Cautious celebrations
Because we all need good news right now
After a rough couple of months, there’s a sense of celebration in New Zealand this week. The last new case of Covid-19 was reported on the 22nd of May, the last known infected person has now recovered and almost all restrictions have been lifted. Businesses can open with no need for distancing. Celebrations, concerts and sporting events can go ahead. We can travel wherever we like, within our own borders.
We know, though, that it’s a different story outside those borders. Globally, Covid-19 has claimed more than 400,000 lives, and there are now more than 7 million reported cases. There were only half that number just over a month ago, which means the virus is still spreading with alarming speed. Many countries are easing restrictions even though case numbers continue to rise. The leadership of some countries has been so spectacularly bad that it’s hard to tell fact from parody. It doesn’t seem as if there’s a lot of good news.
But behind the headlines, it’s not all failure. New Zealand isn’t the only country to do a good job of managing Covid-19. Even early in the pandemic, when the virus was sweeping around the world and seemed completely out of control, stories emerged which gave us hope that it was not undefeatable. These early reports were from Asian countries, all of them wealthy – Hong Kong, Taiwan, Singapore, South Korea. In Europe, Germany was the first country recognised for effectively managing the virus. But as time has gone on, and we have seen more success stories, it’s become clear that managing Covid-19 is not about money. It’s not even about having a well-resourced health system. So, why is it that some places have been successful and others have not?
The first under-reported success stories are all pretty close to home. Our Pacific neighbours, almost without exception, saw the reports from China, Iran and Italy, and acted swiftly. Excluding Hawai’i, the region has seen a total of 309 confirmed cases and 7 deaths. The testing rate (defined as the number of positive tests out of the total number of tests) is half that of New Zealand’s, but it is similar to or higher than most European countries, and much higher than that of the USA. So the case numbers they are reporting are likely to be accurate.
What’s most telling about the Pacific Island results is where the cases have been. More than half of the cases, and five of the deaths, were from Guam, a US territory. When the other US territories – the Northern Mariana Islands and American Samoa – are taken out, there are only 99 confirmed cases and no deaths. If the French territories – French Polynesia and New Caledonia – are also removed, there are only 18 cases, all from Fiji, which hasn’t had a new case for more than 50 days. That is, of all the self-governing Pacific Islands, only one had any Covid-19 cases at all.
The Pacific nations have an obvious advantage in managing Covid-19 due to their isolation, but they also rely heavily on tourism, including cruise ships. Many of these nations could not process test results within their own borders, and most have very limited intensive care beds. In the early part of the pandemic, test results could take a week or more to arrive. It was May before the cartridges designed to fit into existing tuberculosis testing machines arrived, allowing local testing for the coronavirus. Despite this, the testing rate for Pacific nations (excluding those which are governed from the USA and France) is now double that of New Zealand.
Pacific Islands are not the only islands to be successful in managing Covid-19. The nation of Mauritius, a small group of islands in the Indian Ocean, has also largely eliminated the virus. While Mauritius is isolated, with a population of 1.3 million it is also densely populated. And it’s a popular destination for tourists. The Mauritian strategy included border screening implemented in January, quarantining visitors from countries with high case numbers and lots of testing. It ranks 16 in the world for the number of tests per capita, and the countries ahead of it are mostly much wealthier.
A very different success story comes from Vietnam. It lacks any natural advantage in dealing with Covid-19 – it shares a land border with China, and has a population of 95 million people in an area not much bigger than New Zealand. It is also one of the poorest nations in Southeast Asia. Despite this, it has kept its total number of cases to 333.
With China as a close neighbour, Vietnam had to act quickly. The first reported cases were in late January, before Italy but after the USA. By then, Vietnam already had a plan. It implemented border screening, set up quarantine facilities, developed its own rapid test, implemented rigorous contact tracing and ran an effective public awareness campaign. Staying at home is loving your country. Social distancing is a form of patriotism. They even had a song – Let’s wash our hands, rub, rub, rub, rub, rub them – and accompanying choreography.
In the number of tests per capita, Vietnam ranks poorly – somewhere around 150th. But their testing was focused on contacts of known or suspected cases and, perhaps more importantly, it was rapid, delivering relatively accurate results in less than an hour. And the testing rate for positive cases out of the total tests done is seven times that of New Zealand’s (and ours is pretty good, globally).
Initially, there were suspicions that the communist government was being less than transparent in reporting its case numbers. However significant outbreaks of Covid-19 are hard to hide, and multiple strands of evidence suggest that Vietnam’s numbers are accurate. So far, in this country of 95 million, there have been no Covid-19 deaths.
