Connecting illness, death and governance in a COVID world
By Ian Inkster
As much of America, Europe and many anglophone nations face the welter of possible choices of action available to them as they enter what is understood to be a “second wave” of COVID-19, their media repeatedly mention a small group of nations that might best be copied—examples of good COVID governance.
Two points at the outset. For some time now it has been unclear whether this new wave was a direct function of mutation among the many DNA of the virus itself, or mainly a man-made cycle following the ups and downs of civil societies’ adherence to the regulations. Are the spikes resulting from civil laxity? The second point follows from this civil laxity argument—it may well be claimed that a nation’s ability to dampen COVID incidence and mortality is a sign of its existing power of governance. Good COVID management then becomes a measure of strength and scope of policies, of a government’s firmness in convincing its citizens to adhere to regulations, and of its own power to adapt to externally induced changing circumstances. From this, it may be argued that good COVID results act as an indicator of how well a government will lead its nation into post-COVID economic recovery. So, there can be quite a lot at stake here.
Thus, choosing the best example may well reflect an underlying belief among large numbers of people that a particular country has high status among the comity of nations. That is, successful COVID results may be seen by many people throughout the globe as exemplifying both successful governance and a firm moral economy. Contrariwise, failure over COVID in the “second wave” may now be considered a sign of a failing state. We have witnessed the ousting of Donald Trump.
Clearly enough, notable exemplars cannot be so small as to be clearly outliers, else such varied places as the Falklands or Greenland would take the lead. This puts to the side nations that have, indeed, been applauded, such as Hong Kong and Singapore. This applies also to isolated islands and vast territories with very low population densities such as Iceland, Madagascar, Finland, or even Norway. On more direct reasoning, those seeking exemplars should surely omit nations that do not report tests per million, such as Burkina Faso with a population of over 24 million and impressive Cm (cases per million) of 122 and exceptionally low Dm (deaths per million) of only 3, but which does not report test numbers. Of course, there will be nations that have actually had so few hospitalised cases or deaths that they have not instituted tests at all, but they are difficult to clearly separate from ones where cases would be high if thorough testing had been instituted.
Measuring COVID experience and selecting models
Table 1 below lists details for 10 nations, 5 of which are quite commonly exemplified across the world, and 5 others that are not, but whose records are worth serious consideration. World data is included in the last row. Coronavirus Worldometer
Table 1 offers a great many cautionary tales. Cm measures total COVID cases per million, Dm total deaths per million, D/C is deaths as a proportion of total registered cases, which we take as a good indicator of the effective mortality rate; Tests/m is the number of tests for COVID per million of the population. Figures are derived from totals for the period from January 13, 2020, the day of the first confirmed case in Japan, to November 11, 2020.
The five common exemplars are in bold, and they in fact offer very varying COVID experiences according to their own official registered data across the whole period. It seems clear that Germany and Sweden are exemplars, especially in Western nations because they have good records in fighting COVID-19 in comparison to other major European nations (e.g., the UK or Belgium with Dm figures of 719 and 1,112, respectively) and the USA (a Dm of 734). They also have highish results for tests per million, especially Sweden. But the latter’s principal drawback as an exemplar is its much smaller size of population, and the unusual characteristics for Europe of its relative spatial isolation when compared to high-COVID nations such as Italy. In addition, Sweden’s D/C or mortality rate at 3.6 per cent is actually the highest of the 10 nations in this table, despite a high testing rate. This could suggest either a fault in the procedures for effective hospitalisation after tests prove positive, resulting in greater mortality, or it could be a result of its relatively high proportion of older citizens—at 20.3 per cent of its population over 65, compared to say around 16 per cent for Australia and the USA. However, this case is severely weakened when we note that Germany has a ratio of 22.2 per cent of its population in this older grouping, and Japan an even greater proportion of 28.2 per cent. Both have D/Cs of 1.7 per cent. Given the small population of Sweden, this would throw some doubt on it as an obvious exemplar in terms of actual COVID results to date.
Within Europe, this leaves Germany as probably the better case, especially as, unlike Sweden, it is bordered by high-COVID nations such as Belgium, France, and the Netherlands (Dm measures of 1,185, 651, and 484, respectively).
Outside of Europe—problems
But at first glance, neither of the European contenders can match the non-European Australia, Japan and Taiwan, each with exceptionally low Dms (Taiwan with its unmatched 0.3 per cent) and much lower Cms. The seeming weakness of the Japanese and Taiwanese cases is their low levels of tests per million. Other things being equal, this means that lower numbers tested leads to lower “cases registered” if a nation is relying on test results as its principal COVID source, rather than official collections of data from hospitals and general practitioners of patients diagnosed as having the virus. This is not a resounding rejection by any means. It is very possible, certainly understandable, that a nation with actual low covidity would not feel the same need for mass testing as nations with obviously severe problems. It is notable that both the USA and the UK have the highest proportional testing ratios of any large nations—at around 50 per cent of their respective populations tested. Given that numbers of tests say little of the quality of the testing procedures there seems some good reason for holding Taiwan and Japan in high regard as exemplars.
