It is abundantly clear that East Asia has managed the Covid-19 crisis far better than the West. So what is behind this glaring differential?
The first part of this two-part series made statistical East-West comparisons, then dived into culture and communalism, attitudes toward authority, rights to privacy, and differentials in recent historical and epidemic experience.
In this part, Asia Times examines leadership, policy response, vaccination policy, travel and geographic integration, manufacturing capacity, viral variations, genetic vulnerabilities related to race, weather and climate, and, finally, arrogance and ignorance.
From all that we draw certain conclusions to Covid-19’s East-West riddle.
Taiwan famously had the perfect leadership in place for the crisis: Vice-President Chen Chien-jen was an epidemiologist. But across East Asia, bar some vacillations in Japan, leadership has largely been on point in terms of consistency of strategy and following the lead of experts.
“There is unified command and control, the messaging is singular,” said Dr Jerome Kim, director general of the International Vaccine Institute in Seoul, South Korea. “There is no back and forth, like there was [in the US and elsewhere] on masks, there were consistent messages about the dangers.”
“The leadership, in general, has been less politicized and more effective in the East than in the West,” added Dr Ogan Gurel, a non-practicing American neurologist who has been monitoring the pandemic from South Korea. “Name calling and blaming and deflecting responsibility seemed inappropriate.”
Indeed, there have been policy shifts, clashes with experts and inconsistent messaging by Western leaders such as the UK’s Boris Johnson and America’s leader Donald Trump.
Conversely, East Asian leaders have set examples.
Chinese President Xi Jinping is frequently filmed wearing a mask and Japanese Prime Minister Shinzo Abe even wears his in the Diet. Korean officials, including President Moon Jae-in, are frequently filmed wearing yellow disaster-management jackets.
“I was a bit skeptical of government officials wearing yellow jackets, as it seemed more show than substance,” said Gurel.“But in the long run, it reinforced the message that we are in this together.”
Moreover, leadership is not just a matter of “what” but also “when.”
“One of the major differences in terms of casualties is whether [governments] acted promptly,” said Dr Kenji Shibuya, a professor of Population Health at London’s Kings College. “In the UK it took nearly six weeks, and so it did in the US. It is a timing lesson.”
And with the virus originating in the East before moving West, the policy responses have all been pioneered in East Asia.
On the macro level, the key anti-virus strategy for centuries has been quarantine of the sick. The novel coronavirus pandemic has seen quarantine implemented on an unprecedented scale, with both the sick and the healthy “locked down” in entire cities and provinces for weeks or months.
That policy was pioneered by China, where authoritarian governance has likely enabled more effective lockdown than seen in many Western countries. Even so, a number of Western nations have extended the Chinese model beyond cities and provinces to cover entire countries.
On the micro level, the benchmarks for the key tactics undertaken by countries worldwide – the “3Ts” (“testing, tracing, treatment”) – are represented by the democratic East Asian nations.
Taiwan not only reacted with great speed, it provided an early gold standard for contact tracing, having integrated its health insurance, immigration and customs databases, then mined the resultant big data with AI.
South Korea provided a global benchmark for fast, efficient and extensive testing regimens by offering free tests for the infected and pioneering drive-thru and walk-thru test sites. That enabled early discovery, isolation and treatment.
Japan has been widely critiqued for its dearth of testing. However, the country – burdened with the world’s oldest, most at-risk population and armed with a Top 10 global healthcare system (according to WHO rankings) – has pioneered best-of-breed treatment for pneumonia, one of Covid-19’s deadliest symptoms.
The rest of the world has largely followed these various moves and combined the 3Ts with differing degrees of success.
“I don’t think there are any single items that distinguish what Asian countries have done versus those in the West,” said Dr Keiji Fukuda, director and clinical professor at the School of Public Health at the University of Hong Kong. “Each country has basically tried to implement many of the same approaches, but in ways that are possible given their differing cultures and domestic [circumstances].”
Underwriting policy response is quality of medical care. This varies, but most of the prosperous Western countries that have been hard hit have well-regarded medical systems. (Exceptionally, the US does not offer universal health care.) Gurel, who teaches medical courses around the region, suggests that East Asian health systems are more integrated than those in the West.
“In Korea, you get these screening exams that are incredible, you get a CT, a dental exam, a blood test – everything in one morning! It is assembly-line, ultra-efficient,” said Gurel. “In a lot of Western systems, the medical care is advanced but the integration is not.”
And integration is essential when it comes to effectively deploying the 3Ts.
