COVID19: Testing Time for Leadership Globally
This article is authored mainly by: Umesh Sharma[1], Vinod Mishra1, Mohan Yellishetty1, Abhijit Bhide2, Rajiv Padhye3,
[The authors sought the help of Milind Sathye to have a critical look. The original draft has been revised based on some of his inputs. The authors also requested him to put the article on the Medium through his account]
The world is going through unprecedented times due to COVID19. At the time of writing, this article (16th April 2020) over 146 countries around the six continents have been affected. with over 146,870 deaths. The total number of people killed in the five most developed countries (Italy = 22,170; USA = 34,562; Spain =19,516; France = 17,920; UK= 13,729; Total =70,611) accounted for over 73% of deaths. The data are puzzling given that some of these countries are amongst the top in terms of their health care services. Clearly having the best care system at this time of pandemic is not a guarantee that you are safe. Then what else can protect us? Why did some countries respond so well and others struggled?
The countries that seemed to have responded reasonably well during this time are Australia (Infected =6416; deaths= 61; death per/million= ~2), Singapore (Infected = 3252; deaths =10; death/million =~1), South Korea (infected= 10591; deaths= 225; death per million=~ 4), Germany (Infected = 118235; deaths =2607; death/million =31), Canada (infected = 26146; deaths= 823; death/million= ~13) and, India (Infected = 11439; deaths= 377; death/million= ~0.2) (Source: https://covid19.who.int/, accessed on 16/04/2010 at 2 pm). The graph below provides the number of deaths per million across the countries discussed in this paper.
A number of factors have been identified in the media ranging for better health systems, the remoteness of a country, population density, and leadership. One could argue that the health system could explain a country’s robust response and it’s the ability to prevent deaths due to coronavirus infection. We believe the healthcare systems can only explain half the story or even less than that. All countries, except India, are ranked amongst the top 50 in terms of their health ranking. India is ranked 118.
Perhaps one of the most important factors that could explain the better response of a country is it’s “political leadership”. The leaders of each of the countries that have done well have taken a number of steps to safeguard their countries against the pandemic. So what did the leaders in each of the countries do well to slow down the spread of the pandemic in their country and what can the rest of the world learn from these countries?
Singapore
Singapore is a relatively small country in terms of its population and landmass. It had earlier experienced the negative impact of SARS and was reasonably well prepared to respond to COVID-19. The Prime Minister of the country was quick to respond. We can learn five lessons from Singapore.
1. Respond early — Singapore implemented a national plan to protect its citizens well before many other countries (February 16).
2. Test extensively and identify cases that are Covid19 positive as early as possible.
3. Quarantine people who test positive and implement strict self-isolation of family members. Electronic monitoring of the self-isolated members from the community. Heavy fines if someone does not comply with the quarantine and self-isolation rules. Foreign workers could be deported if they found flouting the rules. Fines of up to 10000 SGD or 6 months of imprisonment if someone was found to flouting the self- isolation rules.
4. Strong and regular communication of the key messages in easy to understand formats through a range of media outlets.
5. Avoid going into lockdown based on fear. Making testing widely available so that the citizens can continue to do their normal activities.
Canada
Recently in an article, the Global News compared the impact of pandemics in the USA and Canada. At the time of writing this article, the US has taken over all other countries in terms of a number of deaths and is the new epicenter of Covid19. In fact, just one state in the USA (New York) recorded more deaths than many of the countries that are in the news recently (e.g. China, Iran). The USA did not start testing for Covid19 early and may have lost precious time. Also, the lack of a coordinated effort in the US contributed to the current situation. The situation was much different in the neighboring country Canada. What can explain the success of the Canadian approach? What did Canada do differently?
1. Canada’s approach was guided by the National Influenza Preparedness Plan which was adopted in 2018. Interestingly, the USA also had a similar national plan that was developed in response to SARS in 2009 but it was scrapped by President Trump.
2. There was a coordinated approach and all provinces in Canada co-operated in implementing the national plan.
3. Prime Minister Justin Trudeau consistently followed the advice of health professionals in his daily press briefings to the nation.
