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Five Countries, Five Experiences of the Pandemic

Rana first heard that the coronavirus was spreading in India in early March. “We didn’t know what it was, how it looked,” he said. “We just knew that people were dying in Mumbai. We were very scared.” A few days later, Narendra Modi, the Indian Prime Minister, announced one of the world’s largest and strictest lockdowns. Modi delivered his speech at 8 P.M. on March 24th; restrictions started at midnight. Millions of migrant workers were stranded without wages, food, or shelter. All forms of public transportation—by air, rail, and road—were suspended. Police arrested, and sometimes beat, people who remained out for nonessential activities. The lockdown, initially scheduled to last three weeks, was extended again, and again, and again, through the end of May.

The contractor whom Rana worked for offered migrants a month of rations. After that, Rana and his brother were on their own. They tried to wait it out. “We thought it had to end at some point,” Rana said. They asked their father to send money, but in early May, after they’d exhausted their savings, the brothers bought bicycles and, along with several friends, set out for Odisha—some fourteen hundred kilometres from Mumbai. They began their journey at 2 A.M., carrying rice, utensils, medications, pots, and pans; in ninety-degree weather, they cycled to Nashik, a town in northern Maharashtra, the Indian state with the highest number of COVID cases, where they were forced to spend twenty-four hours at a quarantine center, along with some three hundred people. The next day, petrified of catching the virus while detained, Rana pleaded with the police to let them go.

It took Rana and his brother seven days and nights to get to Odisha on their bicycles. When they arrived, they were quarantined near their village for a month before being allowed back home. Since then, Rana has had trouble finding work, both because of pandemic-related restrictions and because of the stigma attached to those returning from Maharashtra. When we spoke, five months after his return home, none of the men with whom he’d made his journey had managed to find work in the village.

Rana is one of roughly a hundred million migrant workers in India. The sudden lockdown, by forcing their reverse migration from urban centers to rural areas, almost certainly contributed to the spread of the coronavirus; it also created a humanitarian crisis, reminiscent of Partition, in 1947, when the subcontinent was divided into India and Pakistan and millions were forced to trek on foot from one to the other. Five weeks after Modi’s first announcement, the Indian government began operating Shramik Specials—“labor trains”—to transport migrants to their home states. Crowds gathered in congested stations, and packed trains ran with little regard for social distancing; still, millions of migrants remain stranded, and since March hundreds have died of starvation, exhaustion, suicide, and accidents. In one video, a toddler on a train platform tries to wake his dead mother, tugging at the cloth covering her lifeless body.

Many migrant homecomings have been sullied by prejudice against those seen as carrying the virus from one place to another. At times, this stigma has been applied to physicians; some doctors, particularly women, have suffered physical and verbal abuse. According to the World Health Organization, India has only eight doctors for every ten thousand people. (The U.S. has twenty-six, and Germany forty-two.) Even before the pandemic, India had fewer than twenty per cent of the critical-care doctors required for its ordinary needs. The situation is worse in rural areas, where sixty-five per cent of the population lives but only twenty per cent of the country’s doctors work. For much of September, India recorded more than ninety thousand COVID-19 cases a day; while daily cases have since decreased, the country still ranks third, behind the U.S. and Brazil, for most COVID deaths in the world. Many believe that, because of its poor testing-and-reporting infrastructure, the deaths are significantly undercounted. Tested or not, the virus continues to spread: according to some reports, more than half of those in Mumbai’s slums and a third of the people in Delhi have been infected.

Adam Oliver, a professor at the London School of Economics, is one of many researchers who have tracked how different countries have responded to the pandemic. Oliver thinks that our usual back-of-the-envelope way of comparing countries, using a snapshot of COVID cases and deaths, is of limited value. “We have to think about the non-health implications of pandemic response, too,” he told me. “Those are much more difficult to gauge at the moment. When you lock down businesses and citizens, there are many downstream consequences. There’s an economic impact. There’s social damage. There’s loss of freedom—which, especially in countries already bordering on authoritarianism, could be hard to roll back. If you consider these broader implications, I don’t think we’ll know the best path for years, if ever.”

