Overall Strategy

Overall Strategy

Leveraging Prior Experience

Prior experience fighting infectious diseases can help policymakers, citizens, and institutions respond effectively to COVID-19.

One reason some Asian and African countries were able to respond more effectively to COVID-19 than the US or Europe was that they had more experience fighting epidemics. For instance, China, Hong Kong, and Taiwan learned lessons from dealing with SARS (2002-03) that improved their preparedness for fighting COVID-19. South Korea also learned important lessons from its experience with MERS in 2015 (which resulted in 186 cases and 38 deaths); in the aftermath, the government established a legal foundation for infectious diseases with a comprehensive contact tracing strategy and started a program for twice-a-year epidemic simulation training. In 2003, Singapore created a multi-agency task force to coordinate interventions and messaging during pandemics; that task force tackled the H1N1 pandemic in 2009, the Zika outbreak in 2016, and reassembled to tackle COVID-19 in January 2020. African countries, such as Rwanda, Sierra Leone, and Uganda, learned from their experiences fighting Ebola, HIV, Zika, and traditional infectious diseases, such as cholera and tuberculosis.

The Financial Times notes: “The bad news for western governments…is that one vital component of the Asian response cannot be replicated. The region's approach has been shaped by the traumatic memories of other recent epidemics — most notably Sars — which meant that governments were better prepared to react fast and forcefully and populations much more willing to cooperate.” The head of Taiwan's CDC during the SARS outbreak warned in March 2020: “The situation in other countries now resembles the situation we were in during the first few weeks of the SARS spread in Taiwan in early 2003. You are not ready, you have no experience.”

Prior experience fighting epidemics gave the Asian and African countries three advantages:

1. Policymakers were seized of the issues and familiar with the tools available to fight epidemics, e.g. how to screen arrivals at borders, how to conduct testing, contact tracing, and quarantining, how to run public education campaigns, and so on. Rwanda's former health minister's detailed explanation of that country's response to COVID-19 is instructive.
2. Equally important, citizens understood their role in containing the infection, such as complying with social distancing, handwashing, using masks, or stay-at-home requirements; and
3. A public health institutional infrastructure was already in place to address COVID-19, e.g. community health workers were in place, tests and testing facilities were in place or could be scaled up quickly, systems for border screening were established, procedures for repurposing hospitals to treat the infection were in place, and so on.

The lesson for the US and Europe is that they should consciously work to build on their own early experience and also learn from other countries, so that their response to a second wave, if any, is more effective. Similarly, U.S. cities or states in which COVID-19 arrives late should learn from the experiences of states that were first to be hit, e.g. CA, WA, and the northeastern USA. By July 2020, US policymakers and citizens were already learning from prior experience. For example, governors who hesitated to mandate preventative measures, such as social distancing or mask-wearing, were more willing to do so when the infection persisted, and citizens were also more willing to comply voluntarily. Airlines that hesitated to enforce mask-wearing in May or June 2020 were doing so forcefully in July. 

Related ideas: Leveraging Speed; Leveraging Multiple Tools; Leveraging a National Response.

Leveraging Speed

Moving early and briskly is important for containing a virus that spreads exponentially

Asian and African countries that contained COVID-19 effectively moved early and swiftly to control the epidemic. Because the infection spreads exponentially, this meant the infection could be arrested before it went through many rounds of spreading. Starting the fight a few weeks earlier can reduce the total number of cases and deaths very substantially. The Asian and African countries moved swiftly because they understood from prior experience that time was of the essence, having been slow perhaps in responding to earlier bouts of infection, such as SARS, MERS, Zika, Ebola, HIV, or avian flu. All of these countries acted before the  WHO declared COVID-19 a Public Health Emergency of International Concern (January 30, 2020) and long before it was declared a global pandemic (March 11, 2020).

After initial delays in acknowledging the virus, the Chinese government confirmed human-to-human transmission in late January and moved rapidly, implementing a strict lockdown of a province with over 60 million people, reorganizing the entire healthcare system, developing hospitals and temporary facilities, and coordinating massive testing efforts.

