Points of view

Vittorio Valli ^[1]  (February 22, 2021)

ABSTRACT

If we look at the data on the Covid-19 deaths per million inhabitants we can see an immense gap between the West (Europe, US and Canada, Latin America) and Northern Eastern Asia. For example, as of 21 February 2021, the COVID-19 cumulative deaths per one million inhabitants in the major Western countries varied from 1883 in Belgium to 815 in Germany while they were 59 in Japan, 30 in South Korea, 3 in China and 0.4 in Taiwan. What are the main reasons of this enormous gap between the West and the three North-Eastern democratic Asian countries: Japan, South Korea and Taiwan? What are the main lessons that the extraordinary success of Taiwanese anti-covid-19 policies, the great one of South Korea and the substantial performance of Japan can give to Europe and the Americas? The answer is a mix of better policies and of deep demographic, cultural, institutional and historical differences. In the three Asian countries prevention was better than in Western countries and restrictive policies were prompter and more effective, even without the recourse to any generalized lockdown. Early severe screenings in ports and airports reduced the number of imported infections and well-organized tracing and isolation policies limited the diffusion of the pandemic avoiding the collapse of hospitals and other health institutions.  Even though, up to now, the three Asian countries have done a relatively low number of tests (lower in Taiwan and Japan, somewhat higher in South Korea), the tests were much more prompt and targeted than in Europe or the Americas, and so the authorities were able, through careful tracing and isolation, to eliminate the COVID-19 local outbreaks almost as soon as they started, avoiding the two or three great waves of exponential growth of the epidemic which have plagued most countries in the West. Historical reasons such as the large exposition to other great epidemics (SARS, swine flu and MERS), contributed to better planning and prevention and to the strategy of maintaining more hospital beds for 1000 inhabitants in Japan and South Korea. Less individualism and more attention to collectivity contributed to the traditional habit of wearing masks and to respect the directions of health authorities and experts more. Less arrogance of political leaders and more courage towards myopic interest groups contributed to act more readily and severely in restricted zones, and so to reduce the heavy social and economic consequences of long and generalized lockdowns as it occurred in most Western countries.       

ABSTRACT (ITALIANO)

I dati relativi ai morti attribuiti al COVID-19 per un milione di abitanti mostrano chiaramente un enorme divario tra i maggiori paesi dell’Ovest (Europa, USA e Canada, America latina) e quelli dell’Asia nord-Orientale (Cina, Giappone, Corea del sud e Taiwan). Ad esempio, al 21 febbraio 2021, i morti cumulati per COVID-19 per un milione di abitanti nei maggiori paesi occidentali variavano tra i 1883 del Belgio e gli 815 della Germania mentre essi erano 59 in Giappone, 30  in Corea del sud, 3 in Cina, 0,4 in Taiwan. Quali sono le ragioni principali di questo enorme divario e gli insegnamenti che le tre grandi democrazie dell’Asia nord-orientale (Giappone Corea del sud e Taiwan) possono dare ai paesi occidentali? La risposta sta nella combinazione di migliori politiche e di profonde differenze demografiche, culturali, storiche ed istituzionali. Nei tre paesi asiatici la prevenzione fu migliore che nei paesi occidentali e le politiche restrittive furano più pronte e più efficaci anche senza il ricorso a lockdown generalizzati. Misure assai severe di test e isolamento furono applicate agli aeroporti e porti di ingresso dei tre paesi. Misure immediate, rigide ed assai ben organizzate di tracciamento e isolamento permisero di limitare il più possibile il numero di persone infette e di spegnere i focolai non appena essi si manifestavano. Vennero così evitate le due o tre grandi ondate di crescita esponenziale dei contagi che hanno invece investito i maggiori paesi occidentali. Ragioni storiche, quali la maggiore esposizione dei paesi dell’Est Asia a recenti grandi epidemie, quali la SARS, l’influenza suina e la MERS, contribuirono a ispirare migliori strategie di programmazione e prevenzione e a mantenere, almeno in Giappone e in Corea del sud, un maggiore numero di posti- letto per milione di abitanti rispetto all’Occidente. Minore individualismo e più attenzione alla collettività contribuirono alla più massiccia adesione al tradizionale uso delle mascherine ed al maggiore rispetto delle direttive delle autorità e degli esperti. Una minore arroganza nei leader politici e un maggiore coraggio verso le pressioni, spesso miopi, dei grandi gruppi di interesse economici e sociali, contribuirono ad agire in modo più rapido, severo e per zone limitate, e quindi a ridurre le gravi conseguenze economiche e sociali dei lunghi e generalizzati lockdown utilizzati nella maggior parte dei paesi occidentali. 