Oliver classifies pandemic responses into three broad, sometimes overlapping categories: the quick approach, the soft approach, and the hard approach. Countries that took the quick approach used swift action to tamp down viral spread, and were generally able to avoid prolonged lockdowns. Taiwan, for example, acted early and aggressively through closed borders, universal mask wearing, robust contact tracing, and quarantines enforced with mobile-phone tracking. In a population of twenty-three million, it has had fewer than nine hundred cases; for two hundred and fifty-three consecutive days, between mid-April and the end of December, it did not record a single locally transmitted infection. “Many Asian countries recognized very early that this was going to be much deadlier than the flu,” Oliver said. “Some of their speed and effectiveness came from their experience with SARS. They had their public-health infrastructure—track-and-trace programs, quarantine protocols, communication strategies—pretty much ready to go.”

The second strategy—the soft approach—relies on recommendations instead of requirements. Many nations have taken this route after failing to act quickly, or because they are unwilling or unable to pass mandates; instead they recommend, but do not enforce, mask usage, closures, and quarantines. Sweden is the most widely cited and widely criticized example of such a country; while its COVID-19 death toll is much higher than its Scandinavian neighbors’, it is on a par with that of many other Western democracies. Other countries have adopted the soft strategy. In Japan, the constitution imposes some limits on the government’s ability to mandate behavior, and so the country has relied on peer pressure and financial incentives, with surprising success. Brazil, because of its President’s cavalier attitude to the virus—“We need to stop being a country of sissies,” he has said—has also de facto employed the soft approach.

Britain seemed to flirt with the soft option early on. Ultimately, though, it went with the third strategy—the hard approach—which is characterized by more aggressive government action. This approach has been adopted by most countries at one point or another, and is familiar to most of us here in the United States. As cases increase and hospitals fill, the government mandates masks, imposes curfews, prohibits large gatherings, and orders lockdowns until numbers improve. In the U.S., individual states have experimented with the soft versus the hard approach, and have often alternated between them. Most of Europe started hard, went soft in the summer, and then was forced to go hard again as infections surged in the fall. “Some countries have to take the hard approach because their health-care systems are stretched at baseline and they can’t afford a surge of cases,” Oliver said. “Others have simply concluded that it’s the only way to prevent unnecessary death and suffering.” Such decisions are abstract, made at a high level, and yet they have human consequences. Around the world, billions of people have been affected by the virus. There are more pandemic stories than we’ll ever know.

In March, as the coronavirus spread across Europe and into Germany, Kavadias closed the bar, several days ahead of a government-mandated lockdown—the hard approach. “It was starting to get really scary,” he said. For much of April—“the dark month,” he called it—the bar remained shut. Kavadias learned that his aunt, who lived in Italy and was previously healthy, was ill with COVID-19. After weeks in the hospital, she died. “The pandemic became very real for me,” he said. “I really think the Italians saved our asses. They got hit so hard. It was a wake-up call for all of Europe.”

As the weather warmed and people ventured out of their homes, Kavadias devised schemes to generate revenue, so that he could keep his employees on the payroll. “I had to find a way to pay them,” Kavadias told me. “These people are my friends.” He designed T-shirts—one, which he was wearing when we spoke, over Zoom, read “Du Beast or Not Du Beast.” He sold two hundred to local residents, which helped cover salaries, at least for a time. He offered cocktails to go; people who used to frequent the bar would stop by, mostly in an effort to keep it afloat. “The neighborhood was incredibly supportive,” Kavadias said. “It really came together.” One day, a man in his sixties who, prior to the pandemic, had dropped by for a beer almost every day after work—“For him, it was like a cup of tea”—ordered a drink to go and left a two-hundred-euro tip.

