Coronavirus Lessons From Abroad

Since she learned of the coronavirus outbreak, Amy Ho’s daily routine has gotten a bit more complicated. Coming home now involves sanitizing her shoes, washing her hands with soap and water, taking off her medical mask and changing her clothes.

The Hong Kong resident ventures outside only by necessity. She walks to and from work. Goes to the grocery store once a week. That’s it. Her teenage daughter has only left their apartment twice since the end of January.

“It’s annoying, sure. But our health is the most important thing,” she says.

Over Easter, the family looked forward to vacationing in the U.K. and Italy. But with the virus raging, they canceled.

Her precautions may sound drastic, but they’re hardly unique in a city that was among the first to be swept up in the global coronavirus crisis.

That Hong Kong has become a lodestar for its ability to seemingly keep the disease at bay, for now at least, is no accident: it’s desperate to avoid repeating the nightmare of a 2003 epidemic. Globally, SARS or severe acute respiratory syndrome, infected over 8,000 and killed 774, including 299 in Hong Kong.

Though SARS devastated many Asian metropolises, in its wake, some doubled down on preparing for the next crisis.

“Somewhat perversely, we can look at SARS as the dress rehearsal,” says Jeremy Lim, co-director of the Leadership Institute for Global Health Transformation at the National University of Singapore. “The experience was raw, and very, very visceral. And on the back of [it], better systems were put in place.”

Singapore, Hong Kong and Taiwan have been hailed for using those hard-won lessons to combat the new coronavirus—officially COVID-19 and a relative of SARS.

It’s still too early for anywhere to declare victory just yet. But against the odds, these enclaves have succeeded at keeping their virus numbers low, despite their links to China. Perhaps governments in North America and Europe, which are now bearing the brunt of the pandemic, can emulate their best practices, and turn the tide on an infection spreading rapidly through the global population.

Act quickly

For Singapore, Taiwan and Hong Kong, the story could easily have been one of catastrophe. The novel coronavirus emerged just in time for Lunar New Year, when millions travel across the region in the world’s largest annual human migration. All three territories are closely interconnected with mainland China, with direct flights to Wuhan, the outbreak’s epicenter.

Key to their success so far has been the decision to respond aggressively from the outset.

In Taiwan, an island of 23 million, arrivals from Wuhan were subject to health screenings before human-to-human transmission of the virus was confirmed on Jan. 20.

By Feb. 1, Taiwan, Hong Kong and Singapore had all proactively implemented travel restrictions on passengers coming from the mainland, contravening the World Health Organization’s [WHO] insistence that travel bans were not necessary. The precautions came at a significant economic cost to these international hubs, which all rely on mainland China as their biggest trading partner and source of tourists.

The three destinations were also well prepared, making rapid response possible.

Following SARS in 2003, Taiwan established a central command center for epidemics. By Jan. 20, it was coordinating the government’s response to the coronavirus. It quickly compiled a list of 124 “action items,” including border controls, school and work policies, public communication plans and resource assessments of hospitals, according to an article in the Journal of the American Medical Association.

“If you assume that containing an epidemic is like running a 100-meter dash, Taiwan had a head start because it was prepared,” says C. Jason Wang, director of Stanford University’s Center for Policy, Outcomes and Prevention, and one of the article’s authors.

Taiwan, just 81 miles from mainland China, was expected to have among the highest number of imported cases, he adds. But it has now tallied just 50 cases—fewer than Slovenia.

“Epidemic preparedness starts years before an outbreak,” Emanuele Capobianco, director of health and care at the International Federation of Red Cross and Red Crescent Societies, tells TIME. “If [the] number of beds or doctors were cut over the years, for example, it will be very difficult to compensate in a short period of time.”

He adds: “It is hoped that countries with strong health systems will eventually be able to manage this outbreak also, thanks to the lessons from Asia.”

Taiwan’s rapid mobilization contrasts starkly with South Korea and Japan, which are also proximate to China and enjoy advanced healthcare systems. They have faced criticism for their initially sluggish responses and the ensuing explosion of cases.

Rigorous detection and strict quarantine

When the virus began crossing China’s borders in January, Singapore appeared fated for a large-scale outbreak. The tiny city-state was the third country to report cases of COVID-19, and by mid-February, had recorded over 80 infections, the highest outside the Chinese mainland.

But the tally indicated more about the thorough testing conducted on the island of 5.7 million. A study by Harvard University’s Center for Communicable Disease Dynamics estimates Singapore detects almost three times more cases than the global average due to its strong disease surveillance and fastidious contact tracing.

In order to uncover COVID-19 infections that may have otherwise evaded detection, Singapore’s health authorities decided early on to test all influenza-like and pneumonia cases. They have also spared no pains in hunting down every possible contact of those infected. The process, which operates 24/7, starts with patient interviews, and has also involved police, flight manifests and a locally developed a test for antibodies, which linger even after an infection clears.

As of Mar. 13, the city-state had 178 cases and zero deaths.

Singapore is “leaving no stone unturned,” said Tedros Adhanom Ghebreyesus, director-general of the WHO.

Government advertisements carried on the front page of Singapore’s largest daily newspaper urge readers with even mild symptoms to see a doctor and refrain from going to school or work. And no Singaporean has to fear affording treatment. Testing is free, and the government foots the hospital bills for Singaporean residents who have suspected or confirmed cases.

