As Covid-19 has spread around the world, it's challenged preconceptions about which places would best tackle the worst public health crisis in a generation.
Advanced economies like the US and UK, ranked by various pre-2020 measures as being the most prepared for a pandemic, have been repeatedly overwhelmed by infections and face a return to costly lockdowns. Meanwhile, other countries—even developing nations—have defied expectations, some all but eliminating the pathogen within their borders.
Bloomberg crunched the numbers to determine the best places to be in the coronavirus era: where has the virus been handled most effectively with the least amount of disruption to business and society?
The Covid Resilience Ranking scores economies of more than $200 billion on 10 key metrics: from growth in virus cases to the overall mortality rate, testing capabilities and the vaccine supply agreements places have forged. The capacity of the local health-care system, the impact of virus-related restrictions like lockdowns on the economy, and citizens' freedom of movement are also taken into account.
The result is an overall score that's a snapshot of how the pandemic is playing out in these 53 places right now. By ranking their access to a coronavirus vaccine, we also provide a window into how these economies' fortunes may shift in the future. It's not a final verdict, nor could it ever be with imperfections in virus data and the fast pace of this crisis, which has seen subsequent waves confound places that handled things well the first time around. Circumstance and pure luck also play a role, but are hard to quantify.
The Ranking will change as countries switch up their strategies, the weather shifts and the race intensifies for a viable inoculation. Still, the gap that has opened up between those economies at the top and those at the bottom is likely to endure, with potentially lasting consequences in the post-Covid world.
New Zealand tops the Ranking as of Nov. 23 thanks to decisive, swift action. The small island nation locked down on March 26 before a single Covid-related death had occurred, shutting its borders despite the economy's heavy reliance on tourism. Early on, Prime Minister Jacinda Ardern's government said it would target "elimination" of the virus, pouring resources into testing, contact tracing and a centralized quarantine strategy to snuff out local transmission. Having largely achieved it, New Zealanders are basically living in a world without Covid. The nation has seen just a handful of infections in the community in recent months, and live music and large-scale social events are back on. Though its tourism industries are suffering, New Zealand is also well-positioned for a vaccine with two supply deals in place, including one for the shot developed by Pfizer Inc. and Germany's BioNTech SE.
In second place is Japan, which charted a different path. It lacks legal means to enforce a lockdown, but other strengths emerged quickly. Due to tuberculosis outbreaks in the past, the country has maintained a public health center system staffed with contact tracers who were quickly redeployed on Covid-19. High levels of social trust and compliance meant citizens pro-actively wore masks and avoided crowded places. Although it's now seeing a record uptick in infections as winter looms, the nation of more than 120 million people has just 331 serious cases of Covid-19 currently; France, with a population half the size, has nearly 5,000 virus patients in intensive care. Japan's ability to avoid fatalities despite having the oldest population in the world propelled it higher, as did its foresight in sewing up four vaccine deals—including both frontrunner candidates that use the revolutionary mRNA technology.
Third-place Taiwan's success is all the more remarkable considering its linkages to mainland China, where the virus first emerged last December. Whisper networks conveying worrying news from Wuhan allowed Taiwan to act early in restricting entry at its borders. The island then pioneered a tech-focused approach to rallying its 23 million people to protect themselves: launching apps that detail where masks are in stock or list locations where infected people visited. It's gone more than 200 days without a locally transmitted virus case and much like New Zealand, life has largely reverted to normal, though borders remain shut. Taiwan has so far, however, failed to ink any bilateral deals for the most progressed vaccines.
Many in the top 10 pioneered and modeled what have emerged as the most effective strategies for fighting Covid-19. Border control has been a key element, starting with China's original cordon sanitaire around Hubei province, which largely shielded the rest of the country from infection. The economy where this crisis began is the biggest of the top performers, with mass testing deployed at the first sign of new cases and a mandatory 14-day quarantine for travelers. China's propensity to impose aggressive lockdowns on regions where medical or tracing resources are scarce is one downside.
The three Nordic nations in the top 10 reflect how border control has been used effectively in Europe. Finland and Norway have blocked entry to most outsiders since mid-March, though they're part of Europe's passport-free Schengen area. The top-ranked European nations managed to avoid the resurgence now engulfing countries like France, the UK and Italy caused in part by summer vacation travel.
