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Asia is exercising an advantage over the "wild" West, remaining more cautious about reopening stores and restaurants amid the risk of additional novel coronavirus outbreaks. (Photo by Akira Kodaka)
The Big Story

Exits from coronavirus lockdown split 'wild' West from 'cautious' East

Economies are impatient to reopen. Experts say it will trigger a second wave of infections

STEVEN BOROWIEC, Contributing writer, and MICHELLE CHAN and PETER GUEST, Nikkei Asian Review staff writers | South Korea

SEOUL/HONG KONG/TOKYO -- Hanging on a guardrail along a walkway at Yangjae Stream, a large public park in southern Seoul, a massive banner politely asks locals to stay away. Earlier in the spring, the park was closed for weeks as South Korea struggled to rein in what once was the world's largest outbreak of the novel coronavirus outside of China.

It has since reopened, but visitors must wear masks. Takeout food, groundsheets and tents -- mainstays of park outings in South Korea -- are banned due to social distancing guidelines meant to prevent the spread of the coronavirus.

Despite South Korea enjoying a pleasantly cool spring with low levels of air pollution, the park was mostly empty on a recent weekday evening. Lee Su-na was out for a power walk. She said she feels comfortable coming to an open place like a park but still avoids restaurants and coffee shops. "Things are better, but I'm still worried," the 40-something Lee said. "We never know where some new infections could suddenly come up."

South Korea's handling of its COVID-19 epidemic was hailed as a model of a successful response. Widespread testing and contact tracing, social distancing measures and the mass mobilization of health care resources helped to bring new infections under control after an alarming spike in March -- and the country's death rate was low, with only around 270 deaths from more than 11,000 confirmed cases. At the height of South Korea's outbreak, local governments mandated that parks, libraries and schools be closed and religious services halted.

Social distancing is put into practice at Yeouido Park in central Seoul. (AFP/Jiji)

But South Korea has also demonstrated the risks in relaxing social distancing measures. On May 6, the country lifted some restrictions and gradually began returning students to school under what authorities are calling "everyday life quarantine." The country's popular baseball league has resumed games, albeit without spectators. Churches have been allowed to reopen on the condition that all entrants have their temperatures checked and sit at a safe distance from one another.

Days after bars were allowed to reopen, a cluster of cases emerged, linked to nightclubs in the Itaewon area of Seoul. Several dozen people were infected, and more than 35,000 had to be tested.

"We've seen exactly the same thing in Germany, in Singapore, and I think the reason is that they've opened up too quickly and too much," said Adrian Esterman, a professor of biostatistics at the University of South Australia. "It has to be done incredibly slowly, incredibly carefully. And these countries have not managed that well."

All across the world, countries are starting to emerge from lockdowns. Thailand and Vietnam are ending their restrictions; Singapore's "circuit breaker" will be relaxed on June 1. In Japan, a state of emergency was fully lifted on May 25. New Zealand and Australia are ratcheting down their alert levels. Some countries, including Taiwan, Thailand and New Zealand have had close to zero cases in recent weeks. Their successes stand in stark contrast to major Western economies, including the U.S., where the president is urging an end to social distancing measures even as the outbreak rages out of control.

However, South Korea's example shows how quickly the coronavirus that causes COVID-19 can snap back. Even in countries that responded well to the first wave of the disease, the return to normal will be difficult and dangerous.

"Locking down the economy was difficult and painful, but opening up is an exercise in micromanaging"

Antonio Fatas, professor of economics at Insead Business School, Singapore

"Locking down the economy was difficult and painful, but opening up is an exercise in micromanaging sectors, companies, individuals, government actions, health considerations, economic considerations," said Antonio Fatas, professor of economics at Insead Business School in Singapore. "If you do not defeat the health crisis, nothing can happen."

Delicate balance

In countries and cities that have begun to relax their restrictions, the sense of relief is palpable. In Hong Kong, 8-year-old Anson has never been so excited to get back into the classroom. Schools have been shut in the city since the first cases emerged in late January. "I'm most looking forward to the science class," he said. "There are many experiments that we can't do at home."

His mother, Angela, a single mother and an accountant, is fortunate in that she has been able to work from home, but juggling family and work has been difficult. Even now, many schools will only run for half a day or on alternate days. "It's not ideal, but at least we're seeing the light at the end of the tunnel," she said. "What worries me the most is if there are infections in schools ... even a small cluster, all of our previous efforts will go to waste."