To make quarantine less onerous, the government offers self-employed people $100 Singapore dollars ($73) per day, while employers are prohibited from detracting quarantine days from staffers’ annual leave.

But Singapore’s response may not be directly translatable elsewhere. Since independence in 1965, it has been ruled by a single party that maintains tight control and is rarely subject to public criticism. Amid the coronavirus outbreak, quarantine and isolation protocols are strictly enforced. A permanent resident who breached quarantine rules lost his status, while a couple was charged in court with providing false information about their travel history.

“It’s a mix of carrots and sticks that have so far helped us,” says Lim, at the National University of Singapore.

The U.S., he adds, “should learn from Singapore’s response and then adapt what is useful.”

Some suggest Singapore’s effective coronavirus response has less to do with its authoritarian streak than with transparency, comprehensive testing, and quick quarantining and isolation of suspected cases.

“Many have been praising authoritarian responses based on control and coercion, and yet I think what we are seeing is that good public health using modern tools [is] more important,” says Matt Kavanagh, director of Georgetown University’s Global Health Policy and Governance Initiative.

Social distancing and banning mass gatherings

Perched just across the border from the mainland’s health crisis, Hong Kong quickly put social distancing into practice. Schools remain closed through Easter. Normally bustling shopping streets, in some of the world’s most densely packed districts, are largely devoid of foot traffic as residents voluntarily stay sequestered at home. Many businesses have either shuttered or asked employees to work from home. Movie theaters, churches and basketball courts sit empty. Mass gatherings are canceled.

The measures appear to be working. Neighboring Guangdong province has recorded 1,356 cases, the highest number in China outside Hubei where the outbreak was first detected. But in Hong Kong, a semi-autonomous entrepôt, the number of infections remains 131.

In a city deeply scarred by the SARS outbreak—and still populated with hand sanitizer stations—familiar reflexes, like proper hand hygiene, have snapped back into practice.

“People are quite cautious now when they face a major outbreak of an infection,” says David Hui, director of the Stanley Ho Center for Emerging Infectious Diseases at the Chinese University of Hong Kong. The precautions have been so effective, he says, that the city’s annual flu season has been dramatically reduced.

These gains come despite mistrust of the government, which runs deep after nine months of often violent street demonstrations. But faith in the public health system—one of the world’s best—remains intact. People don’t want to get sick, Hui says, “so they are actually compliant with public health measures even though they don’t like the government.”

Effective communication

To ensure people remain vigilant, but don’t panic, experts say a government’s communication with the public is vital. No one appears to be doing it better than Singapore’s Prime Minister Lee Hsien Loong.

After the government raised its outbreak alert Feb. 7 to orange, one level below the maximum, Singaporeans emptied supermarket shelves. To quell the anxiety, Lee delivered an address to the nation in three of the city-state’s four official languages. “I want to speak to you directly, to explain where we are, and what may lie ahead,” he said. The speech appeared to have an immediate effect as supermarket lines soon eased.

“It’s one of the most beautiful pieces of risk communication I have ever seen,” says Claire Hooker, a senior lecturer at the University of Sydney who studies health communication.

The example stands out amid a series of blunders in coronavirus messaging elsewhere. President Donald Trump has contradicted government scientists to downplay the threat, suggest the imminent availability of a vaccine and, in his televised Oval Office speech Wednesday, deliver inaccurate policy pronouncements. In South Korea, President Moon Jae-in infamously declared the worst to be over just before cases mushroomed, prompting political backlash. And at the beginning in Japan, Prime Minister Shinzo Abe was virtually absent.

“In order to be trusted you need to be open and honest and transparent. You need to demonstrate your competence, and you need to show people that you actually care,” Hooker says.

Concerns about the U.S.

Taiwan, Hong Kong and Singapore can’t offer the U.S. an exact virus-fighting blueprint. For starters, their geographic sizes relate more to U.S. cities or states rather than the nation as a whole. Taiwan, the largest of the three, packs its 23 million people into a landmass comparable to Maryland, making containment easier. But there are worthwhile takeaways.

On the side of the world where the virus emerged and the effects of mitigation efforts are now being seen, America’s slow and fumbled response has sparked alarm.

“To be honest, as a public health professional, I am deeply concerned about the U.S.,” says Lim, in Singapore. “It’s become politicized, making it difficult for the average citizen to know who to trust or what to believe.”

The scarcity of diagnostic kits nationwide and delay in testing cases has also led experts to warn that there is no way of even knowing where the hotspots are in the U.S. right now.

“The U.S. has enormous capacity,” says Wang, the Stanford professor. But he notes that it “needs to mount a coordinated effort, like Taiwan, because the infection impacts many aspects of society and really affects people’s lives.”

David Hui, in Hong Kong, says it’s vital that the U.S. starts limiting social contacts to avoid a large-scale outbreak with the potential to overwhelm the health system. Schools need to be closed and mass gatherings canceled—something that is just now beginning to happen.

“It’s clear that where people are more cautious, like Hong Kong, Singapore, Macau, Taiwan, we see a relatively lower number of cases,” Hui says.

“The facts speak for themselves.”

Here’s what you need to know about coronavirus: 

• Where has coronavirus spread in the U.S. and around the world?
• Why is it so hard to get a COVID-19 test in the U.S.?
• How should you self-quarantine if you may have been exposed to coronavirus?
• How can you stay healthy and productive while working from home?
• Should you avoid the gym during the outbreak? 
• Which events have been canceled because of the coronavirus?