1. The immense gap in COVID- 19 mortality

The COVID- 19 mortality rate (defined as COVID-19 deaths per million inhabitants) is a rough indicator of the severity of the COVID-19 pandemic. It comes with a delay of about a couple of weeks after the level of diffusion of the pandemic, it probably underestimates the true level of deaths that can be attributed to the virus and is not fully comparable between countries, but it is much better than other indicators, such as the number of confirmed cases.^[2]

As we can see in table 1, there is an enormous gap between the COVID-19 mortality rates in most Western countries (both Western European and of the Americas) and those of three Eastern Asian great democracies:  Taiwan, South Korea and Japan. As of February 21, 2021, for example, Belgium had a cumulative COVID-19 mortality rate 4707 times higher than Taiwan, 63 times higher than South Korea and 32 times higher than Japan. Czechia and UK had a mortality rate over 4425 times higher than Taiwan, 59 times higher than South Korea and 30 times the one of Japan. As of February 21, 2021, even Germany, which did better (or less badly) among the large Western European countries, had a mortality rate 2037 times higher than Taiwan, about 27 times higher than South Korea and 14 times the one of Japan.     

2. The waves of global pandemic

The cumulative COVID-19 mortality rate is in large part associated to the earlier or later exposition of a country to the virus and to one, or two, and sometimes three, waves of the pandemic.

The first wave occurred in the last days of February or the beginning of March 2020 in countries and regions which had strong and complex trade, foreign direct investment (FDI) movements, migrations, and tourism relations with China. It struck mainly some regions of Northern-East Asia, Western Europe and the United States. For example, In Italy the first wave hit earlier and more violently Northern Italy and Tuscany, which had more relations with China, and only marginally the other regions, which had weaker relations with China.  During the Summer, when in Italy and other Western countries several restrictions had been relaxed, domestic tourism and other forms of contact strongly contributed to spread the pandemic to other zones of the countries, incubating a second and sometimes a third wave in Autumn and Winter.

In most Eastern European and Latin American countries, which had relatively less relations with China, the pandemic started later, in April or May, mainly spurred by contacts with the already plagued Western European countries and the United States. In 2020, several Eastern European (Czechia, Poland, etc.) and Latin American countries had only one long and severe COVID-19 wave, often escalating since September 2020. 

Up to now, due to prompt and strong containment policies, China, Taiwan, South Korea and Japan have been able to reduce to a minimum the COVID-19 deaths since late February 2020, and avoided almost completely the second and third waves, while most Western countries were utterly unable to do so.^[3] 

Table 1. Cumulative COVID-19 deaths for 1 million inhabitants as of February 21, 2021 in selected countries(a). Source: worldometers (2021). 

(a) Countries with over 10 million people only. Hong Kong had 26 COVID-19 death per million inhabitants; both Singapore and New Zealand 5.

3. Why these wide differences in COVID-19 mortality?

 The enormous gap in COVID-19 mortality between most Western countries and North-Eastern Asia is due to a complex of factors:

A) geography

B) demography.

C) the pre-existing health system, health policies and restrictive measures

D) socio-political, institutional and cultural factors.

As to geography, we must remember that Japan and Taiwan are islands and South Korea is a peninsula, but its northern border is substantially closed. It is therefore, easier for the three countries (as well as for Australia and New Zealand) to control the movements of people and of goods at their ports and airports and impose rigid isolation measures.

