Just as a heart attack can jolt a person into changing habits for the better, a pandemic can spur a nation to profoundly improve its public health systems and policies. The harsh experience with Severe Acute Respiratory Syndrome in 2003—and to a lesser extent, H1N1 in 2009–10 and Middle East Respiratory Syndrome (MERS) in 2014–15—had such an effect on East Asian countries. China, South Korea, Taiwan, and Vietnam, among other states, retooled their public health systems after SARS in a manner that allowed them to mount particularly effective responses to COVID-19.

As the world struggles with the coronavirus pandemic, East Asian countries lead the way in both control and recovery. They consistently report lower death rates from COVID-19 than do countries in Europe and North America, suggesting that their governments have been better able to protect those at risk of serious illness and death. By and large, their public discourse has already shifted to restarting the economy and public life instead of remaining focused on initial measures to flatten the curve of infections. East Asian societies have demonstrated solidarity, rather than allowing the disease and its control to become unnecessarily politicized or weaponized. At the root of the efficacy of this response lie the hard-won lessons of the region’s experience with SARS.

A SINGLE SWITCH

Asian countries hit by SARS responded by investing in public health. They built systems and institutions that could marshal the full power of government to confront the next pandemic threat. Some designed and built new infrastructure for disease surveillance, case reporting, and contact tracing. They developed decentralized networks of laboratories, and they invested in the personnel that would be needed to run these new systems. In 2009, for example, Vietnam established a central database for reporting disease cases in real time. To develop and operate the technology required the support of public health physicians, information technology specialists, and a vast network of field-based epidemiologists.

At the same time, countries responding to SARS strengthened their command-and-control centers so that they could provide the leadership and information needed during the chaos and confusion of a pandemic. Some reorganized their nerve centers, as South Korea did with its Korea Disease Control and Prevention Agency. Others purpose built new ones after SARS, including Malaysia’s Crisis Preparedness and Response Centre, China’s Information System for Disease Control and Prevention, the Taiwanese National Health Command Center, and Hong Kong’s Center for Health Protection.

The countries that suffered through SARS learned that to fight a pandemic requires not only top-down systems but also attention to the broader health of the populace. Partly for this reason and partly for political purposes, many of the SARS-affected countries—including Japan, South Korea, Taiwan, and Thailand—have worked since the early 2000s to finance universal health coverage or to enhance existing coverage. Thailand has extended health insurance coverage to documented and undocumented migrants. Universal health coverage helps countries fight pandemics by bringing the population to a healthier baseline, reducing barriers to treatment, and encouraging familiarity with and trust in government services.

At the root of East Asia's response lie the hard-won lessons of the region’s experience with SARS.

The acute emergency of a pandemic, East Asian countries learned, requires governments to take a responsible but nimble approach to regulation. A South Korean task force of researchers, scientists, regulators, and manufacturers developed a process for rapidly approving urgently needed tests and treatments in a crisis. South Korea refined that procedure after SARS so that the country could rapidly develop, approve, and mass-produce PCR, or antigen, test kits. The country further adopted a new set of data-sharing and privacy laws post-SARS—laws that established the political mandate and legal basis for the world-leading, telecommunications-based contact tracing system that the country has used during the fight against COVID-19. Taiwan’s technological expertise and legal flexibility allowed its National Health Insurance Administration to combine data with the National Immigration Agency in just one day, a move that greatly aided contact tracing.

Many of the Asian countries that passed through the SARS crisis have developed strikingly similar response systems. They operate on a single switch, meaning that once public health decision-makers detect a credible threat, they can activate a surge response from the entire machinery of government. A single command center coordinates the work of the different levels of government, with collaboration among the various agencies built into the system’s ethos and operations. Asian governments recognize that science and hospitals cannot fight pandemics alone: the whole of government and society needs to be involved.

CLARITY AND COORDINATION

Government coordination and transparency help countries fight pandemics. These principles may seem intuitive, but the diversity of the world’s health systems, governments, and societies can make them complicated to apply. The SARS-affected countries again had a head start on addressing problems that have brought other countries up short.

Republics, federations, and unitary states differ in the degree to which their central governments command power, raise revenue, make decisions, and administer the affairs of state. Public health, in particular, is an area of responsibility that often overlaps federal, regional, and municipal authorities. Such organizational complexity can make managing public health systems and delivering their services during a pandemic particularly opaque. The countries that confronted SARS have had an opportunity to address such organizational shortcomings.

China is a case in point. In 2003, Beijing’s response to SARS was slow, secretive, and poorly coordinated, opening China to criticism both at home and abroad. This year, despite some uncertainty about the timeline before it reported the novel coronavirus to the World Health Organization (WHO), China has responded to the pandemic with far more effective internal communication and faster scientific and epidemiological exchange. The central, provincial, and municipal governments appear to be better coordinated this time around, with more transparent interactions with the international community than in 2003.

