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A virus spreads in society because those ill with the virus make contact with others who are susceptible. If the virus transmits to more than one other person for each person it infects, it will cause an epidemic. This ratio is called the reproduction number and is denoted as R naught (R0) by epidemiologists. Each infectious disease has a base-line R0 that indicates how well it naturally spreads in a population, but it is possible to alter this number by changing behavior. For example, it appears COVID-19 has a maximum incubation period of about 14 days. If it were possible for everyone to stay home for three weeks (just giving a buffer here) and never make contact with another person, R0 would go to zero. Of course, this is an extreme example. Modern society cannot function without any human interaction. But it does demonstrate that changing human behavior can slow the spread of the virus. As the virus has spread around the world, various countries have tried different measures to stop the spread of COVID-19. In this section, we will examine several successful examples and one poor example currently unfolding.
Initially, China attempted to suppress information about a new type of pneumonia that was popping up in Hubei province. The first case of COVID-19 may have occurred as early as November 17th, 2019, and Chinese authorities tracked at least 266 people who contracted the virus in that year. The Chinese government attempted to hide information about the virus, even punishing doctors who tried to warn their colleagues about a new SARS-like virus that was spreading in the City of Wuhan. To be fair, the initial emergence of a new infection is often mistaken for other diseases, and it is only in hindsight that disease origins become apparent. However, the punishing of physicians trying to raise the alarm suggests a more sinister purpose. Authorities in China finally recognized the virus and reported on January 21st that there was host-to-host transmission of COVID-19.
Once China confronted (or admitted) the growing epidemic, how did they limit the spread of the virus so that only about 84,000 cases occurred? (Note: I doubt the reported cases in any country are the actual real cases due to either inadequate testing or inaccurate reporting of incidents). First, China had a plan in place. Planning is essential to the response to any crisis. Knowing what you are going to do before a crisis hits allows the identification and preparation of equipment and personnel that will be needed. It is much easier to get resources in place beforehand than to attempt to do it during a crisis. Marshaling resources in a time of crisis is always tricky because of the compressed timeframe.
As the seriousness of the epidemic became clear, China implemented a quarantine beginning on January 23rd, eventually encompassing all of Hubei province, putting 45 million people under stay-at-home orders. The government suspended all public transportation, and large gatherings were prohibited. Community committees delivered needed food, medicine, and medical supplies to residents, reducing the need for outside trips. Two emergency field hospitals with 2,400 beds were constructed within a couple of weeks to house those with severe cases of COVID-19. Large venues were transformed into medical observation and treatment centers to accommodate less ill patients. These could support up to 14,000 people. The deployment of medical rescue teams from other areas of China to Hubei ensured enough personnel to staff these treatment centers. Having space to isolate all COVID-19 patients decreased the spread of the disease in the community.
A grid-closed management system prevented unnecessary interaction of individuals. The policy restricted movement, allowing only one person outside to run errands every two days. Each area was closed off, with only one entrance and exit point, facilitating close monitoring of movement. As each person traveled through these grids, they had to scan a QR code. Thus anyone who tested positive could be rapidly identified, and all their contacts quickly traced. This draconian monitoring is a significant invasion of privacy. There are better-designed applications that protect privacy, but allow the same ability to trace contacts (see below). Some of the methods to encourage compliance involved beatings and near imprisonment. These types of responses are extreme and unwarranted. On January 27th, all schools were closed, and instruction went online. Outside of Hubei, all passengers underwent temperature tests at airports, railway stations, and bus stations.
In the economic sector, aggressive measures prevented business failures and helped the medical response during the epidemic. Lower loan thresholds and loan rates allowed businesses to borrow money under more favorable terms. Companies could also apply for tax relief and other government funds to help them survive. Some businesses shifted production lines to produce medical protective equipment and ventilators. China has the manufacturing capacity to do this.
The epidemic is now better controlled within China. To prevent reinfection from abroad, entering flights are restricted to twelve airports, and incoming passengers must undergo COVID-19 testing and quarantine until results come back negative. The aggressive measures taken by China limited the spread of the virus, and new cases of COVID-19 began to decrease within two months. Today, the Chinese government reports that there is no sustained spread of the illness within the country. Hopefully, this success can continue, and again, one should treat the reports from a historically secretive country with skepticism.