Effective testing and tracing is a hallmark of almost all the top 10, embodied in South Korea's approach. The country approved home-grown diagnostic kits within weeks of the virus's emergence, pioneered drive-through testing stations and has an army of lightning-fast contact tracers who comb through credit card records and surveillance camera footage to track down clusters. Like Japan, Pakistan and other parts of Asia, Korea has drawn on recent epidemic experience after suffering an outbreak of Middle East Respiratory Syndrome, or MERS, in 2015.
The experience of the SARS outbreak of 2003—which involved a similar coronavirus—helped East and Southeast Asia this time around, said Helen Clark, who was prime minister of New Zealand at the time.
"They had plans and they knew about contact tracing and isolation and so on," she said in an interview. "That experience was seared in their memories."
The Magic Formula?
The under-performance of some of the world's most prominent democracies including the US, UK and India contrasted with the success of authoritarian countries like China and Vietnam has raised questions over whether democratic societies are cut out for tackling pandemics.
Bloomberg's Covid Resilience Ranking tells a different story: eight of the top 10 are democracies. Success in containing Covid-19 with the least disruption appears to rely less on being able to order people into submission, but on governments engendering a high degree of trust and societal compliance.
When citizens have faith in the authorities and their guidance, lockdowns may not be needed at all, as Japan, Korea—and to an extent, Sweden—show. New Zealand emphasized communication from the start, with a four-level alert system that gave people a clear picture of how and why the government would act as the outbreak evolved.
Investment in public health infrastructure also matters. Undervalued in many places before 2020, systems for contact tracing, effective testing and health education bolstered the top performers, helping socialize hand-washing and the wearing of face masks. This has been key to avoiding economically crippling lockdowns, said Anthony Fauci, the US's top infectious diseases official.
Social cohesion has been a major differentiating factor in this pandemic, said Alan Lopez, a laureate professor and director of the University of Melbourne's global burden of disease group.
"If you look at Japanese society, the Scandinavian societies, there's very little inequality and a lot of discipline in them," said Lopez. "That would translate into a more cohesive response by the country and that's why they're up there at the top."
US Vaccine Advantage
The lack of an effective response to the virus by the US has been one of the most stunning developments of the pandemic. The superpower leads the world in cases and deaths, and its reaction to the crisis has lagged from the start, from a shortage of medical equipment and PPE supplies, to the absence of coordination on testing and tracing efforts and the politicization of mask-wearing.
The administration of outgoing President Donald Trump has instead focused primarily on treatments and vaccines. Some $18 billion was allocated to vaccine developers to speed up their work in an initiative known as Operation Warp Speed, even as states asked for funding help to face the crisis.
This singular focus boosted the US in Bloomberg's Ranking—the swelling case load and rising deaths mean it would be 11 rungs lower otherwise. The extraordinary efficacy of the experimental mRNA vaccines, which could be authorized for emergency use in the US as early as next month, may mark a turning point there.
While a few other places also have agreements with as many vaccines, the US has ordered the most doses in the world—over 2.6 billion—according to potential and finalized supply agreements tracked by researchers from the Duke Global Health Innovation Center. Still, monumental challenges in distributing vaccines across the nation remain.
"In the case of the US, the only thing they've done well is they funded more R&D, not just for US-based companies, but for companies around the world, including a lot of these European constructs," Bill Gates said at Bloomberg's New Economy Forum this month. "That was a good thing. That was a favor to the world. The rest of it, the US is sort of at the back of the pack."
Canada is also bolstered by its vaccine focus, signing supply deals with five different shots in final stage testing, and securing enough doses for many times its population. The European Union—which is forging vaccine deals as a bloc—has three finalized deals.
China also scores highly on vaccine access, though its agreements are largely with its own local developers, which have provided comparatively less insight into their shots' efficacy than some western companies. In the battle of the superpowers, China has all but eliminated the virus within its borders, but scores lower than the US on the pre-pandemic Universal Healthcare Coverage indicator, which measures the effectiveness of a health-care system.
Overall, the Access to Covid Vaccines indicator reflects the enduring power of rich, big nations, even if some have otherwise failed at containing the virus. Smaller, developing economies that have scored deals have largely done so by offering to host clinical trials and vaccine manufacturing.
"Big countries have made sure they are the first in the queue, sometimes by extremely comprehensive measures," Singapore Prime Minister Lee Hsien Loong said at the Bloomberg NEF this month. "I can understand that political urgency. I think it is a reality that they will get some of their way."
Outliers and Surprises
Bloomberg's Covid Resilience Ranking exposes some uncomfortable truths for nations once considered the most advanced in the world. As of Nov. 23, major European countries like the UK and France rank in the bottom half of the list.
