The coronavirus spread so far and so fast at the beginning of 2020 that most countries around the world were forced to resort to restricting citizens’ movement and shutting down all but the most essential businesses to control its spread. These so-called “lockdowns” were not intended as a permanent solution, but instead were implemented to ensure that hospitals were not overwhelmed and to buy governments time to mount a more sustainable response to the virus. A recent article published in the Lancet chronicles the experiences of nine high income countries – five in the Asia Pacific Region and four in Europe – as they implemented and eased lockdowns and other measures to stop the spread of the coronavirus. While all nine countries have instituted control measures to combat the coronavirus, there has been a lack of clarity surrounding how countries decide to institute and lift restrictions. To garner public trust in the response to Covid-19 and mitigate the negative impacts of this pandemic and future outbreaks, transparency, investment in health systems, widespread testing, and strong, compassionate leadership are crucial.
Broadly speaking, countries have taken two approaches to decision-making when implementing and easing Covid-19 lockdowns. In some countries such as Singapore, Norway, and Spain, politicians –informed by public health experts – are responsible for discerning when to put in place and lift restrictions. In these countries, the criteria on which these decisions are based are not available to the public. In other countries like Japan, Germany, and South Korea, the government institutes and relaxes Covid-19 restrictions based on the number of cases in an area.
The authors propose a framework of five requirements that countries should fulfill before lifting Covid-19 lockdowns: knowledge of infection status in the country, community engagement, sufficient public health capacity, sufficient health-system capacity, and implementation of border controls.
Each of the nine countries studied went about calling for a lockdown and easing restrictions in a different way and experienced vastly different numbers of cases and deaths from Covid-19. Out of the countries studied, Spain had the highest number of cases per population – 373 cases per 10,000 people – while New Zealand had the lowest number of cases per population – just 4.3 cases per 10,000 people. The United Kingdom (UK) has had the highest number of deaths so far at 64,500 while there have been just 25 deaths due to Covid-19 in New Zealand. While each country’s experience handling the Covid-19 pandemic has been unique, comparing different approaches can help provide insight into the best way to institute and ease strict control measures for Covid-19 and future infectious disease outbreaks.
The researchers argue that before reopening, at a bare minimum, countries must know the coronavirus infection status in their country. This means having an effective surveillance system to confirm that the number of Covid-19 cases has decreased during the lockdown and to monitor the number of new cases that emerge once restrictions are eased. Countries such as Hong Kong, Japan, Spain, Germany, and Norway have calculated the coronavirus’ reproduction number – or the number of people who one person with the coronavirus ultimately infects – at different points in time. A reproduction number of well below one can be used as a guideline that it is safe to begin reopening. While the driving factor around deciding whether to institute or ease a lockdown should be the number of cases in an area, governments must also be cognizant of the economic costs to citizens and provide the resources required so that people can stay in their homes and provide for themselves and their families.
The researchers also highlight the importance of engaging communities before easing restrictions. Clear communication and involvement of citizens around long-term control measures such as physical distancing, mask wearing, working from home, and school policies are vital so that people are equipped with the information they need to keep themselves and their families safe. Messaging around physical distancing and mask wearing have been especially confusing during this pandemic. Physical distancing requirements vary between countries with a range of one to two-meters (three to six-feet) of separation between people. Adoption of mask wearing occurred at different times throughout the pandemic. Countries in Asia adopted the use of face coverings much earlier than Europe, likely resulting in the lower numbers of cases per population in Asia compared to Europe. Lack of clarity and confusing messaging can decrease the public’s willingness to follow such restrictions.
Time during severe restrictions on population movement should be used by governments to increase public health capacity and prepare to implement widespread testing, contact tracing, and isolation of those with confirmed infection. The two regions in this study have approached isolating confirmed cases differently. Asian countries isolate confirmed cases, regardless of whether or not they have symptoms, in hospitals or other institutions, whereas European countries isolate confirmed cases who are asymptomatic or have mild symptoms at home.