In Vietnam, when the first two cases were discovered in January 2020, the government took swift action, such as precautionary measures at border gates (e.g. 100% temperature scanning of arriving passengers), launched an education campaign, and within days set up a high-level National Steering Committee on Epidemic Prevention headed by the Deputy Prime Minister. Vietnam's Prime Minister said that “fighting the epidemic is like fighting against the enemy.”

Taiwan activated its National Health Command Center (NHCC) in January 2020, even before confirmation of its first case. Drawing from its experience of the SARS outbreak, the NHCC rapidly implemented over 120 policy action items within five weeks. Decisive measures such as travel bans, strict quarantine measures, and increased domestic production of face masks and tests were swiftly carried out. They began screening for possible cases early on, immediately isolating positive cases and tracking down contacts.

After cases were identified in Singapore in late January, contact tracing and traveler screening procedures were quickly established. A major public messaging campaign spelled out how the public should respond and shared information on the outbreak. 

South Korea focused on the rapid development of diagnostic testing. When the first four cases were first confirmed in January, South Korea encouraged local medical companies to begin developing testing capabilities; within one week, the first test was approved. Massive testing efforts were quickly organized, employing innovative methods such as testing booths and drive-through testing.

Rwanda has screened travelers and trained medical and laboratory personnel in preparation for COVID-19 since January 2020. It has since supplemented those efforts with the COVID-19 Command Post, a group of 400 professionals from various sectors, established at the beginning of March 2020 to coordinate ongoing containment efforts across Rwanda. Rwanda has been able to maintain control over COVID-19 since the arrival of its first case on March 14, 2020.

The US and Europe did not have such experience and was therefore slow to recognize the threat and even slower to respond. The lesson going forward is to appreciate the importance of speed and the importance of getting ahead of the virus rather than constantly playing catch-up. U.S.cities and states that haven't yet been hit by COVID-19 should respond speedily if and when they are hit by COVID-19.   Given several months of experience with COVID-19, the American public is now more likely to view preemptive action as nipping the problem in the bud rather than an overreaction.

Scientists and public health experts are already preparing for future disease outbreaks with this lesson of speed in mind. Advocating for greater investment in public health preparedness and surveillance, scientists looking toward the future are envisioning tools such as AI-based diagnostics and continuous pathogen surveillance. Initiatives like the Global Virome Project aim to identify and sequence all infectious viruses, which would enable further research and preparedness.   

Related ideas: Leveraging Prior Experience; Leveraging Multiple Tools; Leveraging a National Response; Rapid Response Teams for Outbreaks

Leveraging Multiple Tools

Countries must use all tools, including public education, border controls, testing, tracing, and quarantining–and not rely just on lockdowns and treatment.

Countries that fought COVID-19 effectively used all of the tools available to public health officials rather than just one or two. They seemed to realize that a lockdown was a very costly and blunt tool for stopping the spread of the virus and therefore had to be complemented from the start by other tools. Lockdowns bought time, while other elements were being organized. Dr. Jim Kim, former president of the World Bank and public health expert, has argued for a five-pronged strategy to fight infectious diseases such as COVID-19, all of which were used in some measure by countries that were effective at arresting COVID-19. Those elements are:

1. Prevention, including public education and border controls. The aim here is to promote social distancing, hand washing, sanitizing, and mask-wearing by citizens, often through creative public education campaigns. In many of the countries, non-compliance (e.g.not wearing masks or violating quarantining conditions) could result in fines or punishment. At the same time, international passengers, especially from countries or cities with high COVID-19 infection rates, were carefully screened through temperature checks, COVID-19 tests, travel history information, and quarantining.
2. Extensive Testing. Anyone showing symptoms or exposed to an infected person or living in an area that was possibly a hot spot was tested. Sometimes large scale tests were conducted in a city or locality to unearth asymptomatic carriers. Innovative testing strategies such as drive-through testing and testing booths were employed.
3. Aggressive contact tracing. Most countries used human contact tracers who were part of the public health network, starting immediately after the first cases were identified. In places like Rwanda, airport screening and testing began even before the first case was identified. Human contact tracing was sometimes complemented by digital contact tracing tools, although the latter often took time to catch on and adoption rates vary across countries. 
4. Strict isolation and quarantining. Anyone who tested positive was immediately placed into isolation, and anyone exposed to an infected person was immediately quarantined. “Strict” often meant that the program was mandatory rather than voluntary, and required staying in a government-run facility rather than at home. Alternatively, in places like Hong Kong SAR, Singapore, South Korea, and Taiwan people who were allowed to self-quarantine at home were monitored using digital technologies and periodical phone calls from public health officials. In Vietnam, even the contacts of contacts had to self-quarantine but could do so at home (with monitoring).
5. Treatment was the last option when all other measures failed to stop the spread. This involved designating hospitals that would focus only on COVID-19, augmenting ICU capacity and health staff, erecting new hospitals or repurposing other public spaces to hold milder cases, and ensuring adequate medical supplies, including through imports or emergency production by state-owned or private firms.