As to demography, it is true that elder people, especially over 65-70 years of age, have a much higher COVID-19 mortality than younger ones. This is essentially due to two main reasons: elder people are more fragile because they have a higher probability to have one or multiple pre-existing major medical problems (cancer, diabetes, heart and lung diseases, etc.) and they are less able to produce an adaptive immunologic response sufficient to successfully fight the virus than younger people.

However, as table 1 and 2 show, demography explains only a part of the differences in COVID-19 mortality. For example, Japan has a percentage of people of 65 years or above higher than Belgium, Italy, Spain and Brazil, but a much lower COVID-19 mortality rate.  It must be underlined that also the health conditions prevailing at each age group in different countries and the effectiveness of each health system and restrictive measures are crucially important in order to explain the COVID-19 mortality.   

Table 2. Population of 65 years and above as % of total population in selected countries in 2019 Sources: UN, World Bank and national statistics for Taiwan 

4. Health Systems, health policies and restrictive measures

The main features of the health systems in Japan, South Korea and Taiwan as compared to other countries are:

a) before the COVID-19 crisis Japan and South Korea had almost three times more beds per 1000 inhabitants than any other OECD country and than China, and also Taiwan had more beds than OECD’s average. Moreover, Japan and Korea had about twice “acute care” hospital beds (which included ICU. i.e. intensive care units) per 1000 inhabitants than the OECD average, though for ICU beds both South Korea and Japan were below the average OECD level.

b) As to practising nurses per 1000 inhabitants, in 2017, Japan had a higher level and South Korea a bit lower one, than the OECD average, while for practicing doctors per 1000 inhabitants both countries had a lower level than the OECD average.

c) all three countries had an efficient territorial health system with varying degrees of a mix between public and private services..^[4]

So, Japan and South Korea had the possibility to promptly host a larger number of symptomatic COVID-19 patients in their hospitals than most other countries and, if necessary, to easily transform simple beds or acute care beds into ICU beds without overwhelming the normal functioning of the hospitals. In this way they could save the lives of a large number of patients hit by COVID-19 or other severe diseases. However, the relative lack of doctors, and in South Korea also of nurses, contributed to the necessity to try to contain at the start the diffusion of the virus with severe containment measures. Therefore, Japan and South Korea, and even more effectively, Taiwan, implemented severe controls at the frontiers, tests also for asymptomatic people, rigid and well-organized tracing and isolation measures which, together with distancing and the pervasive use of masks, could successfully contain, without generalized lockdowns, the diffusion of the pandemic and therefore the number of infected people and ultimately of deaths.  The secret here, later partly followed by other countries such as Vietnam, New Zealand and Australia, but not by most European and American countries, was to very rapidly react and not let the infection surpass a certain threshold corresponding to about 50,000-60,000 active positive cases, beyond which it is almost impossible to be able to trace and isolate all the infected people.^[5] A good territorial health system and a well-organized network of COVID-19 hotels or residences in order to limit the possible spread of the virus within the households by asymptomatic infected people were essential. In Northern-Eastern Asia the containment was also reinforced by swift local lockdowns rather than by prolonged generalized lockdowns followed by excessive liberalizations and then the return to half-baked generalized lockdowns as it happened in most Western countries.   

Though there were meaningful differences between the 2020 policies of the three North-Eastern Asian countries, (see table 3) their basic approach was similar: to extinguish the outbreaks, the small fires, before they rose to uncontrollable giant fires, to use prevention and prompt, severe containment rather than mitigation and tardive generalized lockdowns.