As spring turned to summer, the bar reopened with outdoor seating, and patrons flooded back. “It might have been the best summer we’ve ever had,” Kavadias said. “Everyone was so ready to socialize again. There’s a reason people live in Berlin: they want to have fun. This isn’t Munich or Frankfurt.” Upon entering the bar, people were required to write down their names and e-mail addresses, but many hesitated. “Privacy is a big issue in Germany,” Kavadias said. “I said, ‘Write Mickey Mouse as your name if you want. But I need a way to get in touch with you if someone ends up getting COVID here.’ ” Around that time, surveys showed that nearly ninety per cent of Germans thought that their country was doing a good job of handling the pandemic; seven in ten said that the response had made them prouder of their country. Germany was seen, rightfully, as an exemplar of how to respond to the pandemic, and its policies enjoyed high levels of public support.

Like the United States, Germany has a federalist political system: in addition to the central government, there are sixteen regional governments and hundreds of public-health offices. But, unlike in the U.S., decentralization didn’t prevent the country from mounting a coördinated early response. Angela Merkel, who used to be a quantum chemist, regularly met with regional governors to develop and announce COVID-19 regulations; she has consistently employed science-based messaging in press conferences, interviews, and her weekly podcast. “She’s very effective at helping people understand what’s going on,” Kavadias said. “When she explained this R thing”—R-naught, the virus’s reproduction number, a marker of how many people an average infected person infects—“it was, like, ‘Wow, this is the first time I understand what this means.’ That was really powerful.” Scientists like Christian Drosten, a Berlin-based virologist, have become among the most trusted voices in the pandemic; Drosten’s podcast, “Das Coronavirus-Update,” has millions of listeners.

As the pandemic began, Germany benefitted from unparalleled execution of the fundamentals: clear communication, widespread testing, and robust contact tracing. Germany’s strategy has been to make a team of five contact tracers available for every twenty thousand citizens, and the system includes thousands of German soldiers who can provide urgent backup when needed. A government app sends COVID-19 alerts and monitors users’ potential coronavirus exposures; officials estimate that it’s used by at least sixteen million people—about a fifth of the German population. Given Germany’s past history with surveillance, the app’s adoption was not without controversy: after some early debate, developers opted not to collect GPS data, which tracks location and can leak user-identifying details, but to employ a Bluetooth system that registers only whether, and for how long, a person has been in close proximity with someone who has tests positive for the coronavirus. (If the other person has the app, too, the two phones exchange encrypted codes; if either of them later changes his status to virus-positive, the other gets notified.) Rather than send these details to a central server, the app stores them on individuals’ cell phones only, and for a limited time. The Chaos Computer Club, the largest European association of hackers, has praised the app as posing a relatively low risk for user privacy.

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Germany’s health-care system—with universal insurance coverage, easy access to primary care, and an excess of I.C.U. beds—was also well positioned to meet the challenges of the pandemic. Last spring, the government increased capacity further by paying hospitals five hundred and sixty euros for every bed they kept unoccupied for a possible COVID-19 case; it offered fifty thousand euros for each additional I.C.U. bed they created. Germany wound up with so much capacity that, in May, it was caring for COVID-19 patients flown in from other countries.

More recently, however, the country’s trajectory has changed for the worse. When Kavadias and I spoke, in the fall, Germany was experiencing its largest rise in COVID cases since the pandemic had begun: daily numbers had tripled in the first two weeks of October. Berlin instituted a curfew, and Kavadias’s bar had to close at eleven each night. Still, compared to other European nations, Germany—perhaps lulled into complacency—took a softer approach as the second wave hit. Whereas France, Spain, and other countries introduced stringent restrictions similar to those of the spring, Germany opted for “lockdown light,” which permitted non-essential businesses to remain open. Perhaps because the country had experienced one of the lowest COVID-19 death rates in the world, some two-fifths of Germans believed it unlikely or extremely unlikely they would be infected with the virus, despite soaring case rates. In November, Merkel said that she hoped for a seventy-five-per-cent reduction in social interactions through the “light” approach; the real decline was about half that. Since then, Germany’s COVID death toll has skyrocketed. “Lockdown light” was originally supposed to lapse in late November, but the unrelenting surge prompted tighter restrictions over the holidays. Facing an increasingly strained health system and a new, more contagious variant of the coronavirus, Germany’s health minister has said that they will continue. The country’s hospitals, which once welcomed COVID-19 patients from neighboring nations, are now coping with tens of thousands of Germans.