4. The Canadian health system is robust as all Canadians can access health services without costs or insurance claims.
5. Canada set aside $11 billion dollars solely to combat the virus and further boost the capacity of the health-care system to fight Covid19.
6. Canada enforced strict quarantine measures. Anyone who failed to comply with the quarantine measures could be fined $750,000 and up to six months in prison. Moreover, if someone put others at risk on purpose could face even harsher penalties of up to a $1-million levy and three years imprisonment.
Germany
Surrounded by countries like Italy, Spain, and France; Germany has clearly emerged as an outlier and has managed to keep the number of deaths significantly lower compared to the neighboring countries. The leadership of Angela Merkel is outstanding. What did Germany do differently from other countries?
1. Germany tested widely for Covid19. On average it tested 500,000 weekly and identified positive cases early.
2. Germany launched a number of schemes to protect businesses of all sizes. It provided funds to all businesses which could be negatively impacted by the pandemic. Landlords could not evict tenants if they fail to pay their rents.
3. Responding early (March 22), Germany imposed conditions similar to national lockdown when the number of deaths in the country was just 94. In contrast, similar measures were taken when the death toll was 196 in Spain, 422 in the UK and 463 in Italy.
4. Implemented a national plan. Germany has a highly decentralized health care system. To ensure that the efforts of the government were coordinated Germany launched a national pandemic plan administered which was closely monitored at the Federal level.
5. Enforced social distancing and social isolation rules nationally and allowed regional and local governments to impose even stricter measures within their remits.
South Korea
Unlike many other countries, South Korea appeared to be well prepared to face Covid19 Pandemic. South Korea’s prompt response could be attributed to the lessons it learned from the Middle Eastern Respiratory Syndrome outbreak in 2015. The federal government this time was ready. What assisted South Korea to respond so well?
1. National legislation in place to respond to a pandemic like situations.
2. South Korea widely tested the population for COVID-19. Drive-through facilities were set up around the nation and a person could get tested while he or she waited for the results in the parking lot. Positive cases were quarantined.
3. Innovative use of Geo-tracking and CCTV for contact tracing and prompt actions to isolate at-risk members.
4. Co-ordinated national efforts. South Korea has implemented a well-coordinated national plan.
5. Government controlled distribution of masks and health supplies. South Korea has learned from the past that the supply of essential goods could be severely affected at the time of a pandemic and thus took over the control of the distribution of essential goods. All essential health supplies (e.g. masks, sanitizers) were made available at post offices, pharmacies, and co-operative stores at low costs.
6. Financial support for each COVID-19 positive person. If a person had to stay at home due to Covid19 then all his or her expenses for the duration of quarantine were paid for by the government.
Australia
Australia’s COVID-19 has been a little lackadaisical. While most countries were imposing air travel bans, the Ferrari team from Italy was welcomed to participate in the Grand Prix. Thankfully the Grand Prix was canceled in time. Similarly, other sports activities and large gatherings were canceled when it appeared that COVID-19 had hit the country. Australia did not impose any social distancing and self-isolation regulations until very late (early March). However, within a short time, Australia launched one of the most impressive plans to fight COVID19 which clearly has put it amongst the forerunners. Australia’s response could be characterized by six activities below.
1. A coordinated national plan which involved all premiers of all the territories and states as well as the health care professionals. The plan allowed each of the states and territories to take additional measures to prevent the spread of Covid19. Some states and territories closed down their borders and residents were not allowed to travel interstate. Daily briefings were telecast nationally.
2. Strict travel restrictions for foreign travelers and imposed isolation for 15 days for all Australian residents who arrived in Australia from other countries in hotels. Unfortunately, some passengers from a cruise ship (Ruby Princess) were allowed in the country without any health check-ups which constituted the spreading of Covid19 positive cases in the country.
3. Making COVID-19 screening easily accessible across the country. Widely testing people and close contacts suspected of having the coronavirus.
