A Global Look Back: Phase 1 of Covid-19

Daniel Freer, May 18, 2020

In what appears to be a lull for Covid-19, we are now able to look back on this crisis (or at least the first part of it) with 20/20 vision for the first time to see what went wrong with various healthcare systems, and how these systems can be improved in the future. In this essay, I’m going to assume that the numbers reported by most major media outlets and international organizations are approximately correct. I have also been closely following the numbers on Worldometers.info, though I have recently heard (from CNN, so take it with a grain of salt) the source behind this site is mysterious and unknown. But that is beside the point.

I’m going to attempt to use two metrics to describe a country’s response to the pandemic: 1) infections per capita; and 2) death rate. Infections per capita (i.e. 58 Covid-19 cases for every 1 million people) can generally reflect how well the country did at stopping the virus from spreading. Meanwhile, death rate (as deaths/the number of infected) generally reflects how well equipped hospitals are to handle a lot of patients. Death from Covid-19 (at least from my understanding) has largely occurred due to overwhelmed and under-equipped hospitals that couldn’t keep up with increased and intensifying workload.

Let’s look at some numbers (according to Worldometers.info on May 18, 2020):

	Total cases (active cases)	Infections per 1M	Death Rate
United States	1,527,664 (1,090,297)	4,619	5.9%
China	82,954 (82)	58	5.2%
South Korea	11,065 (898)	216	2.3%
Japan	16,285 (4,388)	129	4.7%
UK	243,695 (N/A)	3,592	14.2%
Spain	277,719 (54,124)	5,940	10.0%
Italy	225,435 (68,315)	3,728	14.2%
Germany	176,651 (14,002)	2,109	4.6%
France	179,569 (90,248)	2,752	15.7%

So, from these numbers we can see that the United States has a similar death rate to China, while South Korea’s appears to be the best of all countries with a significant amount of cases. Germany is the lowest in Europe, though in general Western European death rates are comparatively high. In terms of how far infection spread, however, the United states was on par with Europe, while Asian countries were clearly much more effective in stopping the spread of the virus within their own communities.

Why is this? Because these Asian governments were able to quickly discover who had the virus and efficiently disseminate information to their neighboring people.  A clear message about health and safety (wear masks, wash your hands, avoid contact with others). And the people listened to this message and responsibly followed instructions.

Any increased numbers in infections per capita or in death rate can therefore reflect a country’s failure to do these things. The first point (1), discovering who has the virus, should be the job of the healthcare system. The second (2), the dissemination of clear information to people about how to protect themselves, is the job of the government and the media. The third point (3) is about the people and the culture, whether they listen to authority figures, and whether they act irresponsibly.

1. Discovering who has the virus

A strange and unpredictable disease was first officially reported in Wuhan, China at the end of December. It is known that the virus was circulating before this however, both in China and in other parts of the world. But China was the first to identify it as a threat and report their findings. This may have been because the virus did start in Wuhan, but based on the existing evidence, we can not be 100% sure that this is true, as patient zero has not been found, and likely never will be.

However, imagine for a moment that the United States had no contact with China whatsoever in December and January, and we were completely unaware that there was a disease there. Imagine that a disease started spreading in New York, with the first cases being reported in the middle of March. Imagine that we couldn’t find the direct source of the virus, but attempted to figure it out as several thousand new cases are reported per day. This was the situation in Wuhan, China, which has a similar population to New York City. However, even on this level playing field, if you consider the differences in case numbers between the two states/provinces, the Chinese response was much better, with about 68,000 total cases and 4,500 deaths in Hubei province as compared to 360,000 cases and 28,000 deaths in New York. But in reality, it wasn’t a level playing field. New York had a huge advantage in that they were told about the virus several months before its spike in reported cases, and still failed to stop its spread.

So what is the cause of this failure in the US and Europe? My theory: it is because not enough people went to the doctor.

In China, the first people to notice that a unique and dangerous virus was spreading were doctors. They reported it to their superiors, who told them not to say anything publicly until they had more information. Then, when they had more information, it was disclosed publicly. However, doctors can only notice such a trend if a high percentage of the population actually receives medical attention when they need it. This was not the case in either Europe or the US.

In Europe, I attribute the high amount of infections per capita to their overwhelmed healthcare systems, which can be seen by their high death rates (except in Germany). Because their hospitals didn’t have enough space for the extreme influx of patients, many people who were sick were forced to stay home, and many who needed to see a doctor were turned away. This caused more interaction between, for example, roommates or family, which created additional avenues for the virus to spread. While hospitals in Wuhan were similarly overwhelmed, they quickly built new hospitals to deal with the overflow, and doctors from other parts of the country relocated to help out. Such a response in Europe did not occur, and would likely be impossible.

