One coronavirus, 195 playbooks. Can the world stop a pandemic?

A man in Lagos, Nigeria, wears a face mask outside the hospital where an Italian citizen was being treated with the coronavirus, the country's first confirmed case.
(Associated Press)

China locks down tens of millions in their homes to slow the march of a deadly virus — but furnishes scant information about the mercurial spread of a disease that has spooked the world.

South Korea and Singapore opt to track patients’ movements in granular detail, favoring radical transparency over privacy. In Italy and Iran, politicians trade blame over rapidly growing outbreaks that are seeping across unstable regions, making a global pandemic seemingly inevitable. Infections appear in Mexico. Then Nigeria.

As the world unites in resolve to battle one deadly virus — now known as COVID-19 — it is doing so with as many as 195 separate playbooks, each country calibrating its emergency measures to suit domestic and international politics, local capacity, cultural norms and other considerations that have little to do with public health.

The result is a global response that can appear uneven, inchoate and at times dangerous, with neighboring countries adopting different strategies to similar threats across a closely connected planet.


“Unfortunately we are only as prepared as our weakest link,” said Lawrence O. Gostin, a global health professor at Georgetown Law School. “We are seeing that clusters of cases in one country can quickly move regionally and globally. No one is safe unless we are all safe.”

Responses to recent outbreaks have been hindered, Gostin said, by a range of factors: weak health systems, insufficient testing equipment and medical professionals, authoritarian leaders who restrict the flow of information, political instability and violence, and the limitations of the World Health Organization, which is loath to criticize the very governments it relies upon for funding.

In years past, countries like the U.S. might have played a leading role in spearheading a global response. But President Trump for weeks has minimized the threat of the virus and has been focused largely on the impact on markets, even as the virus began transmitting on U.S. soil in the middle of a divisive election year.

The strengths and shortcomings of governments and institutions have been on full display in recent days, as the number of coronavirus infections soared past 80,000 in more than 50 countries. Nearly 3,000 have died, the vast majority in China.

Employees at Sao Paulo International Airport in Brazil wear masks Feb. 26.
(Andre Penner / Associated Press)

New cases were reported this week in Brazil and Nigeria, increasingly signaling that the virus will reach all corners of the world and that the effort to stay ahead of it will be prolonged, with no end in sight. The novel virus sends shudders daily across the planet, canceling concerts and sporting events, and raising questions over sealed borders, quarantines, the viability of face masks and test kits, the long-term consequences on financial markets and what happens if the disease reaches deeper into Africa.

“My biggest concern is while this is being artificially held back, are countries taking advantage of this time?” said Dale Fisher, a Singapore-based physician and chairman of the WHO’s Global Outbreak Alert and Response Network. “China can’t stay closed forever, and this outbreak, it already has brought cities to their knees, brought countries to social and commercial standstill.”


From being slow to disclose the severity of the virus when it first emerged in December in the animal markets of the central city of Wuhan, China is now winning praise for locking down 100 million people in Hubei province — an unprecedented cordon sanitaire that appears to have slowed the spread of the virus domestically.

For the first time last week, the number of infections reported in a single day was greater outside China than inside.

“What China has done over the past month is astonishing — there are very few countries that could have pulled that off,” said Tom Frieden, a former director of the U.S. Centers for Disease Control and Prevention.

A man crosses an empty highway in Wuhan, China, where people have been restricted to their homes.
(Getty Images)

A WHO mission to China last week lavished praise on the government’s measures. That same organization credited Beijing’s response even as the nation’s leaders were not forthcoming about the extent of the disease two months ago. Questions continue to linger about China’s transparency over the infections it records.

Chinese officials have disclosed only limited information about infections among front-line healthcare workers, when infected people first began to show symptoms and the total number of people it has tested — all of which could help determine how the disease spreads.

“The lack of that information makes it harder for China and the world to do everything possible to limit the impact of the virus,” Frieden said.

There is also the question of whether the draconian measures taken by Chinese authorities can be replicated elsewhere in the world — especially in liberal democracies.

Governments in two new epicenters, Iran and Italy, were scrambling to get a handle on outbreaks that started with travelers arriving from China.

Iran’s theocracy at first downplayed the threat, perhaps to curry favor with China — an important trading partner — and to avoid startling a population already beaten down by years of fiscal mismanagement and U.S. economic sanctions. Some analysts said Iran was also trying to keep up turnout for last week’s legislative elections, a quasi-democratic exercise that helps the ruling clerics maintain a veneer of legitimacy.