The main lesson for the U.S. is that it should leverage all of the above tools and not just one or two. Collectively, they can help reduce the Reproduction number (R_t) to zero so that the infection stops spreading. Even in July 2020, not all U.S. states were seriously promoting prevention and border screening measures, and still fewer were doing systematic testing or contact tracing. Isolation and quarantining was generally not done in designated facilities but at home, and often without monitoring by public health officials. Inter-state movements were unrestricted and although out-of-staters were expected to self-quarantine, there was no monitoring by public health officials. Instead, the response relied too heavily on the last resort, i.e treating the infected. Focusing on treatment while the infection spreads unchecked is bad for public health, bad for healthcare costs, and bad for reopening the economy.

Related Ideas: Leveraging Prior Experience; Leveraging Speed; Leveraging a National Response

Leveraging a National Response

Policy guidance and coordination of sub-national agencies by the central government is necessary to fight COVID-19 effectively

In places like Hong Kong SAR and Singapore, coordinating the response to COVID-19 across several echelons of government was not an issue, but that can be a challenge in countries with large and geographically dispersed populations, such as Ethiopia or Vietnam, and it is an enormous challenge in mega-economies like China or India. The WHO recommends “a whole of society, whole of government” approach to fighting COVID-19. Usually, that requires national-level leadership to guide and coordinate responses across provinces and cities.

In China, the Communist party created a “Central Leading Group for Novel Coronavirus Prevention and Control” in late January 2020, chaired by Premier Li Keqiang, which spelled out very early, for instance, that some provinces could resume production of essential medical supplies, food, etc. after the lunar holidays while requiring them to strictly restrict population movements. It also meant that more than 20,000 medical workers from other parts of China could be brought swiftly to fight COVID-19 in the biggest hotspot, Wuhan, and two 1,000-bed hospitals could be built in less than two weeks. In Korea and Taiwan, their Centers for Disease Control and Prevention (modeled after America's CDC) managed the national response, while in Singapore it was coordinated by the Ministry of Health. Rwanda created a COVID-19 Command Post to plan and implement its response. In Hong Kong, the well respected Center for Health Protection took charge. Leadership from the very top, e.g. Rwanda's president Kagame or Taiwan's president Tsai, lent credence to the program.

One lesson for the US is that the federal government has an important role to play in guiding, facilitating, and coordinating the national response, given the country's vastness and interdependence, while leaving many implementation choices to states and cities. The U.S. has allowed free movement of people across state borders during the pandemic, unlike, say, the European Union, where during the lockdown countries restricted entry even by citizens of other member countries. In contact tracing, for instance, the US response has been patchy, with a mix of initiatives at the town, city, and state levels, but weak coordination across these levels, which creates problems in a country where people move freely within and across states. The Wall Street Journal notes that “a patchwork of often confusing or conflicting rules across government that have proved inconsistent and often difficult to enforce, [has made] the pandemic harder to halt.” 

Related ideas: Leveraging Prior Experience; Leveraging Speed; Leveraging Multiple Tools

China

Country	Population (millions)	GDP Per capita, 2019 (Current US$)*	COVID-19 Cases (‘000)#	COVID-19 Deaths#	COVID-19 Deaths per million population#
China	1,439	10,261	85.4	4,634	3
USA	331	65,280	7,590	214,065	646

^#Sources:Worldometer (as of October 3, 2020);

*Source: World Bank

As the epicenter of COVID-19, China has demonstrated the power of a rapid, centralized response augmented by technological solutions.  Considered to be the largest disease containment effort in history, China's fight against the virus became a national priority influenced by its recent experience as the epicenter of the 2003 SARS outbreak. According to official data, China had 4,634 deaths from COVID-19, or approximately 3 per million population, vs. 646 per million population in the US (as of October 3, 2020).