One country that won’t feature in a list of Covid-19 successes is India. It ranks fourth, after the USA, Brazil and Russia, for the total number of cases. Although it only ranks 9th in terms of the number of deaths, this is largely because most of the infections are very recent. Despite its hasty lockdown, it is reporting in excess of 10,000 new cases per day, with only the USA reporting more. And the numbers from India are probably underestimates, as it has a low rate of testing.
But India has a bright spot, in the southern state of Kerala. There, cases are still under 2,500 and there have been only 20 deaths. The testing rate isn’t high, but it’s comparable to Canada and much of Europe, and much higher than the Indian average.
Kerala, like Vietnam, lacks apparent advantages in managing Covid-19. It had its first confirmed case in January, and its citizens are more likely to travel or work overseas than many in other parts of India. But Kerala’s existing infrastructure put it ahead of the rest of India – it has invested in primary health care, education and a social safety net which includes an unemployment benefit. When they heard of the outbreak in Wuhan, officials were ready, implementing border screening, testing, quarantine and contact tracing from late January
Kerala was ready for the lockdown as well. In many parts of India, the lockdown was chaotic as well as ineffective. It left millions of migrant workers, many relying on daily wages, stranded with no income, no food and nowhere to turn. Many decided to return to their home villages, where at least they wouldn’t starve, but with trains and buses stopped, they had few options. Many walked. Some died on the way.
But Kerala was different. Migrant workers have been given support, and at least half are willingly waiting out the lockdown in Kerala rather than trying to get home. Although the local language is Malayalam, public awareness has also been published in Assamese, Odiya, Hindi and Bengali, to ensure migrant workers are informed.
Some of the least publicised Covid-19 successes have been in Africa. If there has been anything in the western media, it has been the escalating situation in South Africa – the worst-affected on the continent – or perhaps the death of the president of Burundi, Pierre Nkurunziza, suspected to be the first head of state to die from Covid-19. Much of the discussion has been on Africa’s inability to deal with such a crisis, as if disaster was inevitable.
But, just has been seen around the world, wealth is no predictor of competence in handling a pandemic.
Many African nations have fewer than a thousand cases, but unless there is enough testing and accurate reporting, that doesn’t mean a lot. It could simply be that no tests are being done, so nobody is quite sure what people are dying of. But some countries are testing, and testing a lot. Botswana, for example, has only 48 reported cases and one death, but they’ve done more than 26,000 tests, giving them a very respectable testing rate. Rwanda has done more than 85,000 tests and Uganda 111,000, with case numbers of 510 and 686 respectively, giving them good testing rates, and therefore probably accurate data, as well.
Africa has a wealth of hard-won expertise in managing infectious diseases, and this has helped the responses in many countries. Countries such as Uganda, Rwanda and Botswana were organised early, recognising that their best chance of managing the disease was prevention. Rwanda went into lockdown when it had 17 cases, Botswana when it had only four. In March, before it had seen a single case, Uganda had distributed information about Covid-19 in 30 languages, and community health workers were helping local councils and village health teams to implement prevention measures.
Botswana is one country which has showed leadership from the top. Its president, Mokgweetsi Masisi, went into 2 weeks of self-isolation on the 22nd of March after a visit to Namibia. A few weeks later, all MPs were ordered into self-isolation, when a health worker who had been on duty at parliament tested positive for Covid-19. When some MPs broke that self-isolation, they were ordered to a government-supervised quarantine facility. All members of Botswana’s cabinet donated 10% of their salary to the country’s Covid-19 relief fund.
So what do the countries which have been successful in managing Covid-19 have in common? It’s not something simple, like female leadership. It’s not religion, or lack of it. It’s not having an authoritarian or democratic government. It’s not ethnicity. It’s not geography. It’s not money.
Although it’s not universal, one factor that stands out in most of the affected countries is experience. Rwanda and Uganda knew how to implement border screening and contact tracing as a result of the Ebola outbreak over the previous two years. Kerala had an outbreak of Nipah virus – a nasty disease spread by bats – in 2018, and it was the same health minister managing both the Nipah and Covid-19 responses. Vietnam had the first SARS outbreak in 2003. Samoa suffered a measles outbreak last year. While there aren’t obvious examples for all the successful locations, it seems that a willingness to learn from the past is important.
What’s more obvious, though, is what the countries haven’t done. They haven’t dismissed the outbreak as trivial. They haven’t been more concerned about managing photo opportunities than managing the disease. They haven’t tried to fight an indifferent virus with polarising rhetoric. They have not been, as George Monbiot described the leadership of certain countries, “cavalier and reckless” with an “almost instinctive aversion to investment, to carrying a cost today that could be deferred, delayed or dumped on someone else”. Instead, they’ve got on with the job and have received relatively little recognition for it. I hope that this story goes some way to redressing that.
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