China continues to monitor the virus and impose strict lockdowns when infection rates begin in an area. This policy has been successful in controlling the virus and keeping deaths low. As of July 2022, they have recorded 14,647 deaths, much less than many other countries. There is some concern that the reporting coming from China is not accurate.
In hindsight, China's zealous response to the virus may have gone too far. Their zero-COVID policy repressed the virus for years, but in the interim, their population did not vaccinate completely. The inactivated vaccines that China developed, CoronaVac and Sinopharm, provide strong protection after three doses. Too many in the Chinese population did not get three doses, and because of this, when China relaxed the zero-COVID rules late in 2022, infections exploded. The CDC estimates that from December 2022 to February 2034, 1.41 million died in the ensuing wave. Repression of the virus caused significant psychological and economic damage. However, for those who did get vaccinated, they were protected from the illness. The high death toll was caused by a lack of progress in vaccination.
Because of its proximity to China and the previous SARS epidemic of 2003, Taiwan centralized its emergency response to outbreaks by creating a new agency, the National Health Command Center. The NHCC had broad authority to organize the response and to advise the government on appropriate steps. On December 31st, 2019, when China notified the World Health Organization of a viral pneumonia of unknown origin, the NHCC began to act. Taiwanese officials started to board planes that were direct flights from Wuhan and assess passengers for fever and pneumonia symptoms. Any individual with symptoms has to place themselves into quarantine. On January 5th, authorities expanded monitoring to any individual who had traveled to Wuhan, China, not just direct flights. By January 20th, an organized government response involving at least 124 separate items began including border control from the air and sea, case identification (using data and technology), quarantine of suspicious cases, contact tracing, resource allocation, reassurance and education of the public while fighting misinformation, formulation of schools and childcare policies, and relief to businesses.
Why was Taiwan's response so effective? The most critical factor was the speed of the reaction. Within days of being notified of an outbreak in China, Taiwan took aggressive steps to identify potential cases of the new illness. Second, a coordinated response against the virus at the national level enabled the entire society to work together. Third, the leveraging of information and technology helped to identify and contain cases rapidly. For example, within one day, the national health records database was integrated with the national travel database, allowing doctors to immediately know the travel history of any patient coming to their office. Also, citizens who entered quarantine were tracked on their phones and received emotional and financial support, including meals, to ensure they stayed home. This comprehensive response prevented the establishment of the illness in Taiwan. As of May 23rd, there have been 441 cases of COVID-19 and seven deaths.
South Korea is a close neighbor and trading partner of China. Because of the frequent travel of tourists, workers, and academics between the two countries, it was inevitable that COVID-19 cases would ultimately spread to South Korea. Instead of a nationwide lockdown, South Korea focused on rapid and widespread testing facilities and aggressive contact tracing. A vital element of the contact tracing was the rapid development and distribution of apps that helped discern contacts of COVID-19 positive patients. The first confirmed case of COVID-19 entered South Korea at Incheon International Airport from Wuhan, China. The individual was discovered after a temperature screening and immediately tested for the virus. The government quickly reacted, increasing its alert level from Aware to Care and released information about the patient's movement to alert the public of any possible exposure. Korea began to monitor all travelers coming from China and opened screening centers to detect asymptomatic carriers. The government prepared local hospitals as infection control institutes, and anyone testing positive was placed under quarantine and their contacts traced. Authorities also monitored all discovered contacts to prevent further infections. In early February, the number of COVID-19 patients grew steadily, and the government expanded testing to even marginal contacts with known COVID-19 positive cases. The government quickly approved further kits to test for the virus, facilitating the expanded testing. By February 28th, laboratories were able to conduct 15,000 tests per day. Tests were free for all residents, and as of March 16th, the Korean government had tested 250,000 people.
On February 19th, surveillance identified the 31st patient and discovered her to be the origin of a super spreader event. This individual had close contact with many in a church congregation and ended up spreading the infection to thousands of individuals. The government began limiting trips and outdoor activities and imposed emergency safety measures such as basic hygiene rules and social distancing. Drive through testing was first suggested by Jaemyung Lee, the governor of Gyeonggi Province. He observed that one-on-one testing had limited ability for social distancing, put health workers at high risk, and consumed large amounts of PPE. Low-contact drive through testing solved these problems, allowing safe testing in 10 minutes or less. Patients could learn the results of their tests via a text to their phone in three days or less. Due to the rapid deployment of testing centers, it was initially difficult for the public to locate them. To help solve this problem, the maker of the OilNow app, which usually locates the nearest gas station, added a service that mapped all testing centers.