Cases were first reported in December of 2019 in the city of Wuhan but not publicly acknowledged for a while. On January 9, 2020, the novel virus was identified and sequenced, and on January 20, 2020 the authorities confirmed human-to-human transmission. The response thereafter was swift; Wuhan was placed on lockdown three days later, followed by surrounding cities in Hubei province. Over 60 million people were under lockdown by the end of January. Inbound and outbound international travel came to a grinding halt as flights to many countries were terminated indefinitely. The healthcare system was rapidly reorganized, mobilizing more than 20,000 medical workers from across China to assist in the outbreak. Immediately following the lockdown, two hospitals were rapidly constructed in less than two week's time, and adding 2,600 new beds for COVID-19 by early February. A network of FangCang shelter hospitals were established: these were large public venues repurposed into massive, temporary health care facilities for triage and isolation. With all testing and treatment provided free of charge, massive testing efforts were coordinated with the assistance of Chinese companies. After a small cluster of cases was discovered in Wuhan in May 2020, the city organized an unprecedented mass testing campaign in which nearly 10 million people were tested in just 19 days. Batch testing, in which samples from several people are pooled, expedited this effort.

Technological innovations played a significant role in China's comprehensive response. Chinese citizens have individualized QR codes which function to track movement and categorize health status; the code determines access to public spaces and transportation. Robots and drones have been utilized for contactless delivery and disinfection. The temporary Wuhan Wuchang Smart Field Hospital was run entirely by robots and artificial intelligence (AI) platforms. AI and big data analytics have also been applied for diagnostics, thermal imaging technology, and contact tracing efforts.

After a delayed start, strong central leadership guided China's response. Upon early detection of the virus, a national emergency response was launched to establish a centralized Leading Group for Epidemic Response, chaired by Premier Li Keqiang, to coordinate swift, unified responses. A digital national reporting system, developed after the SARS outbreak, was used by doctors throughout the country to contribute epidemiological data to ascertain trends.

Ideas Originating or Applied in China: Rapid Hospital Construction; Individual QR Codes; City-wide Testing; Pop-Up Mobile Testing Sites; AI-Based Temperature Scanning

Hong Kong

Country	Population (millions)	GDP Per Capita, 2019 (Current US$)*	COVID-19 Cases (‘000)#	COVID-19 Deaths#	COVID-19 Deaths per Million Population#
Hong Kong	7.5	48,755	5.1	105	14
USA	331	65,280	7,590	214,065	646

^#Sources:Worldometer (as of October 3, 2020);

*Source: World Bank

The first confirmed cases of COVID-19 were reported in Hong Kong on January 23, 2020. As one of the most densely populated areas in the world, the city of 7.5 million was expected to be at high risk, given its deep interconnections with China, the epicenter of the virus. Hong Kong has the highest cross-border traffic with China, because of its shared border and its position as a Special Administrative Region (SAR); more than 2.5 million people traveled from China to Hong Kong in January 2020 alone. Yet, as of October 3, 2020, Hong Kong had only 105 deaths, or approximately 14 deaths per million population (vs. 646 in the US).

Hong Kong's response was strongly influenced by its past experience with viral outbreaks, particularly its position at the forefront of the 2003 SARS epidemic. Following SARS, the Center for Health Protection was established to coordinate centralized responses for future outbreaks. Drawing on this experience, Hong Kong has demonstrated an ability to handle novel pathogens with enhanced hospital capacity and testing systems. Hong Kong responded rapidly to COVID-19 by declaring a state of emergency on January 25, 2020, prompting social distancing measures, such as school closures and cancellations of major public events.

Despite the swift initial response, there was significant public outcry that the government measures were not enough. In early February, thousands of medical workers went on strike demanding stricter border controls. The government responded by limiting and regulating many entry points and reducing flights to and from mainland China, but the border was never completely sealed off. International travel was progressively curtailed, except for residents.

