioural scientist at Concordia University in Montreal who is leading iCARE, an international survey of attitudes toward the pandemic.
“It’s about appealing to an altruistic sense of taking care of others,” Bacon said.
The results of the survey, answered by 50,000 people in 150 countries, were clear: most people aren’t motivated by guilt, threats or penalties.
“When the messaging is ‘Don’t do this or people will die,’ it doesn’t resonate. It’s a negative consequence. What people are looking for is that by complying with lockdowns, lives are being saved. We see this across the board.”
However, Hopkins noted that New Zealand also had a measure of luck, which it shares with Iceland.
“Because it’s an island, it was easier to contain it,” he said.
Singapore was a case study in good policy with a blind spot. The city-state won praise from epidemiologists for its targeted quarantines and contact tracing system, allowing it to keep school and workplaces open, and apply mild restrictions on internal movements.
But overcrowded living conditions among migrant workers created a hot spot for infection, forcing officials to drastically clamp down.
Still, Singapore reported only 25 deaths attributed to COVID-19, a lower per-capita rate than most countries.
The lenient ones
Sweden gambled on a less stringent approach, letting the disease run relatively free. Health officials did minimal testing, but they did isolate the elderly and vulnerable and asked the public to practise physical distancing.
The country paid a steep price in terms of deaths per capita compared to its Scandinavian neighbours, and its daily cases have not decreased, casting some doubt on the strategy.
Sweden was able to bet on this approach because most of its people trust their government and follow public directives, according to Furness. There are also few multigenerational households, with many young adults living alone.
“The Swedish people were asked to take personal responsibility, and they did. It’s a compliant population,” Furness said.
The same could be said of Japan, which also happens to have a tradition of wearing masks, bowing instead of shaking hands, and meticulous hand-washing — factors also attributed to its success against the virus.
Taiwan received widespread praise for its response, which applied the three Ts and isolated suspected cases, skills gained during the SARS outbreak in 2003. It was able to avoid severe lockdowns, closing only schools and preventing travel from certain regions.
The Western laggards
Wealthy European and North American countries had plenty of time to prepare for the pandemic, but many failed, Stranges said.
Country leaders, such as France’s Emmanuel Macron, went on trips after the first confirmed cases, taking strolls in crowded areas and shaking hands in defiance of public health directives.
The U.K., whose politicians were distracted by Brexit, is now a case study on how a delayed response can be catastrophic even if a country has a good health system and an informed population, Furness said.
“In the U.K. people trust the government enough, they’re compliant enough. But the government was absolutely asleep at the switch,” he said.
The freedom of movement between mainland European states didn’t help either.
“Open borders should have made their pandemic management much harder, or the need greater for far more intense restrictions,” Furness said.
But Western countries had another shortcoming: their health systems are hospital-centred, and many had gutted public health programs.
“The hospital-centred approach is good for chronic disease, but it’s not equipped to deal with a new virus,” Stranges said. “The approach in Western countries wasn’t co-ordinated. The three Ts wasn’t implemented.”
Even between neighbouring countries, cultural differences can account for some of the variations, Hopkins said.
“In some countries, people buy groceries once a week. But in France they go out to buy their food every day. It gets difficult to distil these cultural differences down to a formula,” he said.
Canada and the U.S. are large decentralized federations with autonomous subnational governments, and each responded differently. There was no nationwide agreement on the severity of the crisis and the containment strategy.
When there are different subnational policies, such as provincial shutdowns, the Oxford index assigns the strictest one to the whole country. For Canada, this was Quebec, where bad timing and an outbreak in long-term care homes drove most infections and deaths.
“Quebec was really unlucky. March break was earlier and travellers returned with the virus before the lockdown,” Furness said.
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Experts interviewed by CBC News say despite some delays at first, and the devastating death toll in long-term care homes, Canadians have largely complied with government directives.
“There’s an old joke. How do you get 10 Canadians out of the pool? Say, ‘Everybody out of the pool.’ We tend to respect authority, generally. It seems to be boding well for us so far,” Hopkins said.
But unlike Germany, Quebec and Ontario have sent confusing messages during the deconfinement phase. For example, Quebec changed the dates for reopening schools several times.
