Trust in government and well-funded health systems key to virus control, study finds

Countries should learn from each other in their responses to Covid-19, with those whose citizens trust their governments and have well funded hospital and public health systems reaping rewards in their control strategies.

As countries around the world face a second wave of infections, key questions over what restrictions should be imposed and how to encourage behaviour change are at the top of policy makers’ minds.

A review of the lockdown exit strategies and subsequent control measures of nine countries - Germany, Hong Kong, Japan, New Zealand, Norway, Singapore, South Korea, Spain and the UK - has found there is no one-size-fits-all control strategy but highlights five key factors for a successful return to some kind of normal.

Lead author, Dr Helena Legido-Quigley, from the National University of Singapore and London School of Hygiene & Tropical Medicine, said: “Covid-19 is a serious disease that will be with us for a long time. There is increasing realisation that easing of lockdown is not about returning to a pre-pandemic normal, and governments have to find strategies that will prevent rapid growth of infections in ways that are sustainable and acceptable to the public over many months.”

The researchers found that countries with a thorough understanding of where and how many cases of the disease they had; strong trust in government and institutions; well functioning and funded public health and hospital systems; and tight border controls were the most successful at easing lockdown and controlling infections.

In terms of knowing the status of the disease in the country the paper highlighted New Zealand’s four-level alert system as a clear guide to both authorities and citizens for when control measures would be imposed or lifted. For example, it progressed from a full nationwide lockdown at level four in March to level one in June when infections had fallen. Some parts of the country went back to a higher level when cases rose in their area.

Although Singapore, South Korea and the UK also had alert-level systems the link to control measures in place was not explicit, the researchers wrote. “And it is not clear that the UK’s system is being used,” they added. For example, in March the UK government said five criteria must be met for lockdown measures to be lifted, one of which included having adequate testing in place.

However, several weeks after lockdown was eased it was clear that the test and trace system was not working when cases began to rise again.

Another key factor for success is trust in government, the authors wrote. The paper highlights how Dominic Cummings’ lockdown trip to Barnard Castle undermined public trust among UK citizens and how unrest in Hong Kong had also hampered control efforts.

By contrast New Zealand prime minister Jacinda Ardern has won praise for “communicating firmly, yet empathetically”. 

The paper also highlighted the well-organised public health systems in South East Asian countries, building on experience learned during previous epidemics.

South Korea’s “shoe-leather” epidemiology approach, with public health employees knocking on doors to find the contacts of those infected, contrasted with the UK’s stalled attempts at introducing a contact tracing app and the implementation of a centralised test and trace system, bypassing years of experience in local public health departments.

The paper also highlights the importance of having a well funded and resourced health system. Germany had 34 critical care beds per 100,000 inhabitants at the start of the pandemic, compared with 9·7 in Spain and 5·2 in Japan. Germany’s intensive care units were well under capacity even during the peak of the outbreak.

Researchers also contrasted the tight border controls of all the Asia-Pacific countries studied with the European countries who were slow to implement routine testing of incoming travellers.

Dr Legido-Quigley added it was not too late for countries to learn from each other. “Our review of international experiences identifies lessons governments can learn from each other’s successes and failures. We are not advising that the exact same measures should be replicated in different countries, but it is not too late for governments to consider novel policy solutions developed by other countries and adapt them to fit their own context.”

Experts not involved in the research highlighted the importance of the findings for policy makers.  Dr Michael Head, senior research fellow in global health, University of Southampton, said: “This excellent paper highlights how preparedness has been key in for many Asian countries in promoting a good and rapid outbreak response.  Lessons have been learned from previous outbreaks, such as SARS and ‘bird flu’, which led to investment in public health and surveillance infrastructure.

“Before the next pandemic, for there will be a ‘next time’, preparedness is key to ensure a swift and efficient response.  Here we see some lessons that could and should be learned by European countries in order to mitigate current and future infectious disease threats.”

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