May 26, 2023
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Opinion: When it comes to COVID response, wealth doesn’t always equal health


By Jan Nederveen Pieterse

Differences in COVID-19 public health performance and health outcomes between regions and countries are staggering. A common-sense assumption is that wealth is health and the higher a society’s per capita income, the lower COVID deaths will be, and vice versa.

But the data doesn’t bear this out. For example, compare COVID-19 deaths per million among countries with similar per capital income and geographic and cultural similarities: Canada has had 772 deaths per million, while the United States has 2,738; Norway has had 182 and the United Kingdon, 2,105; and Sweden is at 1,480 deaths per million compared to 483 in Denmark and 225 in Finland.

There are also wide discrepancies among lower and middle-income countries. Rwanda, with per capita annual income equivalent to $2,100, has had just 100 deaths per million; Vietnam has a per capita income of $8,200 and 241 deaths per million; Peru’s per capita income is around $6,000 and its COVID deaths total 5,977 per million.

Based on onsite examinations of pandemic health performance in 26 countries around the world, three key variables stand out in success or failure in dealing with COVID: knowledge, state capability, and social cooperation. Each is crucial, but they work best in combination, so their effects are cumulative.

Knowledge and science are key to guiding collective action, not merely in the sense of expert knowledge, but also in the sense of social knowledge. Social experience with infectious diseases plays a key role, such as SARS and MERS in East Asia and HIV and Ebola in Africa. Lack of such experience plays a part in the lack of public health preparedness in many countries in Europe and the Americas.

A friend in Kigali, Rwanda emails: “The history of the genocide and other health scares are relevant. If you’ve been through a genocide the idea that wearing a mask is some sort of hardship is manifestly ridiculous, and the horror of Ebola has made fear of infection a potent motivator.”

State capability refers to effective, pro-active government; responsible and capable leadership; and efficient use of resources, including time. Examples of capable state action are South Korea, Taiwan, New Zealand, Singapore, Hong Kong and Vietnam.

Legitimacy and credibility of the state are part of state capability, a soft power capacity. Trust in government is earned over years or decades. Distrust of the state plays a part in anti-vaccine attitudes and high COVID-19 deaths in Russia and Eastern Europe. After experiences with deception, such as the forced sterilization of Indigenous women, Indigenous peoples in the Americans fear vaccination. In Peru, where Indigenous people make up 33% of the population, this has been a factor in the high COVID death rate.

In the U.S., frontier individualism and distance from the federal government play a part. In addition, decades of anti-government discourse and dysfunctional government have undermined the trust that was earned during the New Deal period.

Knowledge and state capability work in tandem. A country with a capable state and a high degree of social cooperation doesn’t function without adequate knowledge. Consider Sweden. Anders Tegnell, Sweden’s state epidemiologist and head of the nation’s public health agency, held on to the narrative of herd immunity (when it was abandoned in the UK and the U.S.), along with policies of an open economy and voluntary restraint, which led to loss of trust in the public health agency and cost countless lives and the highest score of COVID-19 deaths in Scandinavia.

Social cooperation refers to the degree of social cohesion and the nature of state-society relations. Social cohesion provides resilience in times of crisis. Where government action fell short, social cooperation, local community action and non-governmental organizations have been able to turn things around and contain damage, for instance in Thailand and Indonesia.

Social cooperation and social support for state action amplify its efficacy, such as in Taiwan, China, Singapore, Vietnam and Cuba. The long-lasting gap between state and society in India hampers pandemic public health performance. When India fell short in dealing with COVID-19, in Kerala a capable state and social cooperation withstood the pandemic with lower death rates.

How these variables work out with COVID unfolds over time. First is the virus control phase, from December 2019 onward, which includes control of movement of people (travel barriers, quarantines, lockdown) and control of movement of the virus (testing, tracing, isolation, treatment). Second is the vaccine phase, from December 2020 onward. Third is the ongoing race with variants, most recently delta and omicron. The greater the level of immunity built with vaccines, the lower the chance that new variants develop and spread. The phases are not neatly separate but overlap and their start time differs by region, country and parts of countries.

COVID–19 started in Asia and spread to Australasia, the Middle East, Italy, Spain and wider Europe, to the Americas and then Africa. A bird’s eye view is that Asia (minus South Asia and parts of Southeast Asia) and Australasia have performed well in the pandemic. Nordic Europe performs better than Eastern and Mediterranean Europe. Overall, the Americas (except Canada and Cuba) and Eastern Europe have performed worst.

• Jan Nederveen Pieterse is a professor of global studies and sociology at UC Santa Barbara. This column is a summary of an article that was recently published in the journal ProtoSociology.