In the US, however, the healthcare system was not as overwhelmed as Western European ones, as can be surmised from the relatively low death rate. But this means that the United States’ high infectivity rate requires a different explanation. My theory relates to the fact that the US largely has a reactive rather than a proactive healthcare system. Because healthcare in the United States is so expensive, people (especially those who are uninsured) are discouraged from seeing a doctor regularly, or even when a problem does arise. They simply aren’t able to afford it, and their body usually gets better anyway. This leads to increases in spread of the virus for the same reason as in Europe: more sick people are around other people rather than in a hospital. In this case, it would also take doctors longer to notice the appearance of a new virus, as the majority of people with the virus may not even contact a doctor to get it checked.

2. Dissemination of information

The next important task to handle an epidemic is to get relevant and helpful information out to the people, allowing them to spread the message further and protect themselves. While I know China’s government has received a lot of criticism on this front, the fact remains that they stopped the spread of the virus much more efficiently than both European countries and the United States. Other Asian countries were also very successful in warning the public about the dangers of this disease, which largely stopped its spread before it became a massive problem.

The United States’ messaging on coronavirus has been utterly terrible. First, the initial claim by the CDC (and many other American and European media sources) that masks are not effective, and then a complete reversal of this opinion several months later. The constant fear-mongering of the media and the blaming of the “other side” rather than attempting to actually solve problems. And of course, the President of the United States, who first said that the virus was nothing to worry about, who actively tried to prevent “the numbers” from increasing to avoid a stock market fall, who spouts random accusations at enemies in order to distract, rather than attempting to actually explain what’s happening to the American people. In fact, he has actively spread misinformation on numerous occasions, though we can’t be certain if this is intentional, or just idiocy.

As I haven’t been in Europe at all for this pandemic, I can’t comment too much on their dissemination of information. However, the UK’s initial decision to try to achieve herd immunity and then their quick reversal gave whiplash to the public and likely led to more spread of the disease. And there were also reports in the early stages of the pandemic that some European governments or institutions were actively discouraging the use of masks, then again changed course once they realized that masks could, in fact, prevent further spread of the disease. Both of these were crucial messaging mistakes which worsened the situation for their own people.

3. Culture

East Asians tend to be more cautious about their health, at least in some ways. I am not Asian, but my wife is Chinese, so I have gotten a bit of a glimpse into this thought process during this crisis. For all of the Americans complaining about having to wear a mask: When many Chinese students flew home from the UK (or elsewhere) to China, they wore hazmat suits. They didn’t eat from the time their first flight took off to the time their last flight landed, which was often more than 24 hours, sometimes even more than 40. These measures, while they might be a bit overkill, were almost certainly effective in some way in preventing spread of the virus.

Americans, on the other hand, don’t like being told what to do and have an incredible amount of self-confidence, even when they are wrong. This has led to significant healthcare issues in the United States even before Covid-19 was ever seen, from diabetes to tiger bites (shout out to Saff). Because of this part of American culture, we have seen hundreds of protests around the country, demanding that government lockdowns be lifted. These gatherings themselves have reportedly spread the virus further than otherwise, and have also been fairly effective in getting businesses to open earlier than they probably should. We will see if our indulgent culture will be able to add an element of responsibility during this reopening, or whether the disease will have a second wave even before the first wave has finished.

I don’t want to change American culture. I am American, so I understand it and might even feed into it a bit more than I should. But at the same time, I want Americans, and all people, to be as safe and healthy as possible, as I believe that this leads to more long-term happiness, which leads to prosperity. And sometimes you have to sacrifice your immediate happiness in order to make it easier on yourself later on.

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So in summary, these are the main differences I see between initial responses around the world, and what they could focus on to improve their response to a similar future crisis:

Asian countries have successfully revamped their healthcare systems as a response to SARS in 2003 in order to effectively handle epidemics of this nature. While they are not beyond criticism, we should look at their response to this crisis in an overall positive light, and should look to more closely emulate it should a future epidemic or pandemic occur.  

Western European healthcare systems do not have enough space or resources at their hospitals for the number of people that live there if a crisis occurs. As a result, they should push to build more hospitals, or increase the capacity of their existing hospitals, and additionally should try to incentivize students to pursue healthcare-related professions.

The American healthcare system is too expensive, discouraging frequent doctors’ visits, but we do generally have enough medical resources for our people. Our government and our media have not provided a consistent or even coherent message at times, leading to confusion and misinformation. Lastly, our self-confident and leader-wary culture has only worsened and prolonged this crisis, and feeds into the divided media. So here, the way forward is to focus on building trust between our people and our healthcare and government institutions. One important aspect of this is reducing healthcare costs so that Americans won’t feel like their doctors are robbing them blind, and might be more inclined to go to the doctor if they become ill. The other important aspect is to make our politics less divisive and more inclusive of different people and ideologies, though this also does not seem particularly likely.

I want to emphasize that what I’ve written here are mostly my theories and opinions, and are also only considering 2 metrics and my own knowledge of healthcare systems in order to summarize the initial response of an entire country or region. The true picture is certainly more complex, and the answers aren’t easy. However, I hope that this will give some global perspective about the crisis, and will help us all move forward into a new age for humanity once Covid-19 is no longer a headline.