The COVID-19 pandemic has significantly altered activities, impacting global economies, governments, and communities. While unique cultural and societal factors have influenced the final shape of public health measures implemented in different countries, the responses share common themes and compromises towards common global aims of mitigating preventable death and human suffering and enabling communities’ recovery.
This article describes a country’s pandemic management, covering four global regions. We unfortunately cannot cover all countries but seek to open dialogue about the diversity and reach of our work and influence as general internists in global communities.
China, the epicenter of the global pandemic, invested astronomical resources to eliminate COVID-19, adopting a four-tier emergency response system (ERS) (Level-I: highest; Level-IV: low). Responses involved building temporary hospitals, implementing prolonged partial or full quarantines, and widely mobilizing health care workers. At peak, all 31 provincial-level regions were simultaneously at ERS Level-I. By May 2020, Tianjin and Hebei, neighboring Beijing, remained on Level-I, along with the hard-hit Hubei Province; and promisingly, less than 3% of patients are yet to recover from COVID-19. Overall, China’s broad-reaching containment strategies curbed otherwise exponential growth of COVID-19 cases by mid-March.1
Strategies to prevent a second wave of infection began as early as February. Domestic and international transit, accommodations, and assemblies were limited; borders closed to inbound foreign travellers on March 28. Gradual loosening of social distancing measures did not translate to loosening of preventive measures—they became even stricter. A crucial measure to prevent a second wave was screening asymptomatic individuals who are/were in close contact with or exposed to confirmed COVID-19 cases, involved in identified cluster outbreaks, and who are travellers from high-risk areas. These cases are mandatorily reported to the National Health Commission for daily surveillance.
In Shanghai, a city of more than 25 million inhabitants and China’s largest metropolis, and more than 500 miles from Wuhan province, COVID-19 peaked at 300 cases with seven related deaths. The Shanghai municipal government has begun downgrading the pandemic response level. Wuhan lifted its lockdown on April 8, however, remains on ERS Level-I—this includes providing a negative nucleic acid report (within seven days pre-arrival) for all arrivals and a digital green health-code (instead of red or yellow, indicating higher risk) before entering hotels, markets, or other public spaces. Hotels verify guests’ health-code status and monitor guests’ temperature twice daily. Also, migrant workers from Hubei province, approximately 23 million overall, are offered free coronavirus testing when they travel to Guangdong province if they have not already been tested.2
As work life resumes in China, so does leisure: in the first three days of a five-day holiday period in May, residents took nearly 85 million domestic tourist trips, generating a total of 35.06 billion yuan (USD $4.97bn) in tourism revenue.3
A student who returned from Iran to Karachi, Pakistan on February 26, 2020, was the first case of COVID-19 in Pakistan. Within the following weeks, all four provinces and tribal territories of Pakistan saw rising cases of COVID-19. By May 5, the country reported 22,049 positive cases with 514 related deaths from this disease.4
The Pakistani government acted early, mandating that the national airline PIA suspend all flights between China and Pakistan beginning January 30. Students stranded in China were repatriated after screening measures were implemented at four international airports across Pakistan. The National Security Council of Pakistan assembled on March 13, deciding to close all non-essential businesses and institutions, including schools and mosques. All land borders with Afghanistan, Iran, and China were closed by the end of March. Around that time, all international flights to and from Pakistan were also suspended. Meanwhile, provinces started their own partial lockdown measures.
Ramadan, a month of fasting that started April 25, often draws many to mosques. Certain religious and political parties opposed closure measures, resulting in a compromise of reopening mosques with specific physical distancing conditions. The scientific community fears an upcoming spike of COVID-19 related to in-person religious observance of Ramadan.
In April, physicians were arrested for clashing with police during a protest for more personal protective equipment (PPE) in Quetta, Baluchistan. A doctor in Khyber Pakhtunkhwa province wore plastic bags on his head and hands due to lack of PPE. Limited testing capability involved PCR kits acquired from China and subsequent antibody point-of-care tests acquired from Finland. There are reports of shared ventilator use in some parts of Pakistan to compensate for resource scarcity.
Most people in Pakistan are daily wage earners. The Pakistani government worries that the lockdown will result in more deaths from lack of food than deaths from COVID-19. Therefore, on March 21, the prime minister announced incentives for construction jobs. The government is watching the situation closely and is extending the lockdown for two weeks at a time amidst increasing numbers of positive cases and deaths from COVID-19.
