Lessons from Asia on COVID-19: What the U.S. Can Learn from Successes Abroad

In May, the United States crossed the tragic threshold of suffering more than one million deaths from COVID-19. Over the course of the pandemic, the U.S. experienced one of the highest mortality rates from COVID-19 of any high-income country. In contrast, some high-income Asian countries experienced remarkably low COVID-19 mortality.  

“European countries, such as the United Kingdom and France, have experienced moderately lower mortality per population than the U.S.,” said Ramnath Subbaraman, assistant professor of public health and community medicine at Tufts University School of Medicine. “But what's really remarkable are the extraordinarily low mortality rates experienced by some high-income countries in Asia, such as Japan, South Korea, Taiwan, and Singapore.

Subbaraman spoke as part of the School of Medicine’s Global Health Seminar series on a panel discussion entitled “Lessons from Asia on COVID-19,” sponsored by the Global Health Faculty Council and Tufts Center for Global Public Health. The virtual event brought experts together from diverse backgrounds to explore how these nations achieved their success, how they approached the pandemic differently, and what the world can learn from Asia’s COVID-19 response.

“If the U.S. experienced a similar rate of mortality per population, eight or nine out of every 10 people we have lost from COVID-19 in the U.S. would still be with us,” he said.  And the gap between America and other countries in terms of COVID mortality is accelerating in the Omicron era.

In a wide-ranging discussion with the panelists, a handful of key takeaways emerged:

Racism influences comparisons of the U.S. with Asian countries—or lack thereof.

Because of longstanding anti-Asian racism in America, said Michelle Ko, associate professor of health policy and management at the University of California Davis, “we don’t even try to learn from Asian countries.” The percentage of Americans who agree that Asian-Americans are at least partly responsible for COVID-19 has doubled from 2021-2022—despite a new administration in the White House, she noted.

Anti-Asian sentiment has influenced U.S. public health policy and the view of Asians as bearers of contagion since syphilis, yellow fever, and bubonic plague infected San Francisco in the late 19th and early 20th centuries. At the time, those diseases were seen as chiefly an Asian problem that could be managed by controlling Asians and Asian-Americans.

“Anti-Asian racism is part of the air we breathe,” she said, adding that this racism plays out in ways large and small and can be seen in media reports comparing U.S. COVID-19 management to other countries.

“Charts of COVID statistics in the media usually list other Western European countries, such as France and Germany, and may include an eastern country such as India,” Ko said. And if the media does report on the COVID response in an Asian country, it is likely to focus on China. Ko said she did a quick analysis of articles from the New York Times on COVID-19. “I got 300-400 articles about China, maybe 10 or less from South Korea, maybe 10 about Japan, one about Taiwan, and zero about Singapore.”

Not only is the volume of stories distorted, but policies in China and other Asian countries are frequently described as “harsh,” “strict,” and “ruthless.” They also suggest that people living in Asian countries wear face masks because they have a collectivist culture, she observed.

“The thinking is that the Asian culture is submissive, it’s a culture of Confucianism, it’s paternalistic,” she noted. “We assume some level of authoritarianism must be involved, without looking at the actual governance models of these countries.”

She accused American politicians of painting precautions in these countries, such as mask wearing, as something Americans could not adopt because Americans want freedom.

“These biases reinforce a false dichotomy between freedom and public health and undermine our ability to implement greatly needed public health policies in the moment,” she concluded.

Asian countries used lessons learned from SARS to improve their COVID response.

When severe acute respiratory syndrome (SARS) began in China and spread in late 2002 to early 2003, it ultimately reached 30 countries, resulting in 8,098 cases and 774 deaths, said James Maguire, professor of medicine at Harvard Medical School and physician at Brigham and Women's Hospital in the Division of Infectious Diseases. SARS was much more lethal, but much less transmissible than COVID-19. While it didn’t spread until people were symptomatic, there were no tests to aid in detection or vaccines to limit contagion as there have been with COVID-19, he said.

In China, the SARS outbreak began slowly. When an explosive outbreak occurred in Guangdong, the government was quiet about it, he recalled. “People were broadcasting about it on their cell phones and the population went into a state of almost panic about what was going on. Finally, the government came out and reported that there’s an outbreak of this new, atypical pneumonia,” Maguire explained.

