Opinion: I Fought the Coronavirus in China. Here’s How I Think the U.S. and European Responses Stack Up

The world is set to enter a period of great uncertainty.

Now the coronavirus outbreak in China has been contained, as the global battle outside China is just starting. New cases in Asia, Europe, the U.S. and the Middle East (Iran) have been increasing rapidly. Various epidemic prevention policies have been introduced by global governments, just like Chinese martial arts, taekwondo, Japanese judo, Western boxing and all kinds of dazzling fighting skills.

Chinese martial arts versus Western boxing

China is in a good position as local cases have been mostly cleared and are soon to be cleared in Wuhan. But it’s difficult for many other countries to commit to an economic shutdown in exchange for epidemic control. Most countries, whether developed or not, follow the U.S. model.

Then why have Asian countries and regions that also copy the U.S. model, such as Singapore, Japan, South Korea, China’s Hong Kong and Taiwan, achieved such different results from the Western countries? If we don’t figure this out, some countries or regions may become the next Wuhan.

Difference between China and U.S. models

America was among the first to impose entry bans on travelers from epidemic-affected areas. But the U.S. will not impose measures such as the Chinese style community management and suggestion of wearing masks, which are likely to cause public panic and affect economic activities. But once infected people show up in communities, it is inevitable that there will be a second generation of cases spreading in communities. The key question is whether the existing health care system can be quickly activated and screen those second-generation cases.

Once community spread occurs, the battle will automatically enter a second stage, which is the prevention and control of community spread. Much of the battle at this level depends on the medical system’s ability to respond quickly.

The U.S. did almost the same as China in the early stage of epidemic prevention. Even today, diagnosis technology is still mostly controlled by the American CDC. But as the epidemic worsens, the diagnosis technology is being gradually decentralized. As health insurance companies are committed to cover testing expenses, professional diagnosis companies are joining in.

There were 1,004 cases in the U.S. as of March 12, which at least means the first-round prevention and control measures of blocking entry were effective. Some argue that the low number of cases in the U.S. reflects insufficient testing. But omissions cannot be covered up in the end. Whether the U.S. can control the outbreak depends on the increased identification of new cases once test kits are in place. 

The U.S. can handle 280,000 severe cases and 16,000 deaths during flu season. Other countries need to consider their own medical capacity before deciding what kind of strategy to take.

Apart from large-scale testing, how else is the Chinese model different from the U.S. model? The main difference is community management and public cooperation.

Prevention and control efforts in China are all-dimensional, including screening by a nationwide network of hospitals, grassroots community management covering the whole of society and joint efforts by the public, making it possible to end the battle in two months. No other country can do the same.

Public cooperation is apparent in several Asian countries and regions, including Japan, South Korea, Singapore, Hong Kong, Macao and Taiwan.

But strict community-control measures like China has can have an impact on the economy. Most countries are reluctant to do so.

As a result, thanks to efficient family doctor networks and national testing capacity, Asian countries and regions, though building their epidemic control system based on the U.S. model, are able to screen suspected cases relatively quickly and deal with subsequent community transmission quickly. Without strong community-control measures, it will be difficult to control community spread of the virus. 

Whether the epidemic will get worse will depend on the speed of virus transmission and screening capability.

Will things get worse in Italy?

Italy was among the first countries that suspended flights to China. But once imported cases were found, the country was unable to quickly conduct large-scale testing. Lack of guidance from the government and zero community control have made the development in Italy look like Wuhan in January. The total number of confirmed cases and total deaths in Italy are very similar to the first phase in Hubei province. If the current trend continues, the number of infected people in Italy will approach 200,000 by the end of May.

The Italian government on March 11 expanded lockdown measures to cover the entire country. But in fact the lockdown is just a closure to the outside. Inside the cities, activities are as normal. There are even demonstrations going on against the lockdown.

It reminds us of the Mexican lockdown in the 2009 H1N1 epidemic, which was a complete failure and caused 22 million Americans to be infected, according to the U.S. Centers for Disease Control and Prevention. Eventually, the U.S. had to abandon its strict control measures and switch to a seasonal flu management model.

Flu management model has premises

In a controllable situation, using a flu management model for Covid-19 is plausible. However, once an outbreak is out of control across a country, the proportion of severe patients who require admission to intensive care units (ICUs) will reach 10%-20% and the fatality rate 3%-5%. This will immediately exhaust medical resources, which in turn will push up the death rate.

That’s the reason the death rate in Hubei in the early stages was significantly higher than in the rest of the country. Among the more than 10,000 patients in Italy, 2,000 are estimated to be severe cases, and there are only about 5,000 ICU beds in the whole country. Italy’s death rate from Covid-19 has climbed to 6.63%, the highest in the world, signaling that the country’s medical resources, especially ICU capability, are already exhausted.

Whether countries can hold their defense lines greatly relies on ICU medical resources. What makes China’s case unique is that Hubei has the full support of other provinces, which contribute medics and ICU equipment. In Europe, with no sign of relief in any country, it’s much harder for Italy to get help from other countries.

Under such circumstances, the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care published guidelines suggesting that the allocation criteria need to guarantee that those patients with the highest chance of survival will retain access to intensive care, instead of “first come, first served” admission.

Such decisions can be painful and stressful for both medical workers and patients, but it might be the last resort when medical resources are severely scarce.

Germany’s situation is relatively under control, thanks to early prevention measures and abundant medical resources. The country currently also takes a U.S.-style approach. Germany had 1,567 confirmed cases as of March 12. Although the number could continue to rise, the outbreak is still controllable. But if Italy falls, Europe will face significant challenges, and the whole continent will face an influenza-like outbreak.

Based on China’s data and my own clinical experience in Shanghai, 10% to 20% of Covid-19 patients turn into severe cases, while only 1% of seasonal flu patients require ICU treatment. Once the number of new cases increases exponentially, the management and allocation of medical resources will be an important cause of a jump in the death rate. Now all countries with the outbreak well controlled have ample medical resources. But once the number of cases gets out of control, the proportion of severe patients will greatly increase and will put significant pressure on medical resources.

China still faces risk of imported cases

The darkest time has passed in China. Its people have paid a heavy price for the victory so far. But the battle is not over. China still faces a great risk of imported cases.

Based on the current global response, it remains unclear whether the outbreak will end this summer, with the biggest constrains in countries such as Italy and Iran.

If the outbreak in these countries continues to worsen, it’s possible the pandemic could last to next year. If so, the battle we are fighting now is just the beginning.

Zhang Wenhong is director of the department of infectious diseases from Shanghai’s Huashan Hospital.

Contact Translator Denise Jia (huijuanjia@caixin.com)