4. Strict social distancing and self-isolation rules. It must be said that initially not all residents followed social distancing rules but within a short time most of the Australian residents started following the social distancing and self-isolation rules. All non-essential services were asked to close down (e.g. pubs, restaurants). Tele-health services were provided so that most residents could access health services and prescriptions at their residence.
5. Australia also launched significant economic stimulus packages which allowed residents to access unemployment benefits (Job Keeper allowance) to those who could keep their jobs and employees who lost their jobs (Job Seeker allowance).
6. Over 2.4 billion were invested in the healthcare system to further boost the capacity of the country to fight against COVID-19.
India
One of the most populated countries in the world after China, India’s response to prevent the spread of Covid19 has been outstanding. It was, therefore, not surprising to see that India emerged amongst the forerunners in the Oxford COVID-19 Government Response tracker research study. The tracker aims to “track and compare government to responses to the coronavirus outbreak worldwide rigorously and consistently”. Some of the key steps that India undertook which continues to assist the country to keep the spread and death rate down are listed below.
1. Proactive approach: India was aware of the high risk of foreign travelers spreading COVID-19 in the country and undertook early steps to slow down the spread. India canceled visas of foreign travelers from China, South Korea, and Iran on 26th February and all Indian residents returning from countries with known positive cases were put in isolation for 15 days. India also banned the entry of residents from all other countries on 18th March prior to most other countries listed in this report. Any passengers (local or overseas) traveling from at-risk countries were required to produce COVID 19 test reports on arrival in India. The screening of all incoming passengers started as early as the 5th of February.
2. National lockdown: India was aware that it may not be possible to provide treatment to a large number of potential cases that may get infected with COVID-19 so as soon as it appeared that there was an increased risk of spread, Indian PM requested for one day (self-imposed) public curfew. Acknowledging the work being done by various sectors during the outbreak, the PM urged people to applaud them for five minutes. On 24th March the country went into complete lockdown for three weeks. It is perhaps one of the largest lockdowns by a country in modern history. More recently, India has extended the lockdown to 3rd of May.
3. Coordinated effort. Different states in India are ruled by different political parties and implementing any national policy or plan at such a short notice is not easy. However, the country has shown remarkable solidarity and all states and union territories have supported the PM in implementing the national plan.
4. Stringent contact tracing and the use of technology: India followed strict measures to locate and quarantine any person who may have come in contact with a COVID-19 positive case. On 2nd April, it launched an app (Arogya Setu) that uses Geo tracking to alert a person who may have come in contact with a COVID-19 patient.
5. Trialing new treatment: India trialed novel treatment using anti-malaria, anti-swine flu and anti-HIV drugs. The initial findings were encouraging. On 23rd March, India recommended the use of hydroxychloroquine for high-risk cases and health professionals. A number of other countries have also found positive results after the use of the drug. India received requests from many countries to supply hydroxychloroquine as India is the largest producer of the drug. At the writing of this article, India has exported hydroxychloroquine to over 30 countries including the USA, Brazil, Israel, and the Maldives.
6. Economic package: On 26th March India announced an economic relief package of US$24 billion (about one percent of its GDP). The relief package would cover food security and provide direct cash transfer, primarily to migrant workers and daily wage labor. A number of other schemes have been announced to ensure direct transfer of benefits to low-income earners.
7. Regional and international cooperation: India is aware that the best way to fight Covid19 is through regional and international collaboration. It worked with a number of countries (SAARC) in the South Asian region to come up with a regional strategy to fight Covid19. India also called for a meeting of the G20 nations to come up with an international strategy to fight COVID 19. At the conclusion of the meeting, the leaders of the Group of 20 countries pledged to infuse over $5 trillion into the global economy, and do “whatever it takes” to minimize the economic and social impact of the COVID-19 either use this format or COVID19 throughout consistently pandemic”.