“You have a social crisis and an economic crisis and now a public health crisis layered on top of one another, and it presents complicated tradeoffs for the Iranian government,” said Esfandyar Batmanghelidj, founder of Bourse & Bazaar, a publication that tracks Iran’s economy. “And we are seeing a failure to judge those tradeoffs wisely.”

People wearing masks wait to cross a street Feb. 2 in Tokyo.
People wearing masks walk Feb. 23 in downtown Tehran.
(Associated Press)

Iran has now reported 245 cases — including the infection of its deputy health minister — and 26 deaths. The unusually high ratio of deaths to known cases has led experts to extrapolate the country may have thousands of undetected infections. Iran is believed to be the source for infections in a half-dozen regional countries, including Lebanon, Iraq and Afghanistan, a prospect that has the virus colliding with conflict zones.

Italy was quick to quarantine two Chinese tourists with coronavirus in Rome last month, and was the first European country to stop direct flights from China, but has nevertheless been hit by the biggest outbreak in Europe.

Cases began rapidly multiplying in towns in northern Italy and spread to other parts of the country, infecting more than 650 and killing 17 as of Thursday, slipping across open borders to other European nations.

The surge of infections began with one man who spent two days at a hospital before his case was detected, infecting patients and doctors. Authorities have been swift to point the blame elsewhere; Italian Prime Minister Giuseppe Conte claimed the hospital didn’t follow protocol, but the local health chief for the region of Lombardy said the European Union could have been at fault.

“I believe if Europe had established a quarantine immediately for all people coming from China, Europe would not be having these problems now,” Giulio Gallera, the health chief, said.

In South Korea and Japan, allegations were mounting that the governments had put geopolitics ahead of the population’s safety early in their responses, in the interest of preserving relations with China.

People wearing masks wait to cross a street Feb. 2 in Tokyo.
(Getty Images)

Japan’s handling of the Diamond Princess cruise ship docked off its shore proved an early example of a bungled response. Critics charged that the government allowed the virus to fester on board with inadequate measures to prevent infections.

Some questioned whether the government made the ultimately fatal decision to keep some 3,700 passengers and crew on board to keep the cases from being counted among its infections in the lead-up to the Summer Olympics in Tokyo. After more than 600 infections and two deaths, Japan allowed passengers to disembark and disperse via public transit when there was still danger of transmission.

The loss in faith in the government’s response is particularly keen because Prime Minister Shinzo Abe came into office promising competence after the nuclear disaster of 2011, said Kenneth Mori McElwain, a political science professor at the University of Tokyo.

“Some people believe the Abe government more or less caved to Chinese pressure, and that dealt a blow to the perception of competence,” he said.

In South Korea, more than 1.3 million signed a petition calling for the impeachment of President Moon Jae-in, criticizing the government’s reluctance to impose swift travel restrictions from China and on Chinese nationals.

“The more we observe his handling of this situation, it feels like we’re watching the president of China, not of the Republic of Korea,” the petition read.

The upheaval was in spite of aggressive and proactive measures taken by the government to track down every contact with an infected person, test them for the virus and publicize that information. South Korea nonetheless saw the ranks of the infected skyrocket to more than 2,000 this week, by far the largest cluster outside China.

Elsewhere in Asia, governments are facing questions over a lack of infections. Cambodia and Indonesia have reported one and zero cases infections respectively, despite having received large numbers of travelers from China in January. Indonesia had daily direct flights from Wuhan, the epicenter, until authorities suspended the flights Jan. 24.

To experts, the low figures suggest that the virus is spreading undetected.

“Indonesia is a textbook example of a country that is likely to have a spread that is unrecognized,” Frieden said.

The risk of the disease taking off across Southeast Asia is high, experts said, due to inadequate health facilities and people packed closely together in crowded cities. It’s also not clear that officials are taking the threat seriously: Cambodian Prime Minister Hun Sen greeted untested passengers disembarking from a cruise ship from Hong Kong with handshakes and hugs, while Indonesia’s health minister said the country’s lack of infections was “because of our prayers.”

Faith does not seem to be slowing the virus’ advance. Nigeria’s first case Friday marked COVID-19’s arrival in sub-Saharan Africa, where health systems already struggle to cope with existing diseases like malaria and yellow fever.

The WHO is rushing test kits to the continent’s hospitals, some of which developed experience testing for infectious diseases during the Ebola outbreak. But the coronavirus presents a more difficult challenge, experts said, because it can be transmitted even by people who fail to show symptoms.

“If COVID-19 reaches sub-Saharan Africa” in large numbers, Gostin said, “it would be our worst nightmare.”

Kim reported from Seoul. Special correspondent Tom Kington in Rome contributed to this report.