Why the coronavirus does not discriminate. 08.06.20
Welcome to The Plague Pit – issue number 29
I’m very pleased to welcome a new student contributor to the site, Te Pungpapong. Te is in the sixth form at Winchester College and getting ready to apply for medical schools later this year. In this splendid article, he looks at how different countries across the world have responded to the COVID-19 pandemic.
The dichotomy of SARS-CoV-2 between high-income countries and developing countries is hard to believe, with the disproportionality of case numbers and subsequent mortality rates becoming increasingly evident as the pandemic rages on. On April 30th, there were 230,000 COVID-19-related deaths, and a whopping 70% of that belonged to just five high-income countries, namely the US, Italy, the UK, Spain and France [1]. Fast-forward to now, and the inconsistencies endure.
Many people, including myself, have long-standing preconceptions as to how a disease should affect different countries. Higher-income countries should tend to have stronger infrastructures, better-equipped healthcare systems, as well as higher health literacy, and therefore should be hit less hard, or at least recover better and more quickly. So far, this is not the case for COVID-19. Two other respiratory viral pathogen outbreaks, namely of SARS in 2003 and H1N1 in 2009, also resemble the current pandemic and remind us that the novel disparities currently being seen are in fact not new. Despite originating in China, where over 5000 cases of SARS were reported, there were less than 10 cases in Malaysia and Thailand each, even though both countries have long frequented the list of top Chinese travel destinations. On the other hand, 251 cases of SARS were reported in Canada [2][3]. Equally, 5.6 million cases of H1N1 were reported in Italy [4], but there were only 12,000 in Vietnam [5], a significantly less amount.
What, then, really determines how different countries will fare against different diseases? We are quick to judge a country’s success at dealing with COVID-19 by looking at their current infection and mortality rates, but it is simply still too early to make that call. It would be foolish to apply a generalised attitude towards each country. Instead, we must try to understand the heterogeneous nature of pandemics. Below, I explore the various hypotheses set forward to explain the strange and unequal distribution of the current COVID-19 pandemic.
It is true that inadequate healthcare systems and infrastructure arise from insufficient national income. Despite this, Southeast Asia, comprised mainly of developing countries and in close proximity to the country of origin, has managed to dodge the crisis currently devastating higher-income countries. Although numbers initially spiked in the beginning, the region has seen relatively low infection numbers and deaths, with the highest number of cases being in Singapore at around 34,000 cases (as of 29 May 2020). There will inevitably be under-ascertainment, however, as limited testing (only symptomatic versus random) as well weak data reporting systems/quality will yield slightly lower and inaccurate numbers. Nevertheless, hospitals are yet to be overwhelmed, and the presence of some of the lowest deaths per capita dispel any doubt of misreporting. As of 29 May, Thailand has had only 0.08 coronavirus-related deaths per 100k population, compared to the UK’s staggering 54.6 figure, even though Thailand has a significantly weaker health infrastructure as evidenced by its low hospital bed per capita ratio (2.1 vs. 2.6 beds/1,000 in 2017).
Social elements may instead be key to understanding how and why COVID-19 spreads in a specific country. How the elderly are housed and taken care of, for example, differs significantly between countries. In high-income countries, we see relatively higher numbers of nursing/care homes, which can be attributed to their populations skewing older. Not only is there increased susceptibility due to age [6], but group living settings make these places prime incubators for the virus [7]. As of May 22, 42% of US coronavirus deaths are from only 0.6% of the population. More specifically, this 0.6% reside in nursing homes [8].
Many countries and their people will also have different attitudes towards wearing masks, with some countries either more accustomed to it or more willing to do so [9]. Todd Pollack, an infectious diseases specialist based in Vietnam, remarks on the relative Vietnamese success to The Economist: “Countries that took early, aggressive action, using proven methods, have severely limited the virus. If you reduce it fast enough, you never reach the point of exponential growth.” Pollack agrees that a generally higher inclination to wear masks has led to more effective suppression [10].
Previous experience with similar coronaviruses may also have an effect on COVID-19’s damage on countries. As a result of this, many countries usually exceed WHO advice in terms of stringency, meaning that restrictions and social isolation practices are implemented earlier and more aggressively. Previous traumatic memories of SARS crises may also lead to a greater willingness from citizens to comply with suppression policies to reduce transmission [11].
Perhaps it is politics which influences this. In an article by the Financial Times, Chang Shan-chwen, a Taiwanese expert on infectious diseases, sheds light on political differences, using China as an example: “In [China’s] autocratic system, every citizen will stay at home when told so. But this is something which cannot be easily achieved in free and democratic countries.” In spite of this, he credits Taiwan’s successful response instead to “transparency”, despite it being a democracy [12].
In my opinion, it is true that some governments may be able to exert more control over more obedient citizens. China’s ability to impose more stringent policies may have resulted in much more effective prevention of transmission, whereas the US continues to struggle as more and more Americans take to the streets, growing tired of indefinite lockdown.
Another possible factor is the relationship between citizens and their leader in terms of trust, as well as the sincerity and readiness displayed. Both the governments of Brazil and the US face growing animosity. Very recently, Brazil lost its second health minister, Nelson Teich, who resigned from his post less than a month after their last health minister was sacked by its president, the controversial Jair Bolsonaro. As coronavirus cases surge and Brazil deteriorates, Bolsonaro continues to uphold unfavourable views, such as the prioritisation of national economy over social isolation to save lives, as well as his advocacy for the use of chloroquine, the malaria drug, in treating the virus [13]. Differing views between health officials and Bolsonaro have seen Brazil climb up the pandemic rankings to second place.
Similarly, the US continues to struggle: the disconnect between Trump and the independent states’ differing views is evident, and disagreements regarding social isolation policies worsen [14] as the US coronavirus death toll passes 100,000 [15]. New York, previously the world’s coronavirus epicentre [16], overcame its peak back in early April; the rest of the country is yet to follow suit.
World-renowned US medical figures such as Anthony Fauci and Deborah Birx face similar frustrations to their Brazilian counterparts, as their expertise and opinions are often downplayed and not fully utilised. It is also interesting to note that Taiwan’s vice-president is an epidemiologist, which may have resulted in their unprecedented success.
All of these examples help to illustrate the incapability of a ‘one-size-fits-all’ response in trying to understand and combat the COVID-19 pandemic. One must acknowledge the heterogeneity of the situation, and efforts must be tailored to local epidemics instead, taking into account specific weaknesses and characteristics, instead of adopting generalised policies. Nevertheless, we remain in the early stages of the pandemic, and as the situation unfolds, bringing about successive waves of infection, anything, really, could happen.
Te Pungpapong
[2] https://www.who.int/csr/sars/country/table2004_04_21/en/
[3] https://www.hvs.com/Content/3109.pdf
[5] https://pubmed.ncbi.nlm.nih.gov/25966032/
[6] https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30243-7/fulltext
[9] https://www.nytimes.com/2020/03/17/opinion/coronavirus-face-masks.html
[12] https://www.ft.com/content/e015e096-6532-11ea-a6cd-df28cc3c6a68
[13] https://www.theguardian.com/world/2020/may/15/brazil-health-minister-nelson-teich-resigns
[14] https://uk.reuters.com/article/uk-health-coronavirus-usa/u-s-coronavirus-crisis-takes-a-sharp-political-turn-idUKKBN21Z2IB