How should governments respond to the Coronavirus?
Co-authored by Matt Barrie, CEO, Freelancer
Government best practice from over 20,000 responses
On March 5th 2020, Freelancer sent out a global survey to 40 million users. We have since received over 20,000 responses. We surveyed on the topics of business, health, behavior, access and government response. You can find a link to the full 100 page report at the end of this article.
On March 8, 2020, Italians woke up to a world in which more than a quarter of the nation's citizens had been quarantined. By March 9, that quarantine had been extended to the entire population.
The country's government placed tight restrictions across the nation, banning all public gatherings, quarantining citizens with a temperature above 37.5ºC (99.5ºF) and mandating that restaurants and cafes could only open from 6am to 6pm, provided they allow at least three feet of space between patrons. Residents have been told not to leave their homes for anything but work or emergencies.
Across the nation, libraries and museums were closed, joining daycares, schools and universities that the Italian government had closed the week before.
The response comes as Coronavirus spreads quickly throughout the country. Italy has the highest number of reported cases in Europe, at 35,713 as of 18 March (See the Coronavirus COVID-19 Global Cases by Johns Hopkins CSSE dashboard for real time updates), and the highest number of deaths by far at 2,978. The next highest number of deaths in the EU is Spain, at 638.
The measures are extreme, but the rampant spread of the virus in the country as compared to its European neighbors will no doubt have many wondering if Italian officials acted quickly enough.
“This epidemic can be pushed back, but only with a collective, coordinated and comprehensive approach that engages the entire machinery of government,” WHO Director-General Dr. Tedros Adhanom Ghebreyesus said, calling on every country to act “with speed, scale and clear-minded determination. […] If countries act aggressively to find, isolate and treat cases, and to trace every contact, they can change the trajectory of this epidemic”.
He has said that “the whole government should be involved” with leadership coordinating every part of government, including the ministries of health, security, diplomacy, finance, commerce, transport, trade and information.
The situation in Italy illustrates a harsh reality. When countries respond slowly to a pandemic, the consequences will be severe. A slow response means that, when necessity dictates that restrictions are ultimately put in place, those restrictions will be more draconian than if the country acted quickly in the first place.
To see this reality played out, one need look no further than the Spanish Flu epidemic of 1918, a pandemic that killed five times more people than World War I. When the epidemic hit the city of Philadelphia in late September of 1918, city officials were slow to take action. School closures and bans on public gatherings weren’t implemented for more than two weeks after the first reported case, and a citywide parade even went ahead as planned.
By contrast, St. Louis saw its first case of Spanish Flu in early October and took quick action to stop the spread of the virus. The city implemented measures to promote social distancing within two days of the first reported case.
BioMérieux Connection describes the response: “St. Louis benefited from the leadership of Dr. Max C. Starkloff, Health Commissioner for the city of St. Louis. Like in Philadelphia, the disease first appeared at a military base in St. Louis, the Jefferson Barracks, which was 10 miles from the city. By Oct. 1, a handful of influenza cases were reported at Jefferson Barracks. Within days, the numbers soared to 500.
Starkloff closely monitored these developments and didn’t hesitate to close schools almost immediately. He went on to close factories, theaters and retail outlets. Starkloff faced intense pressure from St. Louis merchants, public school officials and politicians to reopen these facilities, but he refused. Schools were closed for nearly 3 months, as were many other population hubs.”
The result? Hatchett, Mecher & Lipsitch (2007) in Public health interventions and epidemic intensity during the 1918 influenza pandemic reported “Philadelphia had a peak weekly excess pneumonia and influenza (P&I) death rate of 257/100,000 and a cumulative excess P&I death rate (CEPID) during the period September 8 — December 28, 1918 of 719/100,000. St. Louis, on the other hand, experienced a peak P&I death rate, while NPIs were in place, of 31/100,000 and had a CEPID during the period September 8 — December 28, 1918 of 347/100,000.”
Clearly, the government response to infectious disease has a massive impact on the outcomes for those affected.
Figure: Death Rate per 100,000 Population Philadelphia versus St. Louis (Source: Public health interventions and epidemic intensity during the 1918 influenza pandemic)
A similar scenario played out a tale of two islands- American Samoa and Samoa, where John Martin Poyer, the U.S. Navy-appointed governor of American Samoa, immediately used ships from the U.S. mainland to quarantine anyone with the disease, thus isolating the island. As a result of his actions, not a single person in American Samoa died of the Spanish flu, a disease that infected 500 million people worldwide- a third of the planet’s population- and killed 20 million to 50 million.