After the SARS outbreak, Asian citizens began to see health-care delivery as an essential public good.

Several factors likely account for this improvement. China’s Center for Disease Control and Prevention and its provincial arms were established after SARS, and they facilitated better public health coordination during the current pandemic. The country has embraced greater data transparency now than it did during SARS, evidenced by the higher number of peer-reviewed articles on COVID-19 in major medical journals. New information tools, including social media, may have increased citizens’ expectations and encouraged their participation in scrutinizing their government’s decisions.

The WHO issued International Health Regulations in 2005 that required every country to build public health systems based on coordination and transparency. China responded by developing disease reporting laws, regulations, and strategic plans for disease control. The fields of health policy, health-care administration, and public policy appear to have grown. China now has a health system with clear roles assigned to such agencies as the Chinese CDC. Although the country’s health system is much larger and more complex than it was in 2003, it is also more coordinated and transparent.

China is not the only country in Asia that streamlined and clarified its systems after SARS. That common experience in 2003 inspired governments from Japan and South Korea to Singapore and Malaysia to improve their administrative capabilities and share more information with citizens during pandemics. Their own past experience—and the present experience of other countries—has made clear that cover-ups and disorganization only lead to public anger.

A NEW SOCIAL CONTRACT

The SARS experience put public health higher on the agendas of Asian countries such as China, Thailand, and Vietnam, marking a shift in national priorities. In the late twentieth century, many Asian governments heavily prioritized economic growth, inspiring even sedate institutions like the World Bank to speak of an “East Asian miracle.” The period of sustained economic growth was necessary: it helped pay for public health infrastructure and formed part of the social contract in many Asian countries.

Until the twenty-first century, East Asian governments concentrated on providing the stability that made economic expansion possible. They largely considered good health among the population to be a consequence of progress, rather than a determinant or an end in itself. SARS sparked debates in many Asian countries about the role and purpose of government. Faced with a threat to their legitimacy, many of the region’s governments then taxed or borrowed their way to universal health care, strengthened their public health systems, and improved the conditions in which their citizens lived and worked. Vietnam is a stand-out example: the country increased its per capita spending on public health by an average of nine percent every year between 2000 and 2016.

The SARS experience put public health higher on the agendas of Asian countries.

SARS was not the only reason for this shift throughout the region. As incomes rose in the late-twentieth and early-twenty-first centuries, populations grew more sophisticated and better educated. Consequently, they demanded more social and political rights, such as health care and government transparency, after receiving mostly economic rights up until then. In political science terms, modern Asian governments tend to draw their legitimacy more often from outputs, such as providing effective public services, than from inputs, such as elections. After the SARS outbreak, Asian citizens began to see health-care delivery as an essential public good, and so its provision became critical to maintaining government legitimacy.

A social contract has two sides, however, and even when the government holds up its end, success depends on societal cohesion. Here, too, the experience of SARS has given East Asian societies an advantage in confronting COVID-19. A relatively recent epidemic memory reinforced public awareness of the need for social solidarity and joint sacrifice in such an emergency. Past experience helped Hong Kongers, the Taiwanese, and the Vietnamese to understand and easily comply with physical distancing and facemask requirements. Stay-at-home quarantine orders in Singapore and movement control orders in Malaysia required citizen cooperation on a large scale; governments could ask for this while drawing on the experience of previous pandemics to persuade citizens of their rights and their duties during the current one.

PATIENT PROGRESS

The world now looks to Asia for lessons to apply to the COVID-19 pandemic, but it will find no overnight solutions. Asian governments spent the 17 “peacetime” years between SARS and COVID-19 addressing the very problems that now plague other countries. They built public health infrastructure and did the hard political work of clarifying the roles and power structures that would take hold during a crisis. They built effective communication channels and made themselves comfortable with greater transparency and accountability than they had previously allowed. They even rewrote social contracts to elevate health as a priority.

The lessons Asian governments drew from SARS may not yield an instant cure, but they are useful for other countries fighting the current pandemic and preparing for future ones. As countries grapple with their own national heart attacks of COVID-19, they, too, will learn lessons that lay foundations for improved pandemic responses in the future.

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  • SWEE KHENG KHOR is a Visiting Fellow at the Institute of Strategic and International Studies Malaysia and a Senior Visiting Fellow at the UN University International Institute for Global Health.
  • DAVID HEYMANN is a Distinguished Fellow in the Global Health Programme at Chatham House and Professor of Infectious Disease Epidemiology at the London School of Hygiene & Tropical Medicine.
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