Significant effort was dedicated toward a comprehensive system of testing, contact tracing, and isolation measures. Travelers visiting Hong Kong are screened at the airport and isolated in a repurposed convention center while test results are processed. All arriving travelers are required to undergo a 14-day quarantine period at home, monitored by government-issued electronic tracking wristbands. This “geofence” system operates by pairing with an app, StayHomeSafe, to track if an individual moves outside their quarantine boundaries.  

Hong Kong has generally employed a “suppress and lift” strategy, adjusting its response based on the status of the outbreak. An uptick of cases results in stricter lockdowns and restrictions, and many restaurants and businesses have developed innovative safety measures as they have reopened, including temperature checks and spatial dividers.

The success of Hong Kong's response is often attributed to the initiatives and social norms of civil society, in the face of divided support among the population on how to tackle the virus. The near-universal adoption of face masks is recognized as a critical contributor, despite a ban on face coverings that followed the political protests of 2019. There is also an important cultural emphasis on hygiene and sanitation, influenced by Hong Kong's experience with SARS.

Ideas Originating or Applied in Hong Kong: E-Fencing

Rwanda

Country	Population (millions)	GDP per capita, 2019 (Current US$)*	COVID-19 Cases (‘000)#	COVID-19 Deaths#	COVID-19 Deaths per million population#
Rwanda	13	801	4.85	29	2
USA	331	65,280	7,590	214,065	646

^#Sources:Worldometer (as of October 3, 2020)

*Source: World Bank

Despite being a poorer country with limited medical resources, Rwanda has done well in fighting COVID-19, with only 4,852 cases and 29 deaths, or approximately 2 deaths per million population (vs. 646 per million population in the U.S., as of October 3, 2020). On March 14, 2020, Rwanda identified its first case of COVID-19. Prevention efforts had started two months earlier, drawing on plans developed in 2018 during Ebola preparedness planning. Since January 2020, Rwanda has focused on increasing workforce capacity and protecting its borders. Immediate training of 500 health personnel, including laboratory technicians, took place to ensure adequate response capacity. Medical staff were stationed at Kigali International Airport and border posts to screen visitors for high temperatures. Handwashing stations were placed, for instance, at the capital's bus park to promote hand hygiene and serve as a public reminder about COVID-19's imminent arrival.

At the beginning of March, the COVID-19 Command Post, a group of 400 professionals from various sectors, was established to coordinate ongoing containment efforts across Rwanda. By March 6, the group released guidelines on social distancing and handwashing, and increased access to hand sanitizer in public spaces. Although an initial struggle to bolster testing capacity raised concerns, a strict lockdown was implemented on March 20 to control the risk of virus spread. Schools, universities, and places of worship were closed, and all commercial flights were stopped for a minimum of 30 days. During this time, the Rwandan government also implemented fixed food prices to prevent price gouging at a time when many families were struggling financially. Efforts were made to address the challenges of social distancing in slums and informal settlements in Kigali and other urban settings. Rwandans living in these environments risked exposure to COVID-19 because of overcrowding, shared water sources, and communal washrooms that hindered their ability to self-isolate and wash hands frequently.

While contact tracing, mask wearing, and social distancing have been integral parts of Rwanda's response, the country also leveraged technology. Rwanda was already using drones to deliver blood products to rural areas, and in the fight against COVID-19 a small number of robots were rolled out to help treat patients. These robots performed simple tasks like temperature checking and patient monitoring, but it was hoped that they could be programmed to perform blood pressure and blood sugar checks to reduce clinician contact with patients. Recent developments also include the implementation of drive-through testing centers as of July 2, 2020. Rwanda's response is a useful role model for sub-Saharan Africa, including its reliance on a well-developed primary healthcare system and early, rapid governmental action.