The fruits of prevention and prompt containment were: from the start of the contagion up to now, in Japan the daily COVID-19 deaths did never surpass the number of 121 people (0.96 per 1 million inhabitants), in South Korea 40 deaths (0.78 per 1 million), in Taiwan only 2 deaths (0.1 per 1 million). The bitter fruits of delayed mitigation and generalized lockdowns in most Western countries were a lot of more cumulative COVID-19 deaths (table 4). As of February 21, 2021, the United States had 511,135 COVID- 19 deaths, much more than Brazil (246,560), Mexico (179,797), India (156,418), the UK (120,580), Italy (95,718), France (84,506), etc. while Japan had 7,417 COVID-19 deaths, South Korea 1,557 and Taiwan only 9 (see table 4). Most Western countries also had two or three devastating waves of the pandemic with very high peaks. In Belgium there were 341 daily deaths in the peak of the second wave (29.3 per 1 million inhabitants); in the US 4,532 daily deaths in the peak of the third wave (13.7 per 1 million). UK, Italy, Spain and France had even worse per capita results than the United States. Germany, the EU large country that had done better in the first wave, had highly worse results than the three major Eastern Asian democracies (Table 1 and 4).

All this has led to lower economic losses in the three Asian countries. According to EU, IMF and national projections, in 2020, Taiwan, South Korea and Japan would have a real GDP percent rate of change respectively of +2.5, -1.1 and -5.5, while most Western countries would have real GDP percent losses varying from – 4.6 (USA) to - 12.4 (Spain) with an EU average of -7.4.  Also, the disruption in employment and in public finance and the rise in income inequalities between households, genders and regions has been much worse in Western countries than in Northern Eastern Asia.

Table 3. Japan, South Korea and Taiwan: health systems and main anti-pandemic policies 

Table 4. Cumulative COVID -19 deaths as of February 21, 2021 and rate of change of GDP. Sources: for column 1: Worldometers (2021); for column 2:  IMF (2021); OECD (2020 b) for South Korea; national statistics for Taiwan.                                                       

5. Attitudes, culture and institutions

The attitudes of the political leaders and of the population, cultural values and institutions are also very important in order to understand the great difference between most Western countries and the three Northern Eastern Asian democracies.

A) Attitudes: Japan’s, South Korea’s and Taiwan’s political leaders, governments and corporations usually have a less myopic vision than the political and economic leaders of Western countries. They look also to mid and long-term objectives and not mainly to short term results. So, their health systems are more effective and more resilient. Western experts and politicians rely too much on the great Anglo-Saxon research and Journals, which gave tardive information because the pandemic hit first China and other Eastern Asian countries and China was at first reticent. They often ignored or undervalued the scientific literature and the best practices of Eastern Asian countries. Several Western political leaders, such as Boris Johnson, Donald Trump, Jair Bolsonaro and, at first, also Macron and several Italian politicians, were arrogant and grossly underestimated the dangers associated to the pandemic. Not resisting to the pressure of powerful interest groups, at first, they acted weakly and tardively and then had to recur to generalized lockdowns which produced greater economic damages.  

B) Culture: Individualism is a key in Western culture, while responsibility towards the community is probably stronger in Eastern Asian culture: the habit of using masks is an important corollary.

C) Institutions: In several Western countries unstable governments, heavy and often inefficient bureaucracies, conflicts between Central and regional authorities contributed to delay the anti-COVID policies.

6. Vaccines

Japan, South Korea and Taiwan, having been able to contain the diffusion of the virus much better than most Western countries, had less urgency in starting a massive vaccination campaign. Moreover, Japan and South Korea’s pharmaceutical corporations were trying to develop their own vaccines, while Taiwan tried to obtain licensing for the domestic production of the BioNTech-Pfizer vaccine, but encountered several diplomatic obstacles. However, the comparative success of their containment policy had led to the fact that less people had been infected by the virus than in Western countries and so less people had developed anti-bodies, protecting them, for some time, from new infections. All this, associated to the delays in the domestic production of vaccines and the proliferation of dangerous variants of the virus, induced the three countries to buy massive quantities of Western vaccines, such as Pfizer, Moderna and AstraZeneca, and to start the vaccination campaign in the second half of February (see table 3), with about two months of delay with respect to the UK, the United States and China and over a month with respect to Europe. They also tried to obtain licensing for domestic production of Western vaccines. It must be noticed that the United Nations, WHO and G20 were unable to assure a fair worldwide distribution of vaccines. The production of vaccines has been largely insufficient and the distribution de facto has discriminated against the poorest countries. Large public funding of research and compensations for the patents to leading pharmaceutical companies would have to be given to obtain a rapid and free distribution of licenses to reliable producers all over the world under the control and supervision of the World Health Organization.