Over the next week, Zillo’s condition worsened. His fever soared; he couldn’t taste food; he developed a cough and severe back pain and had trouble catching his breath. By the time he made it to a local hospital, where his COVID-19 diagnosis was finally confirmed, his oxygen levels were so low that doctors considered admitting him directly to the I.C.U. Through labored breaths, he called a friend, Leandro Rubio Faria, a physician at a large hospital in São Paulo, the epicenter of Brazil’s COVID-19 pandemic. Faria had him transferred into his care. In São Paulo, Zillo was found to have a large blood clot in the lungs—a common and serious complication—and doctors started him on oxygen and a blood-thinning medication. After seven days in the hospital, he was stable enough to be discharged. When I spoke to him, more than three months after his initial symptoms, he told me that he still grew short of breath with light activity. “I would say my lungs are about eighty, eighty-five per cent,” he said. “I thought only people who are older or overweight got really sick with COVID. I never thought I would be in this position.” Since his diagnosis, Zillo’s mother, his brother, and his business partner also tested positive for the virus; his uncle died of it.

Faria, who treated Zillo, has lately been seeing patients through Missão Covid, a telemedicine nonprofit he started at the beginning of the pandemic. In March and April, Faria, who practices as an interventional cardiologist, saw his practice shrink by eighty per cent, as non-emergency procedures were cancelled or postponed. As COVID-19 spread across Brazil, he started Missão Covid with a colleague. Initially, he would see patients through Instagram, using the app’s video-call feature. Soon, a whole team of volunteers came together to build a Web site, and doctors across the country agreed to offer appointments for free. The number of patients they saw expanded rapidly—evidence both of Brazil’s growing COVID-19 caseload and of the large and unmet need for medical attention among the infected. Missão Covid’s network now includes more than fourteen hundred doctors, and the organization has cared for almost ninety thousand Brazilians, many in rural areas with limited access to care.

Like Donald Trump, Jair Bolsonaro, Brazil’s President, has led a pandemic response rife with minimization and misinformation. He has called the virus “a little flu” and a “measly cold.” He has ignored and attacked scientists, and openly feuded with his own health ministry, forcing it through two changes of leadership in one month. (One health minister was fired, the other resigned.) He resisted economic lockdowns, saying that the virus does not justify them and that staying home during the pandemic is “for the weak.” In July, Bolsonaro revealed that he had tested positive for the virus; he removed his mask while addressing reporters and then posted a video of himself taking a dose of hydroxychloroquine, the anti-malaria drug disproved as an effective treatment for COVID-19. (One of Bolsonaro’s initiatives involved using workers from the Brazilian Army’s laboratory to increase production of the discredited drug.)

Brazil has more than eight million COVID cases—more than France, Italy, and the United Kingdom combined—and has suffered more than two hundred thousand COVID-19 deaths. (This total, likely an undercount, is second only to that of the United States.) The virus has spread so relentlessly in places like Manaus, the capital of Amazonas, that it’s running out of people to infect: the local population may be approaching herd immunity. (As many as one in every five hundred Manaus residents could die of COVID-19.) Meanwhile, Brazil’s economy shrank by nearly ten per cent in the second quarter of 2020. This failure wasn’t inevitable: Brazil is thought to have mounted among the most creative and effective responses to previous public-health crises, including outbreaks of H.I.V. and Zika. The country has universal health care and a robust system of community-health workers capable of delivering primary care in remote regions. But, through his rhetoric and his actions, Bolsonaro undermined state and local governments’ efforts to combat the virus. The lack of federal leadership has created a vacuum; philanthropic organizations and nonprofits, like Missão Covid, have tried to fill the void.