By comparison, Robert Logan, Military Administrator in nearby Samoa, failed to take quick and decisive action. As a result, around 20% of the population died from influenza.
Smith (2017) writes “Poyer’s work was so impressive, especially in comparison to what Logan had done, that people living on Samoa had decided that they’d rather have the U.S. controlling their territory, rather than New Zealand”.
Poyer was awarded the Navy Cross for his fast thinking action in preventing the spread of Spanish influenza in American Samoa.
Freelancer's recent Global Coronavirus (nCov-19) Survey revealed frustration at the government response in many countries, with respondents citing inadequate testing, poor medical care and a lack of information regarding the spread of the disease.
On 5 March 2020, Freelancer surveyed its 41 million users on the impact of Coronavirus in their communities. The survey drew 20,000 responses within 36 hours, and revealed huge disparities in governments' responses to the pandemic.
One respondent in Japan, which has seen 889 confirmed cases of Coronavirus thus far (outside those on the Diamond Princess cruise ship), called the government response "terrible."
"To be tested, one has to meet certain criteria and also pay $50. I'm sure there are a lot of cases that aren't reported due [to those] restrictions," the respondent said.
While Japan's cases of Coronavirus seem incredibly low compared to other countries in the region, research suggests that the reported numbers are far below the actual number of people infected with the illness, as Japan has yet to extensively test for the virus.
While around 58% of 19,009 respondents globally said they were satisfied with their government's response, there was widespread anger among respondents from some countries.
Respondents in Indonesia, which has reported only 227 confirmed cases of the illness, said the government had done "nothing" and was "spreading lies." One respondent in Saudi Arabia where there are seven confirmed cases of Coronavirus said the government had provided "absolutely nothing but eye wash," though Saudi Arabia has closed its borders in response to the pandemic.
In Australia, which is at 568 confirmed cases with new cases jumping daily, one respondent said the government was "laughably telling us not to worry," while another accused the Australian government of an "unpragmatic approach."
The most fury seemed to be reserved for the government in Bangladesh, where respondents said the government had given them "no information" on precautions taken against Coronavirus, and "didn't take any steps to stop the spread of the virus."
"They don't have any inspection system at any airport in Bangladesh. Also no real quarantine in the whole country. Government hospitals just kick out people who [visit] them for checking or treatment or information. Not a single device in the whole country," one respondent said.
What should governments be doing?
Governments across the world will no doubt continue to face harsh scrutiny and second guessing over their response to the virus, but statistics so far show a stark contrast between countries' responses. Taiwan, for example, seems to have bucked the trend of many other Asian nations, with only 100 reported cases of Coronavirus and one death.
Taiwan has shown exemplary action in taking a proactive approach to containing the virus’ spread. The following is a timeline of measures introduced by the Taiwanese government:
As a result of strong proactive action, the impact of the virus on Taiwan has been muted compared to Wuhan.
South Korea has also taken serious measures to combat Coronavirus, which spread rapidly in the country. But the cumulative case curve has flattened in the country, which currently sits at 8,565 confirmed cases. Slightly more than a week ago, South Korea was second only to China in confirmed cases of the illness. It has since been overtaken by Italy, Iran, Spain, Germany, the United States and France.
Thanks to Korean biotech companies’ early development of test kits for the coronavirus, Korea is capable of running 10-20 times the number of tests compared to China, Japan, and the United States. The country is providing rapid testing to anyone who fears they may be affected, has closed schools and offered free childcare to parents affected by the closures and has restricted movement of residents in areas hard hit by the pandemic.
The South Korean government also took swift legislative action, and passed new laws allowing for the prosecution of suspected Coronavirus patients who don't comply with testing procedures, and banning the export of face masks.
"They [the South Korean government] send alert messages to my phone about what to do and the current status, and we can look online. It’s advised to stay at home, and you can always call a hotline if you have symptoms. They close down areas where infected people have been. [There's] hand sanitizer in every shop and on public transportation [and] cameras to measure body temperature in some buildings," one survey respondent said.
We can see the effect on new cases reported and the shape of the cumulative case curve for South Korea from such action below:
Cumulative case curve for South Korea by day (Source Korean CDC)
The faster a country reacts, the faster the virus will be contained. The Grattan Institute published the following graph based on data being tracked by John Hopkins University Center for Systems Science and Engineering.
