Covid-19: Elimination vs Mitigation – Learning from Asia and Europe

New Zealanders have every reason to be proud of their country’s response to the Covid-19 pandemic. Through our determined pursuit of elimination of community transmission we have one of the lowest cumulative deaths per one million in the world – as low as 5 (according to World Health Organisation data as of 3 January).

New Zealand compares extremely favourably with countries like the United States (1,043), United Kingdom (1,098) and Sweden (864). We also compares very favourably with one of the best performing larger European countries (Germany – 409) and favourably with our Tasman neighbour Australia (36).

Taiwan

This is a tremendous achievement which stems from a critical decision last March to adopt an elimination strategy towards community testing rather than mitigation (or suppression). Nevertheless we can still learn from other countries, particularly Asian.

A case in point is Taiwan with its even more impressive death rate of 0.3. [owing to Taiwan not being recognised as a country by WHO its data is separately sourced and is as of October 2020 as published in The Lancet]

Taiwan is an island much smaller than New Zealand but, in contrast to our 5 million, has a population of nearly 24 million. Like New Zealand it pursued an elimination rather than mitigation objective but, unlike us, didn’t require a national shutdown. Further, despite having over four times more people, Taiwan recorded just over a third of New Zealand’s total cases and less than a third of our deaths.

Contrasting Taiwan with New Zealand

Why this more impressive achievement? Taiwan learnt from an earlier bitter experience. Like other Asian countries, it experienced the SARs epidemic (an earlier coronavirus) between 2002-04. It had the highest global mortality rate recording 73 deaths out of 346 cases (21.2%). In comparison, China recorded 349 deaths out of 5327 cases (6.6%).

Learning from this bad experience Taiwan worked to ensure that it was able to respond more quickly and efficiently when another coronavirus appeared including a streamlined disaster management system for epidemics and pandemics, contact tracing protocols and processes to manage medical equipment like Protective Personal Equipment for health workers, strengthening hospital capacity, and mandatory face masks. These were all areas where New Zealand fell short by comparison.

Despite the official tension between China and Taiwan there are also strong informal communication links between them. Taiwan was quick to comprehend the significance of the Wuhan outbreak (much quicker than New Zealand). Borders were closed to Wuhan on 23 January, two days before the Chinese city went into lockdown.

The Lancet has noted that extensive public health infrastructure, including more hospital beds, was established in Taiwan prior to Covid-19 which enabled a fast coordinated response allowing Taiwan to avoid the national lockdown used by New Zealand. In contrast, New Zealand failed to address both severe capital works shortfalls and a dangerously severe shortage of hospital specialists.

Face masks

Face masks were a major point of difference. Taiwan immediately stopped exports of masks and increased their daily production of surgical masks to 17 million by April. This meant that Taiwanese began to use face masks immediately. In contrast, New Zealand was for some time neither proactive nor firm. The Ministry of Health disregarded the forcefully expressed face mask use advice of local public health specialists such as Professors Michael Baker and Nick Wilson. Instead it stood behind the equivocal position of WHO.

Today both Taiwanese and New Zealanders are able to enjoy reasonably normal lifestyles individually and collectively with the main difference being that the former has an even lower death rate than New Zealand’s impressive performance and didn’t require a lockdown to achieve it.

Even now Taiwan is demonstrating greater vigilance, however. It recently introduced new rules on making face masks mandatory in eight types of public areas to curb virus transmission during the winter. This included places of worship, entertainment and leisure venues, educational institutions, shopping centres, public transport and medical care facilities.

Taiwan not unique to Asia

As impressive as Taiwan’s achievement has been it is not unique to Asia. Even after the massive outbreak in Wuhan where Covid-19 was first discovered, according to WHO data, China through its determined pursuit of elimination has a cumulative death rate of 3 per one million. Vietnam with a similar approach has a rate of 0. Singapore’s and Japan’s rates respectively are 5 and 28.

In WHO’s list of regions Asian countries come under two headings – Southeast Asia and Western Pacific (the second includes China, Vietnam, Singapore, Japan, Australia and New Zealand). The cumulative death rates per one million for these two regions are 91 and 10 respectively Compare these outcomes with Europe (including the United Kingdom) – 631 deaths per one million.

The dramatically contrasting mortality outcomes of the Western Pacific and Europe highlight the difference between elimination and mitigation. Key Asian countries learnt of the effectiveness of firm comprehensive public health measures (with or without lockdowns depending on circumstances) in achieving elimination from previous experiences of epidemics including SARS.

The problem with mitigation

By and large Europe didn’t learn from Asia and focussed instead on mitigation which meant that even after suppressing the virus with lockdowns the door was inevitably left open allowing it to return. It meant that following lockdowns community transmission was significantly reduced but not eliminated and borders were opened much too early. This had led to them currently experiencing a greater crisis than earlier waves.

Mitigation requires lockdowns but at best this only buys limited time before Covid-19 returns with vengeance. Further, the combination of mitigation and lockdowns has the effect of undermining public confidence which has been critical to successful elimination strategies.

Australia’s current difficulties are primarily due to linking lockdowns to mitigation rather than elimination. Lockdowns are not a strategy; they are a last resort tactic where necessary that can work for elimination but not mitigation.  

The problem with WHO

The problem is that WHO has been Eurocentric when it should have been learning from Asia. Although it has rightly commended New Zealand’s successful elimination strategy, WHO hasn’t actively and consistently promoted elimination as the most effective way of responding to the pandemic. It has given mixed messages including appearing at times to give the green light to mitigation in Europe.

WHO’s Eurocentric approach contributed to the delayed description of Covid-19 as a pandemic rather than simply an epidemic, to the failure of much of the world outside Asia to immediately grasp the importance of adopting an elimination strategy, and for waiting far too long to call for mandatory face masks.

This situation helps explain why right at the beginning New Zealand itself was talking the language of mitigation (even if only inadvertently) and was so slow on face masks. Although the Health Ministry has vigorously got behind the elimination strategy, in its application it has been affected by WHO’s Eurocentric paradigm whereas New Zealand’s public health specialists have operated within an Asian paradigm.

New Zealand has still made good but the lesson here is to give greater weight to mainstream local public health specialist advice where there is a substantive difference with WHO.

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