Those in densely populated areas may not have cars or space may not be present to implement drive-through testing. In these areas, walkthrough centers enabled testing of patients from booths equipped with depressurizers (to prevent the spread of infectious virus), intercoms, and attached gloves that allowed doctors to interact with and collect samples from patients. The patient stands outside the booth, and the physician inside performs testing procedures. Daily counts of tested, positive, in quarantine, out of quarantine, and deaths appear at a website that was available to the public. Citizens could drill down into the information looking at all positive tests in their neighborhood, along with individual movement trajectories of COVID-19 positive cases in their area.
Contact tracing in South Korea is more straightforward because each mobile phone account links to a national ID. Combining this tracking data with credit card transaction history, and video footage from public surveillance cameras made it possible to reconstruct the movements of positive COVID-19 cases in great detail. Health authorities targeted contacts of cases for testing and precautionary self-quarantine. The Korean government developed this aggressive form of contact tracing with health emergencies such as the current pandemic in mind. Due to pressure by citizens, the government released this information to the public. Widespread distribution of this information has helped residents understand their risks, avoid hot spots of infection, and decide whether to be tested. Transparency is almost always the best course of action. Authorities used text messaging information systems, initially designed to inform citizens in local areas of disasters, to keep the public informed. General messages were sent to all residents every day to inform them of the number and location of cases in their area. Specific texts were also sent to individuals if their paths had crossed with a known COVID-19 positive case. Some found these frequent contacts overwhelming, but overall it was well received. Armed with the movement data, several private companies developed applications and websites that could trace the user's paths compared to those who were COVID-19 positive. The translation of mapping data into a visual, interactive form made it easier for citizens to modify their behavior. Some apps even alerted the user when they were within 100m of a confirm patient's trajectory.
All residents and visitors to Korea are required to install a mobile app developed by the Ministry of Health and Welfare. This app requires travelers to report potential symptoms for 14 days. If signs of respiratory distress or fever occur, the user must report to local health authorities for evaluation. As of April 1st, all incoming, long-term residents must self-quarantine for two weeks. The Ministry tracks quarantine compliance with the app.
As the number of cases grew in Korea, the government developed a smart management system to speed up contact tracing. Rapid tracing required the combination of data from the police agency, three telecommunication firms, and twenty-two credit card companies. The app was able to reduce the time consumed for contact tracing from one day to ten minutes. People exposed to a known COVID-19 case had to self-quarantine, and the government monitored their symptoms and location for 14 days using another mobile app. Unlike the travel tracking application, this application is voluntary.
South Korea was able to respond so rapidly to the COVID-19 epidemic because they had planned for years for such a possibility. The previous outbreaks of SARS and MERS made it clear that a worldwide pandemic was likely to occur in the coming years. Debates pitting privacy rights and sharing of customer data against public health already happened, and a balance was negotiated beforehand, saving valuable time.
One drawback of the Korean plan, as with the Chinese, was a significant intrusion into the private lives of its citizens to allow effective contact tracing. Other societies, such as the United Kingdom, the US, and Canada, may not be so willing to give up these privacy rights. Fortunately, there are other compelling solutions to contact tracing. (see below)
Before I begin this section, I should warn those who are fans of the federal government response that this assessment is going to be quite critical. This response was so outside what was expected that the medical journals, the New England Journal of Medicine and the British Medical Journal wrote editorials on it. A very unusual response. We must honestly face the mistakes made and the advice that was ignored if our society is going to learn and fight this epidemic productively. If reading about this timeline is going to upset you, you may want to skip this section. However, I encourage you to read it with an open mind.
The crisis in the US was an avertable catastrophe. President Trump willfully ignored numerous warnings from officials in the early months of 2020. On January 23rd, the World Health Organization warned all governments to get ready for coronavirus. Be prepared for active surveillance, detection, isolation of cases, contact tracing, and prevention of spread. After the first initial case arrived in the US on January 22nd, two months of inaction followed, with Donald Trump issuing false reassurances to the nation. China's efforts to combat COVID-19 slowed the spread of the disease and gave the US time to react. Fear of the political and financial consequences delayed the response to the pandemic. We could have increased the production of personal protective equipment, ramped up testing capability, expanded hospital capacity to deal with an influx of patients, and established transparent chains of command between states and the federal government. Afraid that it would spook the stock market, none of this was done.