The rate of increase of cases by country from their 100th case. Source: Grattan Institute & John Hopkins University Center for Systems Science and Engineering
Most respondents to the survey seemed to favor a more proactive government approach to stop the spread of Coronavirus. The highest action supported by respondents was travel bans to and from Coronavirus hot zones which 66% of respondents support, while 62% supported mandatory screening at the borders. Forty percent supported mandatory Coronavirus screening for all citizens, and 24% supported closing their country's borders altogether.
There also seemed to be a common cry for clear and accurate information. A February study by The Economist found that mortality rates during epidemics were higher in authoritarian countries. Much of this discrepancy could be attributed to the economic gap between many authoritarian countries versus democratic nations, but part of the difference in outcomes is down to the flow of information — or lack thereof — under dictatorships. Respondents in some countries where information is tightly controlled by the state bemoaned their government's lack of transparency.
One respondent in the United Arab Emirates, currently ranked 133rd out of 180 in the global Press Freedom Index, called for the government to "release the real count of infected individuals so people will be aware." A respondent in Zaozhuang, China, called for "freedom of speech and press" as a measure to battle Coronavirus. "They mustn't hide the virus from us," a respondent from Azerbaijan said.
Even in open democracies, though, there seems to be frustration with the lack of information offered by the government, and a general feeling that many governments are downplaying the threat. One respondent from the United Kingdom called on the government to "[follow] Korea's example of testing anyone who wants it, so we can get some data on how much COVID-19 is actually circulating, and the rates at which serious symptoms manifest."
While the UK has set high standards for clear communication, as seen below in the materials circulated by the National Health Service, a slow response could see the situation in the country soon rival that of Italy.
The NHS received praise in the survey for clear communication in regards to the Coronavirus
The UK government announced on 9 March that action could be taken in the next 10–14 days to promote social distancing, and finally announced on 16 March that residents were advised to work from home and avoid public gatherings.
The slow response in the United Kingdom came due to an early strategy to let the virus spread naturally in the country, and depend on herd immunity to combat the illness. But a report from immunologists at Imperial College London and the London School of Hygiene and Tropical Medicine released this week suggested that 30% of patients who contracted the disease would require hospitalization, which would quickly overwhelm the country's public health system.
In the United States, meanwhile, respondents to the survey criticized President Donald Trump's appointment of Vice President Mike Pence to head up the government response to Coronavirus.
"Do not have Mike Pence coordinate the US response based on past experience with HIV in Indiana," a respondent in Wisconsin said.
"Putting someone in charge that actually knows something about science and medicine would be great," a respondent from Kansas City, MO, said.
The testing gap
A stark contrast in government responses seems to be the availability and ease of testing for the virus. South Korea seems to have set the global standard, with the ability to conduct 15,000 Coronavirus tests per day, and has conducted 196,000 tests to date, free of charge, with one city even setting up drive-through testing facilities and notifying of results via SMS. It's little wonder given this efficient testing regime that the country's Health Minister, Park Neunghoo, told CNN the country believes it has passed its peak for the infection's spread.
Singapore has also provided a model for other countries, with robust contact tracing of confirmed cases. The country's government meticulously traces any contact patients may have had, with close contacts either closely monitored or quarantined to prevent the spread of the virus. This practice has enabled Singapore to detect cases of infectious diseases at a rate three times higher than the global average, a recent paper from the Harvard T.H. Chan School of Public Health found.
Singapore’s COVID-19 Virus Outbreak Dashboard
By contrast, countries where the spread of Coronavirus is on a steep upward curve have limited testing capabilities. In Australia, for example, doctors in New South Wales cannot perform tests without a referral from the state's health service.The only other option for patients who show symptoms of the virus is to visit a dedicated testing facility where there has been a report of queues up to 300 people long.
"I’m a GP. We can’t order a covid test unless approved by Public Health. We have to contact them on a case by case basis. We had a patient arrive last Tuesday, sick a couple of days after arriving from Italy, still no response from Public Health, as of Friday afternoon," one Sydney area doctor said on Twitter.
Likewise, in the United States, the rollout of testing has been slow. The country's Center for Disease Control (CDC) admitted that the rollout of diagnostic testing had not gone smoothly. By 6 March, only 2,000 diagnostic kits had been distributed nationwide, and in spite of the Food and Drug Administration approving measures to allow clinics to create their own diagnostic kits, the testing process has been slow.
Even now, more than eight weeks after the first confirmed case of Coronavirus in the United States, the country is only able to perform 7,000 tests per day.
The lack of diagnostic resources in many countries presents a worrying possibility: Coronavirus may have already spread much further than official reports indicated. In the vacuum created by slow government response, many companies seem to be erring on the side of caution.
