Not Too Late: International Learning from Covid-19

Sir John Oldham is Adjunct Professor at the Institute of Global Health Innovation at Imperial College London. He is a GP by background and chaired the Independent Commission on Whole Person Care in 2014. He was previously a member of the National Quality Board for the NHS in England, and National Clinical Lead for Quality and Productivity at the Department of Health and Social Care.

It is clear that some countries have fared far better in their health response to the COVID-19 pandemic, and the consequent economic impact has therefore been lessened.

For example, at time of writing the rate of deaths from COVID-19 per million of population in South Korea is 5.7. It is 4.5 in New Zealand and 4.0 in Singapore. At the opposite end of the scale to date are Brazil (308 deaths/million), the United States (406/million), and embarrassingly, the United Kingdom (656). We are “world beating”, but not in a good way.

These differences are too large to attribute to differences in data collection or populations.

Indeed, some of the population demographics are similar. It begs the question, what has made the difference? Paul Batalden said “Every system delivers exactly the results it is designed to give”, and so it is here.

An analysis of the measures put in place by the most successful countries demonstrates some common principles.

1. They approached the pandemic for what it is: a SARS-style virus, not a flu virus.

That matters. Flu is less deadly and more well-understood, and epidemiological models of flu are based on more accurate data.

The opposite is true for COVID-19. Experience of SARS mattered more in these countries’ responses. It engendered a faster and more urgent implementation of measures judged to combat spread. I use the word “judged” deliberately. These countries used available evidence but based decisions on precaution. Waiting for immaculate science engendered delay. Basing decisions on the wrong science even worse.

2. Secondly, the most successful countries implemented a comprehensive and rigorous “test, trace and isolate system quickly” and from the outset.

IT and mobile phone apps were part of those systems - in South Korea, a large part. In all successful countries the testing and tracing was devolved to localities with national support. Getting a test was made easy. Korea even applied continuous quality improvement techniques to enable speeding up of tests to increase throughput.

3. Thirdly, these countries imposed restrictions quickly.

Vulnerable people were shielded (with particular attention to care homes), schools were closed, large gatherings banned, and borders either completely closed or closed to countries with known infection. Restrictions were enforced. Many countries put “stay at home” policies in place for lengthy periods, but again South Korea was the exception in that low risk groups could carry on with their lives while social distancing and wearing face masks. A solid “test, track and isolate” system gave South Korea the confidence to allow for this, and similar systems permitted the subsequent easing of restrictions in the other excelling countries.

There were of course other measures taken, such as re-orientating health care systems to deal with COVID-19 demand.

But the factors outlined above are the key pillars of the system response in successful countries. Together they engendered the other crucial element – trust.

The people in the successful countries all polled as having high trust in the response of their leaders.

Allowing large gatherings, poor test and track systems, and leaders not following their own advice, all eroded trust and therefore adherence to guidance in other countries.

In those countries who haven’t done well, now facing inevitable spikes until a vaccine is available, it is still not too late to learn these lessons.