Not only did Donald Trump not respond to the actual pandemic, his administration actively dismantled the government's preparation. Most of the participants in the pandemic preparedness drills the outgoing Obama administration put on for them have left. The disbanding of the White House Global Health Security office, the elimination of a global early warning system, PREDICT, that identified viruses of pandemic potential, the removal of a CDC expert in China whose job was to monitor outbreaks such as COVID-19, and cutting funding to critical programs at the CDC have all contributed to our governments lack of preparedness.
As the pandemic storm washed across the US, governors were left fending for themselves. The CDC had to resort to advising the use of bandanas as a substitute for PPE, and states competed in bidding wars to secure necessary equipment. The CDC made a critical mistake in designing a different test kit instead of using the one developed by WHO, which wasted valuable time. Stuck with a lack of testing and no ability to trace the contacts of those who tested positive, a large number of states and localities had no choice but to use the blunt instrument of stay-at-home orders for the entire population. Governments ordered citizens to enact social distancing, limit travel, avoid gatherings of ten or more people, and close non-essential businesses. These measures have met with variable success. Citizens of some states have observed these recommendations (NY, WI, CA), while others left open spring-break beaches, schools, daycares, and other non-essential activities, allowing the continued spread of the virus.
The US's patchwork response contrasts sharply with the coordinated response of Taiwan, South Korea, and China to the pandemic. Poor leadership at the federal level is the primary reason that the US was the epicenter of the epidemic in 2020-21, with tens of millions of cases and millions of deaths. Even more frightening is the irresponsible, premature push at the federal level to relax state health orders that, where implemented, have significantly slowed the spread of COVID-19. A rushed "return to normal" risks allowed the virus to again spread in communities, causing illness, death, and economic disruption on a scale not seen anywhere else in the world. The disappointing news that some states may manipulated their numbers is terrifying.
The anti-scientific pronouncements by Donald Trump have made matters much worse, from declaring that the pandemic would disappear on its own (2/28) to prematurely promoting hydroxychloroquine as an effective treatment (3/21). Panic buying of hydroxychloroquine ensued, increasing prices and leading to overdoses. Lupus patients, for which hydroxychloroquine has proven benefits, were unable to fill prescriptions. On the day the CDC announced that masks would help stop the spread of the virus, Trump said he refused to wear one. The penultimate level of ignorance was displayed when Mr. Trump suggested using disinfectants inside the body or UV light treatment of blood might be usable against coronavirus. Experts and companies that made disinfectants rushed to warn the public against inhaling or ingesting bleach products. In late April, Trump's arguably most extreme act was the call for large public protests against governors (conveniently from the Democratic party) for their stay-at-home orders. Mass groups of protestors exposed themselves to the potential spread of the virus, further exacerbating the situation and potentially leading to extended stay-at-home restrictions. Recent data indicates that 72 people likely contracted COVID-19 after attending a rally in Wisconsin protesting the stay-at-home order. So far, the US response at the federal level has been chaotic at best.
The premature reopening of economies in the Southern United States, promoted by Donald Trump and misinformed governors that are hostile to science, has created the crisis that experts predicted. As of July 12th, 2022 new cases in Florida (317,039), Georgia (105,303), Arizona (83,699), and Texas (288,520) indicate a virus raging out of control. Mandatory mask orders and reimplementation of restrictions could have brought the epidemic back under control, but mixed messages at the federal, state, and local level leave populations confused. In addition, propaganda broadcast from websites and news channels makes matters worse. The general population needed to educate themselves, start wearing masks, and social distancing. However, with the contradictory information coming to them from all sides, the general population is understandably confused.
A change of President has helped the US response. However, much of the damage has already been done. Over 1 million Americans have died from COVID-19, making it the 3rd leading cause of death. The vaccination campaign greatly decreased the spread of the epidemic, but because of misinformation, many citizens are afraid to be vaccinated, and we did not achieve herd immunity in a timely fashion. In fact, we are still not there, and I fear we never will be.