Hong Kong was one of the first places outside of mainland China to experience an outbreak; it quickly imposed restrictions on sports facilities, schools, places of worship and many businesses. By May, new infections had largely been stamped out, and with zero new cases having been reported for most days over the previous two months, some of the new rules were relaxed.

Beachgoers crowd together on a Hong Kong beach in May after no new coronavirus cases were reported for two weeks.   © Reuters

Face masks are still compulsory in public premises, temperature checks are required before entering most buildings and restaurant tables are partitioned by plastic screens -- all reminders that the reopening does not mean everything is returning to normal overnight. Even so, seats were filling fast on a recent weekend in SoHo, a popular dining area in the central business district.

"Revenge spending is real. People here are dying to meet their friends and grab a nice drink just like what they did on usual Fridays," said Michael, who runs an Italian restaurant in SoHo. Revenue over the past weekend has already rebounded to 70% of pre-virus levels, he said.

Despite the promise of an economic rebound, he has shelved plans to open a new venue this year. "You don't know when the number [of infections] will go up again," he said. "The situation can flip-flop quickly these days."

Even for countries that have handled their domestic outbreaks successfully, deciding when to start loosening restrictions and in what stages is complex and fraught with risks.

The most common measure of whether the disease has been brought under control is the effective reproduction number, which is the number of secondary cases per infectious individual. An R of 2 means each infectious person spreads the disease to two others. An R number above 1 means that the outbreak is still growing. In New York, the worst-hit city in the U.S. by some distance, the R was as high as 8 at its peak, according to some estimates. Singapore peaked at around 4.5.

Lockdowns bring down the R by limiting the opportunities for infectious individuals to spread the disease. In the U.K., the belated imposition of social distancing measures brought the number down from 3.3 to 0.9 over the course of 25 days, according to modeling by Te Punaha Matatini, University of Auckland. Hong Kong's relatively strict lockdown contributed to reducing its R from 2 to 0.3 in less than two weeks. In South Korea, over 54 days of limited movement, the R fell from 3 to 0.7.

Getting the number to below 1 is an almost universally acknowledged prerequisite for reopening workplaces and relaxing social distancing requirements, there is wild variation around the world in what governments consider to be a safe R.

In New Zealand, which has been widely praised for its rapid and effective response to the outbreak, the government is moving slowly through stages of loosening its lockdown, one of the tightest in the world. The country's "Level 4" restrictions -- the highest on its scale -- meant shutting public venues, closing all but essential businesses, and instructing people to stay at home inside their "bubble" with only immediate family. Those were relaxed in late April after four weeks, once public health authorities were confident that community transmission had ceased. The next level down still required people to limit contact with anyone but their immediate family, allowed gatherings of up to 10 people for specific purposes and let some businesses, such as take-away food venues, reopen.

Banners of illustrated audience members replace people in the stands at a baseball stadium in Incheon, South Korea, in May.   © Reuters

Less than three weeks later, with its R at around 0.1, New Zealand moved to Level 2. Schools and businesses can reopen, but only if they follow strict social distancing guidelines. New Zealand's caution is based on a scientific understanding of the risk.

"It doesn't need a lot of people to start spreading this," said Arindam Basu, associate professor of epidemiology at the University of Canterbury. "The fact that we're not quite at zero [new cases] is not a comfortable situation. ... You can see that there is a distinct possibility that new clusters can form as the conditions are relaxed, even in New Zealand."

Basu pointed out that the country's decision to relax the measures is not just based on a threshold number of new cases, but on its assessment of its ability to detect and manage future clusters. The country has drastically increased its testing capacity and expanded contact tracing. "You can't control what you don't know," he said.

Testing times

The many unknowns around the coronavirus present huge public health challenges. It is still not clear how many people have been asymptomatic carriers of the virus, and the extent to which they spread it. There is also only limited evidence to determine how susceptible children are to catching and spreading infections.

"That means broadening testing," said Nic Geard, a senior lecturer at the University of Melbourne who specializes in infectious disease modeling. "That means doing some sentinel surveillance-type approaches, so rather than just testing on the basis of people presenting with symptoms, you're testing more widely across the population to find out how much infection there is in people who are not actually showing any signs of being unwell."