In late March, as the pandemic deepened, tourism ceased and Rwanda entered a near-complete lockdown. Munyakindi’s travel company told him that his services were no longer needed. He lives in Kanombe, a suburb of Kigali, a few miles from the airport. He has a wife and eight children, although “only seven are on my payroll,” he said—his eldest daughter has married. “It’s a whole tribe,” he told me. “It’s also the reason I lost all my hair.” Since finding himself jobless, Munyakindi has experimented with various schemes to feed and support his family. “I’m doing the best I can, but it’s not easy,” he said. On some days, he travels to the Rwandan countryside to buy fresh fruits and vegetables, then returns to Kigali to sell them in a small grocery store he rents near his house. He’s also trying his hand at husbandry; he now has ten chickens, which produce enough eggs to feed his family, and sometimes enough to sell. His most promising enterprise is a group of pigs, which reproduce rapidly and fetch good prices from local butchers. “Pigs can really make money very quickly,” he said.

Munyakindi has a remarkably upbeat attitude given his circumstances, a resilience borne of the unthinkable tragedy he’s experienced. His family members were among the hundreds of thousands of Rwandans killed in the genocide. He was once one of ten children; during the genocide, both his parents, two of his brothers, and four of his sisters were murdered; his eldest sister was killed with her six young children. Only three of his siblings survived. Munyakindi, who was thirty at the time, was living abroad, studying English literature at the University of Burundi during the genocide. When it ended, he returned home to learn the extent of his loss.

In December, Rwanda was one of only eight countries for which the European Union recommended lifting restrictions on incoming travel. With a population of nearly thirteen million people packed onto land the size of Vermont, it has seen just ten thousand cases and fewer than two hundred deaths. (Pennsylvania, with roughly the same population, routinely logged more than five thousand new cases a week this summer; since November, it has often seen five thousand to ten thousand a day.) Rwanda has been both praised and derided for its aggressive pandemic response. The country has an average per-capita income of around eight hundred and twenty dollars a year, but it has committed to identifying every COVID-19 case, and provides most testing and treatment for free. It also implemented one of the earliest and most stringent lockdowns in Africa. Cell-phone data suggest that, during the pandemic, Rwandans have been some of the most physically distanced people on the continent. “At the beginning of the pandemic, you couldn’t move,” Munyakindi said. “There was police everywhere. You had to have a very good reason to go anywhere and you had to be able to prove it. It was really tough.”

Rwandans are asked if they want to be tested while walking down the street or stopped at intersections. The process, including completing paperwork and collecting the sample, takes a few minutes. Refusal is permitted but discouraged. “You can say, Well, no, I don’t want to,” Munyakindi told me. “But you also think, Maybe I’ll be tracked if I don’t do this. I haven’t seen anyone refusing. If they ask, you take the test.” Those who test positive are isolated at a COVID-19 clinic; close contacts are told to quarantine, at a clinic or at home. To make efficient use of limited resources, Rwanda uses “pool testing”—a process by which two dozen samples might be combined into one vial and tested. If the machine doesn’t find the virus’s genetic material, everyone is cleared. If the virus is detected, each swab is run independently to determine who’s infected.

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Rwanda relies heavily on the public-health infrastructure it developed for H.I.V., leveraging the labs, machines, monitoring systems, and community-health workers it mobilized for that fight. The country’s public-health apparatus is extensive. Drones fly overhead, blaring health messages and recording activity that might be used by authorities to identify areas where guidance is not being followed. The country has sometimes had a strict 7 P.M. curfew: those caught outside have been taken to stadiums, where they spend the night listening to coronavirus-prevention lessons played over a loudspeaker. In late July and early August alone, more than seventy thousand people were arrested for violating the curfew, failing to wear masks, and other public-health infractions. “It’s very serious,” Munyakindi said. “The measures have been military-style. But life is getting better. I haven’t heard of any deaths recently.”

One afternoon in October, she left the office with three co-workers for lunch at a nearby Chinese restaurant. Each of them checked in with a QR code, which logged their names and phone numbers, should health officials need to contact them later about the virus. In the evening, after work, she dined with a friend at a tiny bar across town, again checking in electronically, then made her way back home.