After the first reported COVID-19 case in Argentina on March 3, Argentina’s federal government implemented a preventive and mandatory social isolation rule of law on March 20. All educational activities were suspended, as well as sporting and social events. This early measure greatly contributed to flattening the curve and preventing healthcare system collapse.
Parallel to containment, a tiered-healthcare network for caring for COVID-19 and non-COVID-19 patients was developed. Temporary surge hospitals were built to care for patients, and hotels and other social facilities were repurposed to host quarantined individuals. In this context, hospitals were devoted to care for those suffering a SARS-2-CoV severe infection as well as non-COVID related urgent and emergent pathologies, deferring the provision of elective and non-urgent medical care to a later time in pandemic recovery. Telemedicine played a crucial role in elective medical care and patient triage.
The following sequential stages of social isolation in Argentina were defined based on essentiality of services and were modified based on SARS-2-CoV prevalence:
- Stage 1, or strict social isolation (March 20 to March 31), only allowed essential workers to circulate and led to a city traffic of approximately 10%;
- Stage 2, or administrative isolation (April 1 to April 12), was characterized by intensified vehicular control, closed borders and city traffic of approximately 25%;
- Stage 3 or geographical segmentation stage (April 12 to May 10), during which some public services restrictions were lifted to progressively reactivate the economy. City traffic was calculated to be approximately 50%;
- Stage 4 (May 10 to May 24) allowed for greater activity level, particularly in areas with low community viral transmission; and
- Stage 5 (after May 24), a period of “new normal,” involves use of facial masks in public and new hygiene standards, expected to lead to an estimated city traffic of 75%.
Hospital de Clínicas Jose de San Martin, affiliated with the University of Buenos Aires, modified the delivery of care and institutional geographic distribution of patients based on medical triage: (1) COVID; (2) non-COVID emergencies; and (3) ambulatory and elective care. This innovative model—where patients are cared for at the same institution, but without physical proximity—was feasible and safe.
The first COVID-19 case was reported in late February, within days of Limburg province’s infamous Carnival celebrations, a weekend-long celebration marked by colorful costumes, street parties, and singing local folk songs in this southern region of the Netherlands. Then, North Brabant, about 75 miles from Amsterdam, became the Dutch epicenter for COVID-19.
Measures began with a public call for working from home, staying home except for essentials (e.g., buying groceries or medicine and seeing a doctor), and maintaining 1.5-meter physical distance in public spaces. However, without enforcement, life went on as usual—on March 14, shops and cafes remained open. Days later, financial penalties were issued for non-compliance. Businesses abided. Restaurants operated by takeaway or delivery and shops limited occupancy. As cases grew exponentially, the prime minister and health minister, backed by the Dutch National Institute for Public Health and Environment (RIVM), announced a strategy of “intelligent lockdown”.5 This consisted of a strategy of controlled exposure of the population to the novel coronavirus towards herd immunity.
During the peak (mid-April), more than 1,400 ICU beds were required to care for patients with COVID-19, surging above the country’s typical 1,050 ICU beds. In mid-April, one month after public health measures were enforced, the curve began flattening. Hope was high for Netherlanders, but neighboring Germany remained cautious: before Easter (April 12), traditionally a four-day holiday for most Netherlanders, Germany implemented mandatory 14-day self-isolation for all travellers from the Netherlands as a disincentive. We fortunately never experienced the worst-case scenario of a projected 2,400 ICU beds needed; and field surge hospitals built were never used.
May 11 marked gradual reopening, beginning with contact businesses, such as hairdressers and salons, libraries, and childcare centers. Every 2-4 weeks, staged reopenings are planned; on June 1, restaurants, museums, and movie theaters reopened, with restricted occupancy. More milestones are planned in July, with others yet to be announced pending surveillance despite persistently low testing capacity. Unemployment has risen but staged reopenings may offer a tangible pathway towards local economic recovery.
In closing, as we reflect on global responses to the pandemic, time will tell if these measures—balancing the tenuous social and economic consequences of protecting against an emerging infectious disease—are sufficient to prevent a second wave of COVID-19 cases and its other downstream health consequences.