“If you open society a bit, then try to shut it down, you’ll get people frustrated,” Bacon said. “You gave them a bit of freedom, then you take it away again.”
Americans, on the other hand, are famously defiant of government, and President Donald Trump’s public disagreement with some governors’ statewide lockdowns aggravated the situation, Bacon said.
“In the U.S. and Brazil, people were told by health authorities they should do something, and by the leader something else, or the leader didn’t follow the directives. If there’s an inconsistency, people will do whatever fits more with their values,” he said.
Overall, the U.S. was also slow to get comprehensive testing up and running.
Hopkins believes the high number of religious Americans may also be a factor.
“Many in the U.S. are rejecting science and government, and putting trust in faith. This is reflected in Trump’s desire to reopen churches,” he said.
Churches are high-risk places for infection, as they are large, closed spaces where people gather together to sing and talk.
The effective managers
Not all Western countries fumbled the response. Despite the high number of cases in Germany, there was widespread testing and targeted quarantines, and it’s had one of the lowest mortality rates in Europe.
It is also a model for clear planning and communication by the government, Bacon said. The country has a precise roadmap for opening and closing the country, with specific numbers of cases that will decide the government’s response.
“So, if there’s a problem, if cases go back up, people know there will be an intervention and they know what to do,” he said.
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Australia gambled with a selective travel restriction, barring only nationals from Iran, South Korea and Italy before enacting a full lockdown. In hindsight, this was seen as one of its mistakes, causing a rise in cases.
However, the country did create a national cabinet to enact consistent policies for the entire country early on, such as a ban on large gatherings. And, being an island, it was also easier to test and contact-trace returning travellers.
The developing hot spots
The pandemic hit many developing countries especially hard, and they presently report the fastest-growing infection numbers in the world.
These countries tend to have limited resources for enforcing containment measures and fragile health systems, said Umar Ruhi, associate professor of business analytics and information systems at the University of Ottawa.
Ruhi has argued that understanding a country’s culture is essential for crafting an effective response to a pandemic. In countries with collectivist cultures, where commitments to families and relationships outweigh adherence to government rules, the same strategies that were successful elsewhere may not work.
“In the case of COVID-19, social distancing would have been quite a challenge for these countries,” Ruhi said.
In Russia, governments applied several measures when there were 100 or so confirmed cases, such as restrictions on public gatherings and stay-at home orders. Despite this, many Russians went about their daily lives. A CBC report described bars in St. Petersburg at full capacity, with owners saying that there’s no financial incentive from Moscow to justify closing.
The Russian search engine Yandex publishes a “self-isolation index” that measures how many people are in the streets. Its numbers for Moscow have been falling since mid-April, suggesting Muscovites are leaving their homes more often.
Russia now has the third highest number of total confirmed cases, behind only the U.S. and Brazil.
Brazil, now the world’s epicentre in terms of daily coronavirus case growth, had two major challenges: a delayed response from a vocally anti-science president, and a massive number of citizens living in poverty, many in crowded slums, who can’t work from home.
The religiosity of a country could also be a contributing factor, which may explain why cases are rising in some South Asian countries, Ruhi said.
“In Pakistan, the higher legal courts issued decisions that opposed government public health advisories, allowing businesses to remain open and shopping to continue over the religious holiday of Ramadan and Eid,” Ruhi said. “This was the cause of a major spike in cases in that country over the past weeks.”
Finally, it’s important to note that in some of these countries, the strictness of a policy doesn’t necessarily mean it is enforced, Bacon said.
“Was it a policy or was it more of a guideline?”
A note on the methodology: Comparing countries is challenging, as many factors can affect a successful public health response. The range of factors can include demographics, family structures, internal politics, a population’s trust in authority, the amount of time a country had to prepare before the virus arrived, and even sheer luck. Also, some countries had large localized outbreaks, such as the region of Lombardy in northern Italy and New York in the U. S., while other regions were less impacted
Measuring a country’s epidemic using daily case numbers also has potential pitfalls. Confirmed cases depend entirely on testing and how new cases are defined, which vary by country. Actual infections are likely undercounted.
Another way of assessing a country’s performance is through COVID-19-related deaths per million people, which you can do using the interactive graphic below.
· CBC News