Having lived through the weirdness of Covid I kept thinking it was difficult to see the light clearly in the middle of a storm. However, I had hoped that when the dust settled there would be so many important lessons learned from this devastating outbreak. Some countries like Sweden avoided many of the compulsory restrictions imposed elsewhere, kept compulsory schools for younger pupils generally open and relied much more heavily on voluntary public-health recommendations. I wondered what was their experience in terms of excess deaths.
It is also clear that in 2021 wealthy countries had ordered billions more doses than they required for their own populations. Subsequently one wealthy country, the United States, ended up dumping more than 80 million doses. Although to be fair many of these wealthy countries were major donors of vaccines to other countries.
It’s difficult to have a fair scoring card after all it was not a level playing field. Italy had a first-class health system in its North when the outbreak hit them, but it was one of the first to face the dire consequences of epidemic attacking the health system. No wonder they were quickly overrun with a shortage of ventilators and no available treatments. Others had time to observe their suffering learn from it and take preventative action that helped them cope better.
Perhaps one of the best scores was attained by New Zealand to emerge remarkably unscathed. It did help it was an island, not densely populated and had a leader who acted quickly to defend the population. But despite her evident success, she later became increasingly unpopular and was strongly criticised by sections of a population who perhaps did not know what they had been spared.
But even populations that should have known better had large numbers dying of Covid, not only stubbornly resistant to taking available vaccines but also to using masks or obeying basic isolation instructions. Even when my friend phoned her relatives in the US and learned of more deaths in their ranks all around them, their views remained unchanged. Perhaps the biggest lesson is how misinformation, always disturbing at the best of times, became deadly in the middle of the worst of times. How ignorance became a rock to cling to not a stepping stone to learning more.
You can see I have my own misconceptions and slant on the whole business but surely in six years someone intelligent with insight has gathered together all the experience and facts and made some progress and understanding what worked and what didn’t. So, this was my goal. Step back from my own particular view and consult others whose field of expertise is exactly this!
The Score Card
Probably the best single measure in comparing countries is generally age-adjusted excess mortality, rather than the officially recorded number of COVID deaths. This excess mortality successfully captures deaths missed by testing/reporting and some indirect effects of the pandemic. The age adjustment is required because it was the older population who were hit hardest and if you have a country with a huge population of older people then you would inevitably have higher numbers of deaths whatever your response. By using age-adjusted excess mortality you greatly reduce that variable when comparing countries, although many other differences between countries remain. WHO estimated about 14.9 million excess deaths worldwide in 2020–21, far above the officially recorded COVID death count.
But how did individual countries fare?
1. New Zealand was one of the clearest successes. Its elimination strategy—tight border controls, quarantine, testing, tracing and rapid lockdowns—kept COVID at bay until vaccines were available. Their vaccine uptake was high and it experienced exceptionally low cumulative excess mortality over the pandemic, with mortality actually below expected levels in 2020–21. Mind you islands generally coped better. There is an advantage in having a sea border to protect you. In fact, one international study found that islands fared about 3 times better in terms of age-standardised excess deaths than non-island countries.
2. Norway and Denmark also performed very well. Among the European countries these two had very low pandemic mortality. They reacted while hospitalisation numbers were still comparatively low. This is evidence that one of the strongest lessons to learn in a pandemic is that speed matters. Even a modest intervention at an early stage is much better than a severe intervention when hospitals are rapidly filling.
3. Sweden avoided many of the compulsory restrictions imposed elsewhere and initially suffered considerably higher mortality than neighbouring Norway and Finland, particularly in vulnerable elderly populations in care homes. However, in the longer term its overall excess mortality compared surprisingly favourably with many European countries. One interesting lesson from Sweden is that voluntary behavioural change can accomplish more than was thought.
4. Britain performed badly during the crucial first wave. It entered the pandemic with good scientific expertise but delayed important early interventions due to slow political decision-making and so transmission grew rapidly. It experienced high early mortality however, Britain did considerably better in vaccine development and deployment.
Early in the vaccination programme vaccines showed very high protection against symptomatic disease and also reduced infection and transmission, but this protection against infection became much less reliable as immunity waned and new variants appeared. Public-health messaging did not always make this changing distinction sufficiently clear. A useful message as the evidence evolved would have been:
“The vaccine may not prevent you catching COVID, but it greatly reduces your probability of becoming seriously ill or dying from it.”
That distinction might have preserved more public trust.
In particular, school closures carried enormous costs. Children had a relatively low risk of severe COVID and the long school disruption had detrimental educational and social consequences. Future pandemic policies may require a much higher threshold for closing schools. COVID mortality was extraordinarily concentrated among older and medically vulnerable people and responses should therefore be more carefully targeted according to risk.
In many other countries, those in nursing and residential homes were extraordinarily vulnerable to this pandemic. Protecting them should have been among the highest priorities. Lessons learned were the necessity of rapid testing of staff, good ventilation, adequate PPE, sick-pay arrangements preventing infected staff from working and the residents having early vaccination. More careful hospital-to-care-home discharge policies could have reduced the disease being channelled from hospital wards to the most vulnerable in society. Perversely, some countries concentrated enormous resources on restrictions affecting millions of comparatively low-risk people while the virus was allowed into institutions containing the people most likely to die.
Mind you many of these are easy in hindsight and perhaps much harder when you dealing with something of the unexpected scale of the Covid pandemic.
Another lesson learned was that SARS-CoV-2 is predominantly transmitted through respiratory particles, especially indoors. As a result, improved ventilation, filtration and air-quality monitoring should therefore become routine. Much less was achieved by washing surfaces. I had elderly relatives who spent hours using acholic wipes to clean each piece of grocery delivered by van from the supermarket.
The pandemic revealed that resilience really matters. Countries need spare hospital capacity, trained staff, surveillance systems, testing capability, vaccine manufacturing, strategic supplies and public-health organisations before a crisis begins.
And governments need something much less tangible: trust. People will put up with extraordinary restrictions for a limited period if authorities explain what they know, what they don't know, why a decision is being taken and what evidence would cause that decision to change. A recent academic paper concluded that Countries where people had greater trust in their government tended to have lower infection rates. Even more importantly, countries where people had greater trust in one another also tended to have lower infection rates. Lower government corruption was associated with better outcomes too. High-trust countries also tended to achieve higher vaccination rates once vaccines became widely available.
My asthmatic mother was hospitalised with Covid in her late eighties in Northern Ireland but thankfully survived. One of the genuine surprises of COVID-19 was that ordinary asthma did not substantially increase COVID mortality. In fact, some research suggests that asthmatic airways may have presented the virus with fewer convenient doorways into the cells and that some inhaled corticosteroids, used by asthma patients, may have reduced aspects of SARS-CoV-2 replication or the inflammatory response to infection. These remain possible explanations rather than established reasons for the unexpectedly low mortality risk. But there are conditions that really made catching Covid deadlier. Age is definitely the biggest contributor in risk of Covid death but diabetes and obesity also played major roles, as did a number of other underlying medical conditions.
Perhaps the Lancet summed it up best: the countries that did best weren't necessarily those imposing the most restrictions. They tended to be those that acted early, protected vulnerable people, maintained public trust, had competent health systems and adapted policy as the evidence changed.
That are probably lessons we should all remember.