Testing has changed dramatically throughout the outbreak as tests have become more widespread. Drive-through testing in South Korea and Germany and at-home testing in the UK and Hong Kong have improved access to testing and decreased the potential for people to become infected while getting a test at the hospital. South Korea, the golden standard for testing, mass tests all people who have visited public venues or been to events where anyone with Covid-19 was present. This has resulted in one of the lowest infection rates per population in the world. Contact tracing has also improved throughout the pandemic as apps and other technologies are being used to assist individuals working for local health departments the world over.
The largest reason presented for why lockdowns are put in place is so that health systems are not overwhelmed. To that end, the researchers describe the importance of ensuring that the health system has the capability to handle new Covid-19 cases that may occur once the lockdown is lifted. This means making sure there are enough staff, personal protective equipment (PPE), intensive-care unit (ICU) beds, and ventilators to treat Covid-19 patients with severe disease. Decisions made before the pandemic on health expenditure are now having a large impact on the set of options that a country has.
Germany invested in its health system before Covid-19 and, even during the peak of its outbreak, always had plenty of ICU beds. Other European countries were forced to find other spaces within its hospitals and use other wards to treat all of those with severe Covid-19. Some countries have also struggled to provide healthcare workers with the proper PPE. This has had disastrous consequences in Spain where over ten percent of Covid-19 cases are healthcare workers. Countries in Asia such as South Korea, Singapore, and Hong Kong, however, stockpiled PPE before the pandemic and have had very few cases among healthcare workers.
Lastly, before easing restrictions to decrease the spread of Covid-19, countries must have a plan to decrease the risk of Covid-19 traveling across borders between countries. The five countries in the Asia Pacific region have much stricter border control measures compared to their European counterparts, which have been slow to require travelers to be tested routinely. New Zealand, which had no community transmission of Covid-19 for over 100 days, allows very few people to enter the country and requires any travelers coming from overseas to remain in a quarantine facility for two weeks. In contrast, Spain fully reopened its borders in July. These border policies likely played a role in the vast discrepancy between the number of cases and deaths in Spain and New Zealand – Spain has had 373 cases per 10,000 people and 48,013 deaths from Covid-19 while New Zealand has experienced only 4.29 cases per 10,000 people and 25 deaths from Covid-19
In many countries, Covid-19 has exacerbated existing inequities and had a disproportionate impact on already marginalized groups. This was especially true in the UK where Black people were diagnosed with Covid-19 at over 2.5 times the rate of white people. More data is needed from countries like Germany to understand and address the full scope of how Covid-19 disproportionately impacts people of color.
During the periods of lockdown, the authors found that governments varied in the amount of support they provided to their citizens. In the Asia Pacific countries, governments provided one-time cash handouts to the public. European countries have been able to provide longer-term support. The UK paid the wages of furloughed workers until the end of October and Spain is providing a minimum monthly wage of around $500 for its poorest citizens.
The authors also noted that countries with female leaders have been the most successful at gaining public confidence and convincing citizens to follow both the lockdown requirements and the more sustainable public health measures necessary after the lockdown is lifted. New Zealand and South Korea – both of whom have female leaders – have the two lowest infection rates per population.
As the vaccine rollout begins and the days of severe restrictions are hopefully coming to a close, some may ask – why focus on lessons learned from easing lockdowns now? The answer is that, with infectious disease outbreaks occurring with increased frequency, we need to heed the lessons of this outbreak to prevent future widespread epidemics. The authors of this study found that Asian countries were much more prepared for the coronavirus outbreak due to their past experiences with Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). This is also a call to invest heavily in health and public health systems around the world. Austerity in Europe for the past ten-years has weakened health systems and decreased social protections. With the exception of Germany, all countries in Europe faced shortages of ICU beds and other necessities to fight this pandemic.
Investments in our public health and health systems globally will enable countries to respond much more quickly to future outbreaks and increase the capacity of health systems so that they do not come so close to collapse. It is not nearly enough to hope that this is a once in a century pandemic, we need strong leadership, investments in health systems, and social protections that decrease inequity to ensure that we are all better prepared for the next outbreak.