8. Conclusions

The extraordinary success of Taiwanese anti-covid-19 policies, the great one of South Korea and the substantial performance of Japan are in small part due to geography (Japan and Taiwan are islands, South Korea is a peninsula with a closed northern border) which made less difficult to control the movements of people and goods at the border. The success of the three large Asian democracies is predominantly due to better prevention, good health systems and health policies, attitudes, culture and institutions. The secret was to readily and severely contain the diffusion of the virus at the start, through rigid border controls, isolation, tracing and swift local lockdowns, extinguishing the outbreaks as soon as they appeared.    

References

Flaxman Seth et al. (2020), Estimating the number of infections and the impact of non-pharmaceutical interventions on COVID-19 in European countries: technical description update. https://arxiv.org/abs/2004.11342

Kim  Hyunjung (2020), What Lessons Can the US Learn from Japan and South Korea for Combating Coronavirus?  https://globalbiodefense.com/2020/03/16/united-states-lessons-learned-covid-19-pandemic-response-south-korea-japan-observations-hyunjung-kim-gmu-biodefense/

IMF (2021) World Economic Outlook Update, January.

KCDC (Korea Center for Disease Prevention and Control) (2020) http://ncov.mohw.go.kr/en

OECD (2020 a), Beyond Containment: Health Systems Responses to Covid-19 in the OECD, Paris, 16 April. 

Kwon, S., Ikegami, N., & Yue-Chune, L. (2020). Private health insurance in Japan, Republic of Korea and Taiwan, China. In J. North (Author) & S. Thomson, A. Sagan, & E. Mossialos (Eds.), Private Health Insurance: History, Politics and Performance (European Observatory on Health Systems and Policies, pp. 304-324). Cambridge: Cambridge University Press. doi:10.1017/9781139026468.009 https://www.cambridge.org/core/books/private-health-insurance/private-health-insurance-in-japan-republic-of-korea-and-taiwan-china/17116B514968FCF1528A7CF4D00669D6

OECD (2020b), OECD Economic outlook, December.

Phipps Steven J., Gratton R. Quentin, Kompas Tom (2020), Robust Estimates of the true (population) infection rate for COVID-19: a backcasting approach, Royal Society Open Science,7 200909  http://dx.doi.org/10.1098/rsos.200909 

Summers Jennifer et al., (2020), Potential Lessons from the Taiwan and New Zealand Health Responses  to the Covid-19 Pandemic, «The Lancet Regional Health», Western Pacific. https://doi.org/10.1016/j.lanwpc.2020.100044

Valli  Vittorio (2020) , Coronavirus and the art of not learning from other countries’ experiences https://www.osservatorio-economie-emergenti-torino.it/images/15_may/15newsletter_Valli2.pdf

Worldometers (2021), February 22 https://www.worldometers.info/coronavirus/

^[1] Professor emeritus of Economic Policy, University of Turin, Questo indirizzo email è protetto dagli spambots. È necessario abilitare JavaScript per vederlo..This note is an enlarged and updated version of my presentation at the sixth OEET workshop (Turin, December 10-11, 2020).

 ^[2 See Valli (2020) as to the weaknesses of the main indicators used for COVID-19.

^[3] On the cases of Japan and South Korea, see, for example, Kim (2020), KCDC (2020, Valli (2020). On the case of Taiwan compared with New Zealand, see Summers et al. (2020).

^[4] See Kwon et al. (2020). See also OECD (2020 a) for a comparison with other health systems.

^[5] We must remember that the true number of infected people is a multiple of confirmed positive cases resulting from the tests. According to Phipps, Grafton and Kompas (2020, p. 6), as at 31 August 2020, the true number of infected people in 15 countries was estimated at about 6.2 times the number of reported positive cases, but the ratio considerably varied among countries and in different times of the pandemic. For alternative estimates for European countries see, for example, Flaxman Seth et al. (2020).