Australia has no such problem, its rates of testing being amongst the highest in the world and notably above those of Germany. Its Dm is exceptionally low. The only problem area here is the unusual character of its demography (a huge proportion of the population live on the massive coastlines), its absence of land borders, its overall relative isolation from all high-COVID hot-spots, and its ability to close itself off despite high numbers of tourists and business connections. These features cannot simply be emulated, yet they may be more determinate of its success as a dampener of the virus than any single element of policy or of any special sequence of official interventions.
There is more to be said about why some nations appear as exemplary and others not, despite their directly COVID-related data. This is broached in three rows of Table 1. Pol-FrR provides an indicator of political freedom within nations, as measured over the years since 1973 by Freedom House, Washington, DC. The figures are an Index with 100 (Sweden) at the top among all major nations. Our Table 1 also indicates—with an * by the names of the 10 nations—all those that are labelled by Freedom House as “electoral democracies,” and it can be seen that all 5 of the major exemplary nations are in this category, and each is highly ranked on the Pol-FrR index, ranging between 93 and 100.The exemplary 5 are a free democratic group, sharing a series of status markers, attributes of a political culture, with many of the nations that regard them as exemplary.
Even though Taiwan with its amazing COVID history is not officially recognised as an independent nation by the other 4 within this select group, its characteristics fit perfectly with those of that group, as a whole. The PPP column shows that these nations are among the richest, most established industrial nations in the world, and estimates of their exemplary character by the major media outlets of the world must surely reflect something of a cultural club. The PPP column is a World Bank measure of purchasing power parity per capita, which adjust simple per capita income comparisons to account for cost-of-living differences by replacing normal exchange rates with those designed to equalise the prices of a standard “basket of goods” and services.
The index is based on the USA as 100. It seems clear enough that the chosen exemplars are seen as ones appropriate to emulate—democratic and free—and this is what is fastened on by the media that create the mantras of “lessons to be learnt,” or “following the science,” and so on. This is confirmed in column Econ-Fr, which provides an index of political freedom for 2020 calculated by the Heritage Foundation, Washington, DC, in its huge and freely available 2020 Index of Economic Freedom, where Singapore tops the world at 89.4, Australia appearing 4th with 82.6, Sweden appearing at rank 22 with 74.9, and so on. That is, this group is considered exemplary, despite the great differences in COVID performance within it, on grounds of a global culture in which, through an international media, market-based liberalism at high incomes is awarded the highest status among the nations of our world. With status comes notions of veracity, probity and high trust, the secondary rewards of high income.
It may thus be argued that the notion of what might be an exemplary nation in a COVID world, is not principally founded on the COVID record but on some evidence of COVID achievement plus much evidence of high national status among the other nations of our world. So, despite all the caveats and drawbacks noted in this paper, it would appear that the seemingly very different nations of the group will persist as exemplary.
Beyond the pale: Another perspective on best COVID performances
Our other 5 nations are a different cup of tea altogether. Although Poland and India are both parliamentary democracies, they share with this second group much lower income per capita, with Ethiopia being one of the most impoverished nations on earth. They all have lesser degrees of economic and political freedom, but they all also have very good COVID performances as measured in columns Dm and D/C, and generally reasonable numbers for tests per million (the worst being Angola which actually exceeds the figure for Taiwan!). These are not small countries demographically, and to that extent deserve some attention as possible exemplary cases.
With its large Cm measure, Poland looks at first an unlikely candidate, but note that its figure is equal to that of Sweden, and much lower than those of Spain (29,692), or France (26,769), or the huge Belgian figure of 42,547. Its tests per million exceed those of Japan. Its D/C ratio is very low, much below those for the UK, Italy, France, and even Germany. It borders 7 nations of high or uncertain covidity, such as the Czech Republic. And, of course, it is European. We might suggest that it has never been seen as exemplary in the West because of its cultural distinction of having low per capita income, equal to that of Malaysia, and its lower degrees of economic and political freedom than those found among the accepted exemplary group. And, of course, the same must be said of Ethiopia and Angola. The most likely causes of their low COVID measures is a lack of the infrastructure for effective testing and the low number of the elderly in their populations, primarily a result of low incomes. As noted already, this alone would tend to bring down the mortality rates. India and Malaysia are by far the more likely examples for others to follow. India’s massive population and extreme poverty, both noted in Table 1, has not inhibited low Cm and especially low mortality measures. As a well-established parliamentary democracy, India has a relatively high level of political freedom, although its determination to continue to plan high economic growth (an annual growth rate of GDP of over 7 per cent from 2012) means that government does not let market forces rule the production and distribution of goods and services. Aided by its age distribution but remembering the enormity of its population, India might well be seen as among an exemplary group of low-COVID nations.