Businesses moving ahead
Many businesses seem to be taking a more precautionary approach to Coronavirus than governments. Already, Amazon, Twitter and Microsoft have encouraged workers to stay home to avoid contact with infected individuals. In a memo sent to employees this week, Apple CEO Tim Cook called the Coronavirus outbreak "an unprecedented event," and told employees they could work remotely. Facebook shuttered its Seattle office until at least 31 March after confirming that a contractor working in the office had contracted the illness.
Tech companies haven't been alone in adopting remote work policies in response to the outbreak. Banking giant JPMorgan has imposed a two week work from home quarantine on employees returning from trips to China, and Ford, Kraft and PwC have instituted similar policies.
Some companies are viewing the measures as a test case for a shift towards a broader remote workforce in the future. Twitter CEO Jack Dorsey has stated he wants to move the company towards a remote workforce model, and the company's head of human resources, Jennifer Christie, said the company would likely "never be the same" after the forced work from home experiment in the wake of Coronavirus.
“People who were reticent to work remotely will find that they really thrive that way. Managers who didn’t think they could manage teams that were remote will have a different perspective. I do think we won’t go back,” Christie said.
Indeed, 62% respondents to the Global Coronavirus Survey said they would shift towards relying more on a distributed freelance workforce rather than hiring in-house employees.
And of respondents who had employees, 61% said they would be allowing their staff to work remotely more often.
While the window may be passing for governments to take decisive and swift action, businesses and individuals still have the opportunity to mitigate Coronavirus' spread. Shifting to a remote workforce model could be one of the most effective forms of social distancing, and history would indicate that social distancing is an incredibly effective measure for controlling disease outbreaks.
Even before the outbreak of Coronavirus, businesses and workers worldwide were beginning to gravitate towards a remote workplace model, often using freelancing platforms to replace traditional means of sourcing labor or finding work. Coronavirus has accelerated this trend, and, as Twitter's Jennifer Christie said, it's likely the workplace will never be the same.
Specific actions suggested in our survey
Best practice suggestions from the Freelancer.com Global Coronavirus (nCov-19) Survey:
Travel bans from hot zones. This was the most supported government action in our survey at 66% of respondents.
All travelers, including returning residents, must have a medical certificate issued by a registered medical practitioner issued within 3 days before their arrival into the country (Samoa)
nCov-19 swab test at airports (Singapore)
Pamphlets at the airport (Australia)
Banning of international cruise ships (Taiwan implemented this February 6th)
Monitoring of self-quarantined Coronavirus cases via government issued cell phone (Taiwan implemented this January 29)
Foreigners must see customs officer and not use e-Gate fast entry (Taiwan implemented this February 7th)
$10,000 USD fine for people breaking self-quarantine (Taiwan implemented this February 7th)
Drive through Coronavirus testing. It's safer and faster to test for the virus at the drive-through than in a hospital or health clinic. Results are available by SMS in three days. (South Korea)
Cameras to measure body temperature deployed at ports, airports, public places and office entrances (Philippines)
Paused all schools and universities (Bahrain)
Banning public gatherings of over 1,000 people (France)
Move classes to 100% online format (Stanford University)
Closing down of areas where infected people have been (South Korea)
Thorough contract tracing (See Singapore’s dashboard here)
Banning of visitors to aged care facilities
Cancellation of public events (Palestine)
Closure of hot zone areas (Italy, China)
Distribution of free face masks and hand sanitizer to the general public
Price controls on the sale of face masks (Taiwan has dropped mask prices to around $0.20 USD)
Activation of local health response teams (Philippines)
Temporary export ban on surgical masks
Travellers can only take up to 250 masks, fines equal to 3x mask value
Only 1–3 masks available for purchase from retail stores (Taiwan implemented this Jan 30th)
Heavily subsidized fees for visits to doctor for those with Coronavirus symptoms. (Singapore)
Accelerated training of additional medical staff (India)
Ramp domestic mask production (Taiwan has ramped their production to 10 million masks per day. Taiwan’s population is 23 million)
Mobilize military to help production lines at mask manufacturers (Taiwan implemented this Feb 2nd)
Clear information describing prevention and protocols distributed to the general public, businesses and healthcare workers
Constant notifications to wash hands (New Zealand)
Alert messages sent to phones on what to do and the current status and online link.
Hotline to call if you have symptoms (South Korea)
Outgoing phone calls play Coronavirus message (India)
Hand sanitizer in every shop and public transportation (South Korea)
Compulsory wearing of face masks in public, traveling, shopping and even in the office (China)