“The process all has to work together. In America, they say ‘We need more testing,’ but testing without tracing and treatment is meaningless,” he said, noting, most particularly, the weakness of tracing in the US. “You learn this in Med School 101.”
Hopes for a silver-bullet medicine to counter Covid-19 have so far proved unfounded. While the world awaits a dedicated Covid-19 vaccine, BCG, a 100-year-old tuberculosis vaccination that appears to train or stimulate the overall immune system, may provide a very important shield.
“If I were to identify one factor” in the East-West conundrum, “it would be levels of BCG vaccination,” said Gurel.
Maps of the level of BCG vaccination show a strikingly close correlation to numbers of Covid-19 casualties. According to the BCG World Atlas, most of Western Europe including France, Spain and the UK had past national BCG vaccination policies. In Italy and the United States, BCG was only recommended for select groups.
Most of Eastern Europe and Asia, which have weathered the crisis more effectively, maintain ongoing national BCG vaccination programs.
Differences between neighbors are striking. Spain suffered high infection and mortality rates, while Portugal (which has a BCG program) did not, despite their shared border, Gurel noted. Moreover, Covid-19 rates in western Germany were higher in the country’s east, which previously had BCG vaccinations, he said.
He is not alone in focusing on BCG.
“There are countries trying to encourage BCG vaccination,” said Kim. But there is a complicating factor: “Every country has a different brand of BCG.”
Early findings in Japan are that the Japanese and ex-Soviet variants may be the most efficacious in preventing mortality said Jake Adelstein, a US reporter in Japan who has investigated the issue.
Movement and integration
The EU and the US are internally borderless, permitting free and easy movement of people, goods – and, in the early stages before barriers rose, viruses.
Indeed, of the world’s Top 10 destinations for international tourism arrivals in 2018, most were in the West: France was in first place, Spain in second, the US in third, Italy in fifth, Germany in eighth and the UK in the 10th spot.
The only East Asian destination (in fourth place) was China.
Regarding outbound tourism, the top 10 sources of travelers were predominantly Western: Americans (second), Germans (third), British (fourth), French (fifth), and Italians (tenth). However, Chinese were in the top spot, and South Koreans were ninth on the list.
In East Asia, there exists neither a free trade area nor a federation of states that permit borderless movement. Moreover, Taiwan and Japan are island nations, as is – de facto – South Korea, which is separated from continental Asia by North Korea.
Swift border closures by Vietnam and Taiwan – two countries that are politically wary of China – to Chinese citizens have been assessed as key reasons for pandemic control by those two countries.
China is “the workshop of the world” and all Northeast Asia economies boast powerhouse manufacturing sectors, from light industry to high technology.
East Asia’s manufacturing muscle, combined with prior experiences with pandemics and its social habits of mask-wearing, has allowed regional economies to churn out massive quantities of masks, personal protective equipment (PPE) and test kits.
Western economies which have shifted heavily toward services have suffered shortages of test kits, of PPE for medical workers and even the most basic, low-tech anti-virus supplies for their populaces.
“Masks have been an issue here, not being able to get them,” said London-based professor Terri Kim, a South Korean native. “I gave some masks from Korea to my neighbors.”
China, Korea, Taiwan and Vietnam are all net exporters of virus-related products and are engaged in “mask diplomacy” by deploying cargos to favored nations. (Quality issues have arisen over Chinese gear in locations as diverse as Czechoslovakia, Spain and the UK.)
A related issue is that overbearing US medical device and pharmaceutical manufacturers have off-shored production.
“In the US, the manufacturing of medical items is done by a few companies that have monopolies and many have subcontracted their manufacturing overseas,” said Dan Strickland, a US-based retired epidemiologist. “And small manufacturers are blocked from jumping into the arena by big businesses which have the monopoly.”
Could the variant of the virus in the West be deadlier than the version that emerged in the East? Viruses mutate, and according to research published by Los Alamos National Laboratory published on April 30, a mutation that appeared in Europe in February then spread to the US is more infectious than the original.
“Los Alamos looked at all the sequences around the world in March … the outbreak is now dominated by this form of the virus,” said Kim of the IVI.
However, he cautioned that the research has not yet been peer-reviewed and its findings are nascent. “It is more transmissible, but is it associated with higher death rates?” Kim wondered. “These are early, initial findings.”
Still, if the variant in the West is more dangerous than that in the East, it could help explain why two nations that are largely “Western” in their systems and practices but are physically in the East – Australia and New Zealand – have been relatively unaffected.
