How countries on five continents responded to the pandemic, helping shape future of health policy

The opening lines of Tolstoy's "Anna Karenina," where the Russian author posits that "Happy families are all alike; every unhappy family is unhappy in its own way," can also be applied to the responses to COVID-19 by countries around the world, say researchers at the University of Michigan.

U-M professors Scott Greer and Elizabeth King and colleagues in Brazil analyzed early government responses from 34 countries on five continents to the emerging COVID-19 pandemic and how those decisions impacted their citizens' health and lives.

They brought together a team of about 70 public health researchers and political scientists who dove into understanding policy and politics to measure the effectiveness of governments' responses—instead of looking at classical data like the number of deaths and the contagion curve of the disease.

In a broad and in-depth portrait of how different nations responded to the same pandemic, the U-M-led team found that the few countries who were relatively successful by the end of 2020 were alike in regard to their responses.

These "happy countries"—South Korea, Vietnam, Germany and Denmark—had a fast public health response through pharmaceutical interventions (mask-wearing, strict guidelines on shutting things down). They quickly implemented robust testing and contact tracing responses to stop the virus from spreading, paid people to stay home and did serious public health work quickly—ending up with "the best of both worlds," the researchers say.

"Governments have responded in divergent ways to manage the COVID-19 pandemic and our work shows what countries have succeeded or failed," said Greer, professor of health management and policy at the U-M School of Public Health. "We wanted to start identifying what mattered the most and explain it to shape future conversations about the meaning and lessons of this disease for comparative politics and health policy."

Greer and King, who co-authored "Coronavirus Politics" with their Brazilian colleagues, professor Elize Massard da Fonseca of Getulio Vargas Foundation and public health specialist André Peralta-Santos, gathered data from the first nine months of 2020 when the pandemic management depended on nonpharmaceutical interventions and test-trace-isolate-support systems.

"The main goal was to gather an impressive group of interdisciplinary scholars with deep country or region-specific expertise to describe the public health and social policy responses," said King, associate professor of health behavior and health education at the U-M School of Public Health. "And also to provide explanations for how and why the countries were responding in the ways that they were during the first wave of the pandemic."

Unhappy countries

While the "happy countries," or those that did the pandemic response right, were similar in their approaches to managing the pandemic, the "unhappy countries," or those that did it wrong, were uniquely unhappy, the researchers say.

These countries, like the United States and Brazil, responded with varying policies—some expected and some not. For example, these governments gave some stimulus and essentially made it possible to stay home, but then didn't really build any public health infrastructure.

In both cases—and for different reasons considering the political systems are different—the U.S. and Brazil were "two really salient countries that did a huge stimulus and then just did not make coherent policies," the researchers say.

"You see the effects in mortality, you see the effects in the number of cases," Greer said. "The people appreciated the money and a lot of them stayed home, but then, in the absence of public health policy, you got state-by-state chaos. It seems that you have to combine social policy and public health work right."

India may have used a different method for "getting it wrong," say Greer, King and colleagues. India ignored social policy, producing a tragedy of a different kind. The government told the population to stay home, later realizing that millions of migrant workers had to work to eat.

"When they shut down their employment, they're all starving," Greer said. "We don't know it yet, but it could be that the lockdown in India killed more people than the virus. It's quite possible."

For King, it is hard to have a successful COVID-19 response without responding with social policies that allow individuals, communities and businesses to survive the social and economic consequences of the pandemic.

Leaders matter

The politics and policies implemented were often even more predictive of how a country responded to COVID-19 than the state's capacity to do so. Leaders considered controversial, such as Donald Trump, Jair Bolsonaro (Brazil), Sebastián Pinera (Chile), and Boris Johnson (United Kingdom), acted with authoritarianism when responding to COVID-19, the researchers say.

Both Trump and Bolsonaro adopted destructive denialist approaches to the epidemic, which undermined efforts to respond effectively, they say.

"Presidentialism and authoritarian governments, in general, guarantee these leaders powerful instruments, which in the hands of a populist denialist can have devastating effects on the response to COVID-19," said co-author Fonseca, assistant professor of public administration at the Sao Paulo School of Business Administration at Getulio Vargas Foundation.

"Brazil was very well positioned to deal effectively with the pandemic but unfortunately failed to do so even having a relatively robust research and health infrastructure."

For Greer, this pandemic shows there are serious coordination problems in global health governance. In country after country, the difference in what people's lives are like today compared to about a year ago is the result of public policy decisions.

"Political institutions matter, and we need more political analysis to better understand and prepare countries for future health crises," he said. "There are a lot of dead people around the world because of political decisions.

"There is also great hope that many countries will be able to change their trajectory in the COVID-19 pandemic. Vaccines show promise that surprised most informed observers. They created hope amid the disarray seen in many countries."

A free online version of Coronavirus Politics will be available April 22.