Malaysia as best practice?
As an exemplary case in many senses, Malaysia has been the most neglected by international mass media commentators. Yet with highish levels of economic freedom, it has achieved remarkable COVID statistics based on a reasonable level of testing. In this, it has been aided by being bordered by nations of low covidity, such as Indonesia (Dm of 55) or Thailand (Dm of 0.9 and total cases of only 3,861!). Its Dm and D/C levels are remarkable. Moreover, its history of COVID defence shows a great deal more alacrity and intelligence than most nations in the West. Screening was adopted at all airports after the first case in Thailand was made public on January 13, and Malaysia only reported its own first case on January 25–well after Japan, South Korea, the USA and Taiwan. Thermal scanners were adopted early. Under the Movement Control Order of March 18, the government, with good cooperation from the media, actively spread the “#stayhome” instructions, NGOs and prison inmates fabricated PPE for those on the frontline, and initial financial stimulus to prevent full economic downturn had been initiated in February. Very early on, Malaysia accepted that China had proved that by isolating the infected group of individuals and practising social distancing, the pandemic could be contained. In order to fund new hospitals and create stocks of medicines, the Ministry of Health and Tenaga Nasional Berhad (TNB) established an “action coalition” to obtain financial aid from corporate companies, government-linked companies (GLCs), and other organizations in Malaysia, a form of private-public sector funding that the West has yet to truly exploit. Government dampened any division between private and public sectors, enlisting help directly from the social media, and NGOs (not private companies) were used early on to provide protective masks, disinfection chambers, and to educate citizens on COVID-19. By April 11, Malaysia had reported a total of 4,346 cases and a total of 1,830 recovered, a proportion of 42 per cent. Today the numbers are 32,969 and 45,095, a proportion of 73 per cent.
Far quicker than countries such as the UK, the Malaysian authorities recognised the key problem of the elderly in care homes. As early as March 27, the Malaysian government introduced the Prihatin Rakyat Economic Stimulus Package (PRIHATIN) with RM 25 million allocated to provide assistance for aged care homes, including cash disbursement, food supply and healthcare items, as well as an RM 250 one-off payment for government pensioners. Malaysia was directing a much higher proportion of its very limited resources to helping the elderly than did most of the Western nations and at a much earlier date, and this was evidently rewarded through its very low Dm and D/C statistics.
Beyond casual statements—selecting with mindfulness
The Malaysian example details the variety of positive responses that have been made in nations not hitherto considered exemplary yet showing very superior COVID results over far more wealthy nations. In itself, this sort of evidence cannot pick an exemplar for all. Picking an exemplar by looking at single cases is unlikely to help very much. But what seems clear is that global exemplars do not have to look the same in terms of political structures, incomes, or economic ideology. Better that any nation looks at its own circumstances and selects elements considered appropriate. The best option might be to consider the more global picture but allow especially for differences in income and age distributions, the character of borders, densities and levels of urbanism, and degrees of air pollution. Such elements may guide selection towards countries or a country of similar circumstance, and the best COVID performer amongst them may well be your best exemplar. But just do not jump too soon!
Elements such as age structure or borders may be reasonably recognisable and objective measures. Political systems and policies are quite the opposite, these alter with regimes (we can look forward to developments in the US). The only way out of the seeming conundrum is to first admit that COVID incidence and mortality is only very partially related to any one nation’s official management policies. In fact, to date, only the dimmest light has been shed on what is the relationship between illness, death and governance in a COVID world. For this reason alone, a great COVID exemplar may not be a great example of political and civil life, especially as defined by decision-makers in parliamentary democracies. Perhaps choosing between Australia and Japan, between India or Malaysia, ought not be so normative. Perhaps it should carefully weigh up seeming COVID performance in the context of all the elements, admitting that the policies of governance may not be foremost amongst them.
Professor Ian Inkster is a global historian and political economist at SOAS University of London, who has taught and researched at universities in Britain, Australia, Taiwan and Japan. He is the author of 13 books on Asian and global dynamics with a particular focus on industrial and technological development, and the editor of History of Technology since 2000. Forthcoming books are Distraction Capitalism: The World Since 1971, and Invasive Technology and Indigenous Frontiers. Case Studies of Accelerated Change in History, with David Pretel. Follow him on Twitter at @inksterian