Ideas Originating  or Applied in Rwanda: Drones for Remote Testing

Singapore

Country	Population (millions)#	GDP Per capita, 2019 (Current US$)*	COVID-19 Cases (‘000)#	COVID-19 Deaths#	COVID-19 Deaths per million population#
Singapore	5.8	66,189	57.8	27	5
USA	331	65,280	7,590	214,065	646

^#Source:Worldometer (as of October 3, 2020)

*Source: World Bank

Singapore has been celebrated for its handling of the COVID-19 pandemic, with only 27 deaths, or approximately 5 deaths per millions population (vs. 646 in the US, as of October 3, 2020). Using technology and a flexible response, Singapore has contained COVID-19 well, with the exception of unanticipated outbreaks in migrant dormitory communities.

Singapore, like other East Asian countries, learned from its prior experience with severe acute respiratory syndrome (SARS) in 2002. Since the SARS outbreak, the government has strengthened its public health systems by establishing a task force to quickly mobilize resources in response to emerging diseases.

Singapore's government has facilitated its rapid, national response through clear and consistent information about COVID-19. The country's first COVID-19 case, a traveler from Wuhan, was identified on January 23, 2020. The government quickly established contact tracing, isolation, and traveler screening protocols. In the following weeks, the government ordered additional public health safety measures, including border closures, but these measures were implemented more gradually than in some other countries. For example, schools initially practiced distance learning for only one day per week before transitioning later to distance learning on all days of the week.

The “circuit breaker” response was effectively a multi-stage, multi-pronged lockdown and reopening procedure. Effective April 7th, the circuit breaker policies involved closing all non-essential businesses, requiring the wearing of masks, social distancing, and other policies to protect the public from infection. Since June, the circuit breakers have been lifted in a three step process: the first step, “Safe Reopening,” allowed low-risk businesses to resume, while restricting high-risk activities, such as entertainment and large gatherings, and laid out “safe work,” and “safe home” policies; the next stage was called “Safe Transition,” and the final stage was called “Safe Nation.” Part of the reopening process includes travel bubbles, which are agreements to permit freer travel between countries that have contained their domestic outbreaks.

Singapore's TraceTogether app was launched in March 2020 to support contact tracing efforts. With the app installed, a bluetooth signal is relayed between nearby cell phones, which makes it easier to find the contacts of positive cases quickly and anonymously. The government launched a wearable device for people without cell phones that also captures contact data.

The Clean Ambassadors program represents an innovative way to disseminate COVID-19 information. Volunteer ambassadors speak with people in public places about masking, social distancing, and other public health concepts. The “SG Clean” certification program incentivizes businesses that meet a set of sector-specific guidelines by publicly recognizing their adherence to public health policies. It spelt out specific guidelines for 15 sectors, from retail stores, malls, and restaurants to hotels and cruise lines.

Migrant dormitories, where up to 20 low-income migrant workers live per room, have become the center of Singapore's COVID-19 flare-ups. The government has responded by testing workers and reforming dormitory standards, but the efficacy of these measures remains to be seen.

Ideas Originating  or Applied in Singapore: Clean Ambassadors; Industry-Specific Clean Certification; Digital Check-In System; Disease Severity Indicator; Safe Elections

South Korea

Country	Population (millions)	GDP Per capita, 2019 (Current US$)*	COVID-19 Cases (‘000)#	COVID-19 Deaths#	COVID-19 Deaths per million population#
South Korea	51.2	33,340	24	420	8
USA	331	65,280	7,590	214,065	646

^#Source:Worldometer (as of October 3, 2020)

*Source: World Bank

South Korea's COVID-19 success story centers on testing, tracing, and isolating. The country leveraged its prior experience fighting epidemics to pursue a rapid, national, and multi-pronged response to contain COVID-19. As a result, it had only 24,027 cases and 420 COVID-19 deaths, or approximately 8 deaths per million population (vs. 646 deaths per million population in the US, as of October 3, 2020).

South Korea changed its epidemic control policies in response to an outbreak of Middle-East respiratory syndrome (MERS) in 2015. MERS, a disease also caused by a coronavirus, was a wake-up call for South Korea and other East Asian countries. Following the MERS outbreak, the government immediately created a legal foundation for dealing with infectious diseases, which included a comprehensive contact tracing strategy. Twice-a-year epidemic simulation training was also implemented to prepare response strategies; coincidentally, the exercise held in December 2019 involved a novel coronavirus, which later helped to facilitate the early response to COVID-19.