In the past, peoples of different ethnicities who had little or no contact with other peoples built up resistance to different diseases. When different peoples met, catastrophe was often unleashed.
Most notoriously, in the “Columbian Exchange” a range of Old World diseases wiped out 80-95% of the native population of the New World within 150 years, including in the US.
Could ethnic Asians today have more in-built resistance to this disease than ethnic Westerners? Experts hedge on the issue.
“The SARS-CoV-2 is a new creature in a family of similar creatures, so maybe there is some crossover immunity,” said Strickland. “In East Asia there were other coronaviruses so there might be some sort of cross-immunity,” added Shibuya, though he said he was skeptical.
“It seems unlikely, the interconnectedness of the world is why this is not feasible today,” Strickland said.
Even so, research from the UK’s National Statistics Office on the vulnerabilities of different racial groups found that the only ethnicity with potentially lower risks of fatality than Caucasians, apart from mixed-race persons, were “Chinese.”
However, it is hugely difficult to disentangle the various factors beyond race built into the data.
“We may see something” in ethnic genes offering more resistance, said Kim of the IVI, but there are other health issues such as hypertension, diabetes and cardiovascular diseases. “How do you separate this out? You have to control for ethnicity, demographics and risk factors.”
Socio-cultural issues are also in the mix.
“In New York, it is disproportionately minority populations suffering the most,” said Joe Terwilliger, a genetic statistician at New York’s Columbia University. “They are lower on the economic scale and work at crap jobs. And Hispanics often live in multi-generation families, so it spreads like wildfire.”
Yet Terwilliger did not rule out ethnic vulnerability. “With infectious diseases, you never know,” he said. “It would not surprise me if there was ethnic variation, but you can’t say there is, there is no data.”
Weather and climate
The outliers among “Western” nations are Australia and New Zealand, which do not lie in the geographic West. Though they share similar systems of governance and social culture with Western Europe and the US, they have been far less impacted by the pandemic.
Setting aside policy responses, did their location assist? The pandemic struck in the Austral summer, and some believe that the virus is less dangerous in hot weather.
Climate, perhaps in combination with Asian cultural and/or genetic characteristics, could potentially also help explain the low death tolls in Southeast Asia, which have warmer climates but are less prosperous than the West.
Vietnam claims zero deaths from Covid-19. Malaysia has suffered just 111 dead, Singapore 21 and Thailand 56. The toll is heavier in Indonesia, with 1,028 deaths, but the country also has a vast population of 267.7 million, giving it a death per million ratio of 3.8, broadly similar to the countries of East Asia.
Arrogance and ignorance
Since the 19th century, East Asia has looked up to the West in multiple sectors, from science and technology to governance systems and popular culture.
Despite the postwar economic ascent of the East, the West has not reciprocated with similar levels of interest. As a result, Western barriers to adopting Eastern models may exist, combined with disinclination toward critical introspection.
“The East-West dichotomy, in terms of perception, imagination and real politics, has become again very dominant in media discourse and people’s conversation during the pandemic,” said Terri Kim, a London-based professor.
“The National Health Service in the UK is a sacred institution, and I even had a tiff with a friend, critical comments and comparative perspectives are not accepted! People don’t even know that Korea has a universal health-care system.”
This cultural superiority complex has extended to actual abuse. For the first time in her three decades in London, Kim said she had experienced racial prejudice when a white woman in a shop told her to “go home.” Amid the pandemic, other Asians have suffered verbal abuse and physical assault in Western nations.
And the answer is …
The crisis is not over as clusters continue to emerge and concerns rise of a “second wave” as lockdowns worldwide are eased. Even so: Why has East Asia so clearly outdone the West in the early stage of pandemic management?
One temptingly simple answer would be that the more authoritarian a nation, the more effective pandemic response has been. This would explain Vietnam’s and China’s low per-million death rates, though questions linger about the accuracy of both nations’ data.
Democratic Japan, South Korea and Taiwan only partly contradict the authoritarian argument, for as noted in Part One, their populations may be more culturally conditioned than Western nationals to follow rules from above and to prioritize society before individual.
But experts rightly warn against such glib interpretations, given that the East-West disparity combines a bewildering multiplicity of facets.
“It’s a mystery,” said Shibuya. “The simple answer is, ‘It’s complex’,” added Gurel.
Experts also advise against assigning any single factor or jumping to hasty conclusions. “It’s the whole package,” said Strickland. “It will take us years to figure this out. If I were young and in mid-career, I would be drooling over this.”