Connectedness has emerged as a curse in the Covid era, with global travel hubs and world cities like London, New York and Paris becoming epicenters where infections were first seeded by travelers from elsewhere. Places like Thailand and Singapore that count on travel and tourism have seen greater blows to their economies.
In contrast, developing countries like Pakistan and Bangladesh have benefited from their relative remoteness. Their populations are also much younger on average, which has helped hold down their overall mortality rates. Limited testing and poor-quality data obscures the picture in these places, though under-reporting of cases and deaths is occuring everywhere.
Western Europe is now in the throes of a ferocious wave that's forced governments to impose new lockdowns. The containment achieved in the spring was undone by the easing of restrictions, allowing the virus to be seeded again by summer vacationers.
Belgium has the worst overall mortality rate of the 53 economies after the virus ripped through aged-care homes. This position is a product of Belgium's decision to record all nursing home deaths at the height of the first outbreak as Covid-19-related, even without an official diagnosis through testing.
The UK, Italy and France have all seen cases and fatalities soar over recent months, with France's stricter lockdown pushing it down in the Ranking. France's positive test rate rose to more than 20% at the start of November from around 1% in July. After imposing a new lockdown on Oct. 30, the rate has fallen to below 12% as of Nov. 23.
Pilloried initially for eschewing lockdowns, Sweden is now scored relatively highly on nearly all of Bloomberg's metrics, ranking 16th overall. After an initial wave of deaths among older people, Sweden's performance on the indicators reflect fewer cases, fatalities and less disruption than other parts of Europe.
A less disruptive approach is more sustainable in the long run, said Hitoshi Oshitani, a professor of infectious diseases at Tohoku University and the key architect of such a strategy in Japan.
"I don't think this virus will go away in the coming months, and probably the coming years, so we have to find the best way to live with it," Oshitani said in an interview.
The Poverty Trap
While they may have been wrong-footed by the insidious nature of the virus, advanced economies like the US and Germany have seen their testing capacity and doctors' ability to prevent Covid deaths improve over time.
These advantages don't exist in Latin America, the region most devastated by the pandemic. It populates the bottom half of the Ranking, with Mexico faring the worst of the 53. The nation's latest available positive test rate is a whopping 62%, suggesting undetected infection is widespread. Mexican officials have acknowledged that the country's death toll is likely significantly higher than official data, due to limited testing.
Brazil—home to the world's third-largest outbreak after India—ranks 37th.
Like Trump, Brazilian President Jair Bolsonaro and Mexico's Andres Manuel Lopez Obrador have repeatedly downplayed the coronavirus threat.
This "cavalier" leadership approach, plus a lack of social safety nets and strong public health systems, has worsened the crisis, said Cynthia Arnson, Latin American Program director at Washington D.C. think-tank the Wilson Center.
Latin America is the most urbanized region in the world, and much of the population live in crowded conditions where social distancing is difficult. The high proportion of people who rely on informal work and daily wages means that few are willing to stay home.
"The gross disparities between public and private health care have caught up with the region, as have other forms of inequality, including in education," Arnson said.
Most countries in Latin America will be unable to return to pre-pandemic growth levels until 2023 and per capita income won't recover until 2025, later than anywhere else, said the International Monetary Fund.
Though attention has focused on the upheaval in developed countries, the pandemic's hit to emerging economies is likely to be longer and more sustained. In India, decades of social and economic progress has been wiped out as children are taken out of school to work, and the discriminatory caste system rears its head again as jobs become scarce in the cities.
The pandemic will widen the gap between rich and poor nations, with as many as 150 million people pushed into extreme poverty by the end of next year. This will put progress in poverty reduction back by three years, according to the World Bank.
In places like Sub-Saharan Africa, the crisis has a long tail.
"We're seeing in Africa there's a lot more deaths from the interruption of primary health care, including vaccination. That's created a bigger toll than actually the coronavirus itself has," said Bill Gates, who also pointed to disruption in education as a major setback.
"We need to build back in those countries and we need to get the innovation back underway. It's, I would say, at least a three or four year setback for Africa."
Winter, vaccines, virus mutation: the outlook for the pandemic remains uncertain into 2021 and beyond. Still, having endured a year of fighting Covid-19, governments and populations now have a better understanding of the pathogen, how best to curb its spread and mitigate the damage it inflicts.
As the data shifts over the coming months, Bloomberg's Covid Resilience Ranking will change too—we'll update the picture as it evolves.
Disclaimer: This article first appeared on bloomberg.com, and is published by special syndication arrangement.