A TALE OF THREE COUNTRIES
Why is the United States still battered by coronavirus while other countries have gotten the epidemic under control?
By Seth Freeman and Peter Katona
In 2003 Vietnam was among a handful of countries hardest hit by an epidemic of Severe Acute Respiratory Syndrome (SARS), but it quickly became an international success story. By April of that year, Vietnam had became the first of the seriously infected countries to have twenty straight days with no new cases. The country learned from its SARS experience, so that when Covid-19 hit in late January of this year, it was ready to mount a robust response, a response which thus far, even despite a slight recent uptick in new cases, has limited the outbreak to under 1,000 cases in total and just 24 deaths, often 0 on any given day.
Italy recorded its first Covid-19 case around the same time, in late January, as Vietnam. By early March physicians in the United States were receiving texts and emails from their colleagues in Italy alerting them to the devastating impact of the coronavirus outbreak on their population. In a first world country with a sophisticated health system, doctors were telling many patients with Covid-19 symptoms, usually those who were older, that they did not have the resources to treat them. Sick people were being sent home to manage for themselves, some to die. By March 22, the daily number of new cases had spiked to 6,557. Now, a little over four months later, the epidemic is still active in Italy, but continues to be well-managed. New cases are averaging around 200 per day across the country with daily deaths in Lombardy, once the epicenter of the outbreak, often 0.
The United States recorded its first case of Covid-19 within a few days of those in Italy and Vietnam. As of this writing, the United States has experienced five and a half million known cases and suffered more than 170,000 deaths, adding 50 thousand, 60 thousand and sometimes as many as 70 thousand new cases to the toll per day. The U.S. now suffers over 1,000 deaths daily from the coronavirus, the equivalent of a 9/11 attack every two or three days or three to four jumbo jet crashes, per day. On some recent days the U.S. experienced a Covid-19 death every minute.
What accounts for the difference in crisis response between these three countries, with Vietnam responding forcefully and fast and getting in front of its outbreak early, with Italy caught flat-footed at the beginning but aggressively turning things around and getting control of the virus within a few months, and with the United States of America turning a serious but manageable threat into a vast, unmitigated humanitarian and economic disaster, which is still spiraling out of control?
There could be an element of luck. In Southeast Asia, often the starting point where viruses like the common cold and seasonal flu spill over from animals such as bats into human populations, some people might have developed a degree of “inherent immunity,” protective adaptations at the cellular level in their immune systems. Inherent immunity could have a significant impact on a group’s reaching herd immunity as well as on how sick individuals get. It is possible that people elsewhere, in Europe and the U.S., who never get symptoms even when they test positive or never get very sick, have similar inherent heightened immunity. But such factors do not begin to account for the divergence in the course of the epidemic in different countries. The diverse outcomes are clearly traceable to policy decisions and governmental actions.
Vietnam got its response right on a number of different fronts, reacting quickly and efficiently with innovative Internet technology, appropriate, well-received non-pharmaceutical interventions (NPIs), and clear, scientifically-based messaging, but above all with confident, honest leadership. The country started targeted testing early and often, quickly ramping up the production of tests kits and putting labs into the service lines, and from the outset it began thorough, efficient contact tracing of positive cases back from 14 to 28 days out from exposure. Local manufacturers started producing face masks immediately, making enough for domestic use and even export, which actually aided the economy. Public funding was invested in research institutions, which rapidly designed several new test kits. The kits were initially used just domestically but then also exported. There was an immediate temporary, enforced lock down. Schools were closed in January, and selected severe travel restrictions were enforced. There was widespread, appropriate — although not universal — masking. The government imposed rules on residents in an at times Draconian yet respectful manner. Citizens collaborated well with the Ministry of Health, the military and other organs of government. Government messaging was accurate and consistent, providing a single, reliable website which citizens could access to ask questions, find health support, and get advice on health protocols. There were other helpful measures as well but all the actions adopted have a common theme: the country took the threat seriously, early on, and people worked together to confront it.
In Italy the current positive outcomes are the product of a strong, well-enforced nationwide lockdown and a heavy reliance on scientific and technical expertise. Medical supply lines, starting with an already amply stocked health system, were surged to increase capacity. The health of the populace was emphasized as a priority over the economy, and as a result, despite the pain of the lockdown, the economy can begin the process of recovery. The economic hurt was also mitigated by government aid to workers and to businesses. Compliance in Italy with mask wearing and other measures has at times been imperfect, but after a fumbled start, the imposition of a strict lockdown functioned like a powerful, single-dose bolus of medicine on a sick patient, setting the entire country on the path of recuperation. What Italy’s response, although unique to its culture and circumstances, had in common with the response in Vietnam was that the country took the threat seriously, early on, and people worked together to confront it.