8. There has been some criticism of India’s response that it acted too quickly. The criticism that was levied against India’s proactive approach towards banning foreigners from entering India and the eventual complete nationwide lockdown was that the Indian government was too quick to shut down the economic activity. Some critics argued that the lockdown was doing more economic damage than the disease could have done. However, as argued above, that is not the same in the Indian setting. A delayed start to the strict medical containment measures could have led to the worse health crisis and worsening economic crisis. While in the state of lockdown, the Indian government is already planning for a medium-term strategy of developing rapid medical response and increasing the treatment capabilities. For instance, Indian Railways has converted 2,500 Rail Coaches into isolation wards that can house 40,000 patients.
So what did we learn?
The tough trade-off between economic cost and health cost
The COVID-19 presents policymakers /leaders with some tough decision choices. The more aggressively a country implements medical containment measures, the more success it will have in minimizing the public health crisis and the associated cost. However, aggressive medical containment measures will worsen the economic crisis. Both types of crises will disproportionately impact the economically disadvantaged sections of society.
The only balancing strategy that can prevent the crisis from swinging too much on one side or the other would be tough and decisive medical containment measures at the early stages of the pandemic to contain the spread accompanied with economic policies/measures to reduce the adverse impact on the most economically vulnerable sections of the society. In the medium run, the policy should be focused more on medical readiness by increasing the testing and treatment capabilities, with the gradual opening up of the economy, with a focus to contain the economic crisis. The countries that have successfully managed this pandemic are more or less adopting policies along similar lines.
The countries need to use the context of relevant practices and make the best use of the available resources.
A country cannot apply a strategy that has worked in another country without paying particular attention to the local context and availability of resources. For example, countries such as Australia went overboard with spending money to contain the economic fallout of COVID 19. As per treasury estimates, the Australian Government has pledged a total of $320 billion (representing 16.4 percent of annual GDP.) as of writing this note to support businesses and households with the economic fallout associated with COVID-19. On the other hand, India, the only developing country in the list, went with a relatively conservative and cautious approach towards spending money. India’s relatively modest relief package of US$ 24 Billion focused on covering food security and providing cash transfers to the most economically disadvantaged sections of the society. We think the key focus of the Indian leadership is to focus on containment measures at the moment; followed by studying the impact on various sectors of the economy. For a populous developing country, it does make sense to avoid panic spending, and haphazard fiscal stimulus announcements, which can substantially increase the budgetary deficit without much towards economic recovery.
Some countries, including India, have been criticized that they have not tested widely for COVID-19. While we do agree that testing widely for Covid19 is appropriate, however, when there is not enough testing capacity available in-country care should be taken who is tested. India’s approach to widely testing the people in high-risk areas is appropriate. India has also conducted random testing across the country to identify community transmission of cases. Countries with limited resources need to make the best use of available resources.
Proactive and coordinated approaches. The countries that have emerged as the forerunners have acted fast and did not wait for directives to be issued by international organizations. For example, Australia imposed a ban for air travel from China prior to WHO declaring the pandemic. Similarly, India imposed a nationwide lockdown even though some may call it was too premature or too early. According to some estimates if India did not lock down the country early the number of deaths could have reached over 150,000 by mid-April. Similar steps were taken by countries like Singapore, South Korea which largely accounted for the success behind arresting the spread in the country. We also noted that countries that have been successful in slowing down the spread worked cooperatively with health professionals and political leadership at the regional level. They all supported each other in any decisions they made and communicated clear messages to the community.
These are early days and most countries are talking about flattening the curve or reducing the spread of infection by using multiple measures. The numbers are moving so fast and it is difficult to predict the future. The lessons learned today may or may not be applicable tomorrow. However, what we do know is that we need to look after ourselves, we also need to look after our neighbors and those who are more vulnerable in our society and around the globe. This lesson applies to an individual, a family as well as to the leaders around the globe if we wish to survive this pandemic. Rather than thinking of a national strategy, we should now start thinking about a global strategy to fight the pandemic considering corona-virus does not follow immigration rules and can cross into any territory without a valid visa!
[1] Monash University,
[2] Professional
[3]Royal Melbourne Institute of Technology
[Please contact the above main authors for further questions]
