Instructions and QR code for SafeEntry contact tracing is displayed amid coronavirus at a Sejong Culture Center ahead of musical 'Mozart'
Recent good news about COVID-19 vaccines must be taken with a dose of caution, as the vaccines’ long-term effectiveness, manufacturing, financing, and logistics remain daunting challenges. Therefore, as the world settles into a multi-year pandemic, non-pharmaceutical interventions will remain a crucial part of the pandemic response. As Asia has generally fared better than other regions in humanity’s first year with COVID-19, what lessons from Asian countries should we consider for global public health?
Start the Long-term Work, Today
Much of Asia’s successful responses are due to steady progress since SARS in 2003. Three main improvements are a rapid expansion of health infrastructure (both for public health and towards universal health coverage), a clear command-and-control structure (with well-defined responsibilities for federal, provincial, and district governments), and embedding health into the social contract (mobilizing more funds and bipartisan political consensus during pandemics).
These timeless lessons are immediately helpful for countries in other regions. COVID-19 provides the right timing for a combination of political will and public consensus to kick-start a strategic development plan to strengthen public health and health systems. Cheap worldwide borrowing costs will provide the necessary funds, aided by an emphasis on health by development banks and major development aid agencies. As SARS triggered long-term work in Asia in 2003, COVID-19 can be the same trigger for other regions.
However, Asia’s progress took place over 17 years, and it is difficult to compress decades of work into the mere months demanded by the urgent realities of COVID-19. Country-level progress is also complicated by the current distrust of governments worldwide, political and societal polarization, and a fraying of the multilateral order that reduces global collaboration.
This is where COVID-19’s first year in Asia can provide three low-hanging fruit policy options for rapid implementation in other regions, over and above the oft-analyzed successes of testing, tracing, decisive decision-making, and trust in technocrats. The policy options are described as follows.
Aim to Change Behaviors, not Restrict Activities
In public health theory, there is a difference between human activities (such as exercising, shopping, socializing, and traveling) and human behaviors (physical distancing, wearing masks, and regular handwashing). Pandemic responses had to both restrict activities and change behaviors in the initial phases marked by uncertainty about the virus and a desire to implement all options simultaneously.
For every country, restrictions on human activities helped to flatten the curve and buy time for health systems to strengthen or for health workers to rest. However necessary, these restrictions are damaging to the economy, population mental health, and societal cohesion when prolonged.
Therefore, movement restrictions should become a last-resort option not to be endlessly deployed in a multi-year pandemic. There are several reasons for this. Restricting human freedoms is morally, legally, administratively, and economically costly, no matter its short-term benefits in reducing cases. Restricting freedoms also attracts a lot of public scrutiny and risks a slippery slope to authoritarianism. Therefore, it is a strategy with rapidly diminishing returns and progressive costs to the government.
After a few months of fighting COVID-19, the strategy of Asian governments moved away from emphasizing restrictions to emphasizing behavioral changes and public health interventions like testing, tracing, and isolating. Restrictions on activities were progressively minimized, especially as populations began adopting new norms of behavior. This approach is more sustainable and effective while avoiding the false binary choice of lives versus livelihoods.
Adopt A Moderate Path
The Wuhan lockdown set the scene for nationwide movement restrictions of varying names, durations, and intensities, for example in Malaysia, Singapore, and South Korea. However, these blunt instruments were soon replaced by more surgical approaches with less severity, shorter durations, and smaller geographic impact. This was enabled by increasing data and understanding of the virus, increasing confidence and capacity of public health experts, and increased understanding of and compliance to new behavioral norms by citizens.
In parallel, the communications strategies of Asian governments helped. They either pushed the narrative that the pandemic will be present for years or did not push the narrative that there will be a magic solution like a vaccine. Crucially, every leader embraced science and no leader tried to falsely reassure their citizens (in stark contrast to the outgoing United States President’s repeated assertions that COVID-19 will “disappear”). Therefore, populations settled in for the long-haul and began accepting a desirable middle path between zero and full restrictions.
All these factors combined for nuanced decision-making. Despite subsequent waves of COVID-19, Asian governments no longer resorted to severe nationwide lockdowns. In sterling examples, Taiwan, Thailand, and Vietnam have had long periods of almost no community transmissions using only minimal restrictions, proving the success of moderate paths instead of lurching between zero and full restrictions.
Combine Existing Non-Health Infrastructure with Public Health Infrastructure
When the pandemic hit, China, South Korea, and Taiwan quickly combined data from their non-health infrastructure with their public health surveillance architecture. Data from credit card transactions, ATM withdrawals, security cameras, telco metadata, and gig economy platforms were combined with data from COVID-19 testing, epidemiological models, and healthcare facilities, greatly increasing contact tracing capabilities.
The good news is that these data sources and infrastructure are already available in many countries. Combining it with public health data systems will require some platform inter-operability and a new partnership between epidemiologists, data scientists, and engineers from various sectors. It will also require new legal and privacy frameworks with appropriate oversight and governance. However, rapid collaboration is not an impossible task, especially if built on years of progress, stakeholder familiarity, and institutional frameworks. The European Union’s General Data Protection Regulations (GDPR) in 2018 provides an instructive example.
Since much of the non-health infrastructure in many countries is privately-owned, collaboration may usher in a period of re-examining the political economy of providing public goods. In broad terms, Asian governments have a cozier relationship with nominally private companies, like China’s state-owned enterprises, South Korea’s chaebol, and Japan’s zaibatsu. In contrast, western governments try to stay out of business. Both models have exhibited effective and viable public-private partnerships, which makes it imaginable to integrate the health and non-health infrastructure.
In the longer-term, greater examination is needed of how these models differ in the vertical and horizontal integration of effective public goods provision, such as in platform- and data-sharing during pandemics. Other more complex areas of public-private provision of public goods are in vaccines research and manufacturing, building and operating laboratory networks or even the entire public health surveillance system.
Final Lesson: Humility
These realistic policy options will help fight COVID-19 but must still be complemented by large-scale improvements in other regions. Tectonic issues such as an increasing distrust of science, the politicization of evidence-based policymaking, and long-term trends towards individualistic behavior must be addressed.
The first year of COVID-19 has shown that Asian leadership in both public policy and health deserves greater global attention, with a final lesson from Asia being humility. No Asian government has loudly announced success against COVID-19, because they know the pandemic is long, hubris is deadly, hard and unglamorous behind-the-scenes work must continue to protect their citizens, and that everyone can learn from everyone else.