The disaster in the United States stands not just in contrast to Vietnam and Italy but also compares negatively to almost every other developed country in the world, even with each different country having its individual glitches and upticks in managing the virus. In trying to account for this stunningly bad performance, David Leonhardt, in a recent deep dive into the problem in The New York Times, hones in on two factors. First, he points to America’s “tradition of prioritizing individualism over government restrictions.” That libertarian tradition, as he sees it, is “one reason the United States suffers from an unequal health care system that has long produced worse medical outcomes…than in most other rich countries.” The second, more significant, factor to which the Times attributes the poor U.S. response is simply “the performance of the Trump administration.”
But both Vietnam and Italy (famously) and many other countries have their own traditions of individualism and resistance to authority, and the U.S. has (also famously) shown itself capable of rising to the challenge and working collectively in other national emergencies. The health care disparities in the United States actually derive less from a dedication to the values of self-reliance and individualism and more from a politicized disrespect by a powerful, privileged minority for the values, religious and scientific beliefs and concerns of other citizens. At the end of Leonhardt’s exhaustive analysis, and that of nearly every other informed journalist or public health professional, there is clearly only one salient reason for the mammoth U.S. failure in response to Covid-19 — willfully ignorant, intentionally misleading, inconsistent and incompetent leadership. “In no other high-income country have the messages from political leaders been nearly so mixed and confusing.” New York Times columnist Roger Cohen, presently traveling in Italy, where a “coherent policy, science and a measure of discipline” has countered the pandemic, finds that posture of the U.S. “elicits a pained Italian bewilderment.”
Is it too late to change course and get the response right from this point forward? In an “open letter to America’s decision makers” hundreds of leading experts, as well as entire schools of Public Health and Medicine, ask the country’s leaders to “hit the reset button.” If the country were to immediately instigate all the measures which we now know work to contain the coronavirus, tens of thousands of lives could be saved and the economic damage could be significantly reined in.
Covid-19 is a nasty pathogen, highly contagious, with a long silent incubation period. It affects different people very differently. It primarily affects the lungs but can also impact other organ systems such as the nervous system, the vascular system — sometimes with long term impairment — and of course it can result in death. It can spread effectively between people mainly through the air but also when an uninfected person touches a contaminated surface and then, without washing hands appropriately, touches the mouth, nose or eyes. It is powerful. It is scary. But it is also limited.
The virus cannot replicate on its own. It can only make more virus when it is able to invade and coopt a host animal’s cell. The virus can’t jump or fly under its own power or walk or crawl. If it can’t move between people, it can’t spread. Therefore, if people keep apart or create barriers (like masks) between them when they are closer together, the epidemic can’t expand. We don’t yet have treatments which can cure the disease, and we don’t yet have a vaccine to prevent its spread, but NPIs do work if they are complied with. Just as a forest fire, in the absence of water or retardant, can be contained with firebreaks which deny the fire fuel, the virus can be contained if we restrict its ability to move from person to person.
This is not complicated. We can beat this epidemic, by resetting and doing things right from here on out. We might disagree about exactly how much testing and contract tracing is needed, and for whom and when, although we can agree that we need more. We might differ in the exact amount of mask-wearing which is required, where it is required, and which businesses need to be closed and which don’t. But we could, without question start today to turn this crisis around by working together and being completely honest about the situation we face.
This last element — honesty — is critical. The most important lesson human beings have ever learned about fighting pandemics was emphasized by John M. Barry — before anyone had ever heard of Covid-19 — in the 2018 Afterword to his insightful book on the pandemic of 1918, The Great Influenza: “Those in authority must retain the public’s trust. The way to do that is to distort nothing, to put the best face on nothing, to try to manipulate no one.”
Instituting a rigorously honest, consistent and disciplined approach at the highest levels of national leadership would spell the end of Covid-19 in the United States.
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Peter Katona, MD, is Clinical Professor of Medicine at the UCLA David Geffen School of Medicine and Adjunct Professor of Public Health at the UCLA Fielding School of Public Health. He chairs the UCLA Covid-19 Infection Control Working Group.
Seth Freeman, MPH, is a multiple Emmy-winning writer/producer for television, a playwright and a journalist, and serves as Community Representative to UCLA Health.