One day at work, she noticed that, down the street, a tent had been set up outside a large office building. “It was like a pop-up store,” Kim said. More than a dozen COVID cases had been tied to the building; now everyone who entered or exited it was tested. Kim doesn’t know anyone who’s had COVID-19, or anyone who knows anyone who’s had it. “Maybe I don’t have enough friends,” she said. But this circumstance is not unusual: when we spoke, her district of nearly half a million people had recorded fewer than two hundred and twenty cases.

South Korea’s economy is estimated to have shrunk by just over one per cent in 2020—the smallest decline among countries in the Organisation for Economic Co-operation and Development. In its pandemic response, it has surely benefitted from its experience with MERS, in 2015, after which the government assumed more expansive disease-surveillance capabilities; it also has a relatively unified system of government and high levels of institutional trust. But much of the country’s early success has to do with the nuts and bolts of public health: its system for testing, tracing, and isolation. In South Korea, coronavirus testing is free. Anyone who wants a test can call a hotline, which directs callers to a local public-health center, and most people get their results the next day, if not sooner. Those who test positive, regardless of symptom severity, are isolated in a hospital or a government-run dormitory. Treatment for COVID-19 patients, even foreigners, is also free. The most remarkable aspect of the response may be its sophisticated use of digital contact tracing. When a new case is identified, officials send text alerts to area residents. For much of the pandemic, the alerts included details about the infected person’s age, sex, and employer, as well as lists of places they’d visited in the past few days. (Eventually, out of concern for privacy, the details were scaled back.)

Some weeks, Kim receives daily alerts from her district’s health department; at other times, she might get one or two a week. On October 7th, she received Message 129, in which district officials shared details about an infected person’s recent activity. The message explained that it wasn’t known how Patient 207 had become sick; he had worn a mask at every recent destination. On September 28th, between 12:55 P.M. and 2:06 P.M., he’d eaten at a Thai restaurant called Tamarind; on October 2nd, between 5:54 P.M. and 7:39 P.M., he was at the J. W. Marriott. On October 3rd, he’d visited a local golf club, and on October 6th he’d eaten at Burger King. The next day, he tested positive for the coronavirus and was transferred to a care center. Every establishment he visited was notified and cleaned, the message explained. During this time, he’d had close contact with five individuals; two later tested positive for coronavirus, becoming Patients 208 and 209. “It can feel intrusive,” Kim said, “and some people aren’t happy with this or that. But this is how we’ve kept cases and deaths so low.”

When Kim and I spoke, in mid-October, South Korea, a nation of more than fifty-one million people, had recorded fewer than five hundred COVID-19 deaths. “Of course, five hundred is still too many,” Kim said. I agreed, but noted that, during the same period, nearly a quarter of a million Americans had died. Since then, South Korea has experienced a steep late-year spike of cases. New restrictions have been imposed on gatherings and social functions; clinics in Seoul have grown crowded, and many professionals have switched to working from home full time. By mid-January, the country’s death toll had passed twelve hundred. The toll in the United States was approaching four hundred thousand.

The new coronavirus vaccines represent another opportunity for governments to prove themselves or fail. Like the pandemic, vaccines will have an effect that falls unevenly on people across the world; in different places, they’ll confer protection and usher a return to normality at different times and to differing degrees. Governments will rush to produce, procure, and distribute the vaccines in needed quantities; many will struggle, and that will lead to its own set of inequities and inefficiencies.

However it turns out, the virus will cast a long shadow: families broken; businesses shuttered; children left untaught. Years from now, after the headlines and statistics have faded from our minds, it’s these stories that will be our bridge to this time. What it was like to be infected or susceptible, to be trapped at home or stranded far from it, to lose a livelihood or a loved one. Isolation, loss, grief, death, hope, healing, and perseverance. Individuals coping with an event far bigger than themselves. Humanity grappling with the deadliest pandemic in a century.

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