Within a month, half of hospitals were filled with SARS patients. People didn’t know what was causing it or how to treat and prevent it. Over time, the Chinese medical and public health community learned that creating hospitals solely for SARS patients, implementing strict infection control in hospitals, providing dedicated fever clinics for those who might think they had SARS, and conducting strong community surveillance, contact tracing, and quarantine, could quell the outbreaks. But as experts were learning all that, the disease was spreading to other countries as infected individuals moved from one country to another, unaware they carried the disease.

“Throughout, the Chinese government was not communicating in a forthright manner and people were afraid to go to the hospital because they might contract SARS,” Maguire said.

“And then, in a remarkable two-hour press conference, the government came clean and said, ‘we’ve screwed up, we’ve got an epidemic, and this is what we are going to do.’ And as a demonstration of sincerity, the Mayor of Beijing and the Minister of Health were fired,” Maguire explained.

The government closed schools and public gathering places put hospitals on quarantine for 15 days, halted travel, started contact tracing and quarantine enforcement, and implemented an educational blitz. By June they were SARS-free, Maguire said. Today, Maguire feels China is using the SARS playbook to attack COVID-19.

“SARS was an excruciatingly painful experience for Singapore,” said panelist Jeremy Lim, an associate professor at the Saw Swee Hock School of Public Health at the National University of Singapore. “But we learned that we needed to build up our public health capabilities. As a result, when COVID emerged, Singapore was able to mobilize the military to do everything from packing masks to setting up makeshift residential facilities for migrant workers. We had plans in place to ensure that Singapore’s health system was as resilient as it could be.”

SARS left Taiwan with trauma, as well, said panelist Peter Chang, an adjunct professor of public health and community medicine at Tufts School of Medicine and international director of the Show Chawn Medical Group in Taiwan. But it also gave the government the opportunity to upgrade its regulations for national emergencies. “When COVID started, we had early fire alarms and actions prepared to put in place. We started contact tracing when the numbers of cases were low. We recognized that healthcare needed to be available for all, and that masks needed to be available for all. We even supplied masks to other countries,” he said.

Noting that Taiwan deals regularly with typhoons and earthquakes, Chang added: “Our capacity to deal with disasters is in our DNA.”

Trust in government was key to Asian countries’ successes.

When discussing the success of Singapore and Taiwan in combatting COVID, Lim and Chang emphasized the importance of frequent communication to the public and citizens’ trust in their governments. Singapore achieved a 91.5 percent vaccination rate compared to 66.6 percent in the U.S. with 253.4 deaths per million residents compared to 3,016.5 per million in U.S.

“While some in the U.S. might describe our government as ruthless, we in the East would call it decisive,” said Lim. “When COVID first was identified, there were large numbers of Chinese tourists in Singapore for Lunar New Year. The government encouraged tourists to be tested, hospitalization was free, and individuals were given 100 Singapore dollars a day for every day hospitalized. During the pandemic, the government paid part of people’s salaries to stay home. They subsidized the airlines, hotels, and other businesses to help people do the right thing and not increase their risk of spreading the virus.”

This strategy was very pragmatic—and very successful. “Singapore was described as the gold standard,” Lim said.

In Singapore, a fall from grace occurred when the virus spread to congested migrant worker dormitories. “Our policymakers were out of touch about conditions in migrant worker dormitories,” Lim said. “Singaporeans realized we are only as strong as the weakest link,” and improving conditions in worker dormitories became a high priority.

“It was quite remarkable for the Singapore government to admit when there were mistakes and to address them honestly and transparently,” Lim said.

In Taiwan, where health literacy levels are high, daily communication from leaders through the media was also key, said Chang. “The prime minister was in the media at least one hour every day.

“Health is a national priority in Taiwan,” Chang added. While Taiwan did not have its own vaccines, they received shipments from the U.S., Japan, and Europe. Despite a later start in vaccinating the public, Taiwan now has much higher overall vaccination rates than the U.S.

“Through COVID, I feel trust was important—the chasm between public, private sectors, and individuals was bridged,” Lim said. “Sadly, not just for the U.S. but for many countries, trust in government, media, international organizations, and health authorities are all declining,” Lim noted.

“Communication works best in a field of trust,” Lim added. 

“But trust has to be built on something,” Chang observed.