South Korea detected its first case of COVID-19 on January 20, 2020 in a traveler from China. Several weeks later, a large gathering at a church in Daegu became a superspreader event. South Korea's outbreak was rapid and was the largest outside of China for a short time, but its response was equally rapid. In the days following the Daegu outbreak, church members were tracked and tested, travel restrictions were imposed, but unlike other countries, lockdowns were not implemented.

South Korea responded rapidly to the emerging COVID-19 epidemic with aggressive testing strategies.  In comparison to the US, South Korea has performed six times the number of tests per confirmed case, according to analysis from Our World in Data. South Korea developed innovative testing strategies, such as pressurized testing booths and drive-through testing, and launched an online portal that helps citizens find testing sites.

Through several innovative ideas beyond testing, South Korea instituted a multi-pronged strategy that has enabled the country to contain COVID-19. The government has maintained guidelines for screening travelers. If positive, they are moved to either a hospital or an isolation center until their symptoms resolve and subsequent tests come back negative. If negative, they are required to quarantine for 14 days and download an app on their phone. Mobile apps, such as those that anonymously track and report the movements of COVID-19 positive citizens or that track those entering high-risk locations via QR codes have played a significant role in South Korea's COVID-19 response.

Ideas Originating  or Applied in South Korea: Drive-Through Testing; Testing Booths; Traveler Screening; COVID-19 Mapping Apps, Safe Elections

Taiwan

Country	Population (millions)	GDP per capita, 2019 (Current US$)*	COVID-19 Cases (‘000)#	COVID-19 Deaths#	COVID-19 Deaths per million population#
Taiwan	23.8	24,827	.51	7	0.3
USA	331	65,280	7,590	214,065	646

^#Source:Worldometer (as of October 3, 2020)

*Source: World Bank

Like other parts of East Asia, Taiwan's rapid COVID-19 response, along with 99.9% national health insurance coverage, allowed it to fight COVID-19 effectively, with only 7 deaths, or approximately 0.3 deaths per million population (vs. 646 deaths per million population in the US, as of October 3, 2020). Drawing on lessons learned and lives lost during the 2003 SARS outbreak, Taiwan took control of the situation even before the first case was identified on January 21, 2020. It raised alarms over an unknown pneumonia as early as January 15, 2020 and activated the Central Epidemic Command Center (CECC) to quickly mobilize resources and take action. It was fortunate that Taiwan's Vice President, Chen Chien-jen, is also an epidemiologist.

Early transmission from outside countries was reduced by banning visitors or placing them in a mandatory two-week quarantine. Taiwan has been able to successfully enforce the 14-day quarantine period through the use of digital fencing, also known as e-fencing, which uses cell phone location data to track people's movement. Those under quarantine have a set radius in which they can travel; going beyond the e-fence or attempting to turn off location data will trigger a swift police response and result in a hefty fine. Taiwan's Digital Minister, Audrey Tang, has pushed for transparent digital democracy which involves sharing citizen data to solve societal issues more quickly. This concept lent itself well to the incorporation of artificial intelligence as part of Taiwan's COVID-19 response.

While masking is part of a normal lifestyle in Taiwan, a mask rationing system was established early on to grant priority access to the country's medical staff. Organized by the CECC, Tawianese citizens could present their national insurance card at a pharmacy to receive their allotted two masks per week for around US$10.  Additionally, strong collaboration between local governments and private companies has allowed resources such as hotel rooms to be used to isolate patients, and to produce personal protective equipment for essential workers.

As Taiwan is not allowed to participate in the World Health Organization, it has not received medical information and updates like other members, similar to its experience during the 2003 SARS crisis. However, that has not prevented Taiwan from keeping COVID-19 cases and deaths at very low levels.

Ideas Originating  or Applied in Taiwan: Access to Masks; E-Fencing

Vietnam

Country	Population (millions)	GDP Per capita, 2019 (Current (US$)*	COVID-19 Cases (‘000)#	COVID-19 Deaths#	COVID-19 Deaths per million population#
Vietnam	97.5	2,366	1.09	35	.4
USA	331	65,280	7,590	214,065	646

^#Sources:Worldometer (as of October 3, 2020);

*Source: World Bank

With a population of 97 million and only 1/20^th of America's per-capita income, Vietnam has had only thirty-five COVID-19 deaths (as of October 3, 2020), despite sharing a 800-mile border with China and being economically intertwined with it.

Vietnam built on prior experience fighting SARS, Avian flu, and other epidemics. The country pursued an effective strategy, including taking swift action, such as temperature scanning at border gates before WHO declared a health emergency. In January, the PM declared that “fighting the epidemic is like fighting against the enemy.” Foreign arrivals filed health declarations and were tracked. Vietnam's multi-pronged strategy included early lockdown and extensive testing. Vietnam had one of the strictest isolation and quarantining policies in the region: Anyone testing positive was isolated for two weeks in institutional facilities (free of charge), their direct contacts also faced mandatory quarantining in institutional facilities (also free of charge), and even indirect contacts had to self-quarantine at home. In all cases, they were closely monitored by public health officials. On four occasions, entire villages, communes or hospitals were quarantined. Government campaigns, including a popular cartoon, educated the public on preventive measures. Vietnam's political system probably helped with enforcement. Vietnam was the first Southeast Asian country to reopen.

Ideas Originating  or Applied in Vietnam: Strict Isolation and Quarantining

Africa: Ethiopia, Sierra Leone, Uganda

Country	Population (millions)	GDP Per Capita, 2018 (Current US$)*	COVID-19 Cases (‘000)#	COVID-19 Deaths#	COVID-19 Deaths per Million Population#
Ethiopia	115	771	77.8	1,214	10
Sierra Leone	8	534	2.25	72	9
Uganda	46	767	8.66	79	2
USA	331	65,280	7,590	214,065	646

^#Source:Worldometer (as of October 3, 2020)

*Source: World Bank

Like Rwanda, Sierra Leone and Uganda seem to have benefited from prior experience fighting epidemics: Sierra Leone with Ebola (where it lost over 4,000 lives) and HIV, and Uganda with Ebola. In both cases, public health policymakers, institutions, and citizens were familiar with the basic steps of fighting an infectious disease.

All three countries moved speedily to take preventive measures, knowing that their hospitals were incapable of treating large numbers of patients. Although Africa was less interconnected to other parts of the world by international flights, countries like Ethiopia and Rwanda had strong ties to China and were therefore vulnerable. An Ethiopian minister noted that “Ethiopia's success in combating COVID-19 would depend not on the number of respirators it had, but on the public-health measures taken to contain the virus's spread.” Ethiopian authorities were quick to close schools and ban large gatherings, and launch a door-to-door health check of 11 million households covering 40 million people, including residents in the capital city of Addis Ababa. Sierra Leone prepared for COVID-19 weeks before the first case was detected, taking the help of Partners in Health, a US-based nonprofit. Uganda, too, moved quickly to prepare for COVID-19.

Of the many tools available, the three African countries relied most heavily on preventative measures, taking advantage of their community health workers to educate and monitor people's symptoms. In Sierra Leone, an important first step was educating the public, local chiefs, community health workers, and residents of border towns about COVID-19. Quick surveys were used to keep tabs on the infection. Border controls, followed by monitoring by public health officials, was critical, because COVID-19 was most likely to be brought into the country by international travelers. Uganda's president shut down schools and instituted border checks (mainly truck drivers ferrying cargo across the region). Sierra Leone also emphasized basics, such as handwashing and social distancing, and the closing of schools. In Ethiopia, strict isolation and quarantining from the start allowed the country to fight COVID-19 without a national lockdown. Treatment was the weakest link in all three countries, and international NGOs or individual countries provided help, e.g. China's help to Ethiopia.

In all countries, the response to COVID-19 was guided at the highest levels, i.e. the prime minister (Ethiopia) or the president (Uganda). The public health system operated nationally and was managed centrally. National institutions, such as the military, were sometimes brought in to help, e.g. in border controls.

As of this writing, the above policies–relying heavily on speedy and prevention-oriented measures–seemed to be keeping COVID-19 in check in Ethiopia, Sierra Leone, and Uganda.