Countries that believe they have brought their epidemics under control can go backward quickly if outbreaks occur in a blind spot. This happened in Singapore, which had managed to keep community transmissions low and falling until the virus hit cramped and crowded migrant worker dormitories. Cases then spiked dramatically. From just over 200 cases recorded in mid-March, the city-state's epidemic exploded to more than 9,000 a month later.

Geard said governments need to develop "real-time situational awareness," and cannot rely on simple metrics to set thresholds for moving between levels. Macro-level numbers are easy to communicate to the public and help to show a direction of travel, but they are not enough to get a full picture of how the outbreak is developing.

In South Korea, the Korea Centers for Disease Control & Prevention operates a 24-hour emergency situation room to allow for "early detection" and "rapid response" to react quickly to suspected cases of infections, immediately locking down the area and testing everyone who could have come into contact with a carrier. The center also maintains reserve space for physical quarantine.

Widespread testing is another key facet. After the Itaewon infections were reported, the city government made tests available, anonymously and for free, near the outbreak. Some of the venues associated with the new outbreak were popular with the LGBT community, and anonymous testing was an acknowledgment that some people may have hesitated to come forward due to the stigma homosexuality still carries in the country.

"At this point, the government needs to use every means to track down any suspected carrier of the virus, have them tested and figure out anyone they could have contacted," said Seol Dai-wu, a professor at Chung-Ang University in Seoul. "It's also important for the government to make sure they can remain publicly anonymous, and for regular people not to blame them. That will just make them want to hide more."

The Itaewon cases have prompted a reassessment of the pacing of South Korea's return to normal. "What the government is doing is quite experimental," Kim Tae-hyong, a professor in the Department of Infectious Diseases at Soon Chun Hyang University Hospital. "At some moment, we need to be brave and open back up, but that time is probably not now.

"Before the Itaewon cases, it really seemed like it was the right time to open up. People were getting really tired and discouraged with the restrictions. ... We have to watch and see. Even I can't tell you whether this will work or not."

Exit, strategies

Even with the risks of prematurely reopening being so starkly demonstrated, some countries still experiencing infections are plotting their exit strategies.

In the U.K, the R edging below 1 was enough for the government to begin to loosen restrictions, already lax by global standards. In England, some people were told they could return to work, and some controls on movement were lifted, with Prime Minister Boris Johnson asking the population to "stay alert" and "use common sense." The U.K. has registered more than 250,000 COVID-19 cases and over 36,000 deaths, one of the highest mortality rates in the world.

In the U.S., the Centers for Disease Control and Prevention advises that states should consider beginning their staged reopening after 42 days of continuously declining cases. However, a White House advisory recommended a far shorter time scale and said "nonessential travel" would be able to begin after 28 days, with other activities resuming before that.

"We did the right thing, but now it's time to open it up," U.S. President Donald Trump said while touring a factory in Michigan on May 21. Many scientists dispute both of those assertions. Asked to assess the approach in the U.K. and U.S., one epidemiologist contacted by Nikkei Asian Review -- who asked not to be quoted directly -- swore creatively.

Migrant worker housing in Singapore: Living in dormitories with shared sanitary facilities, cases spiked in the city-state when lockdown forced these workers to stay home. Migrant worker dormitories in Singapore feature shared sanitary facilities. Coronavirus infections jumped in the city-state when lockdown measures forced residents to stay home.   © Reuters

The U.S. crisis has been and remains several orders of magnitude greater in scale than those in most countries in Asia, with the exception of China. On May 20, the U.S. reported 22,368 newly identified cases.

By comparison, that same day, Japan reported 39 new cases, which was not considered sufficient to lift the state of emergency in several regions.

The absolute number of new daily cases in the U.S. has fallen, but that is partly because the largest localized outbreak in the country, in New York, is now under control. However, that has little to no bearing on other places, such as Wisconsin, which has allowed businesses to reopen despite rising case numbers. Epidemiologists told Nikkei that these unstructured exits from social distancing are highly likely to result in new outbreaks.

The political drivers for a more rapid opening of the economy are clear. The U.S. is spiraling into an unemployment crisis. Jobless claims have hit almost 39 million since the crisis began, a disastrous figure in an election year.

"Rushing into reopening dangles immediate benefits in front of the eyes of [people] who are impatient," said Patrick Reinmoeller, a professor at IMD Business School. "The idea of an immediate reopening is associated with the illusion of an immediate bounce back ... shops open, sales up, shares up, votes in."

However, economists say the choice -- either keep deaths and economic activity low or accept more deaths and economic activity -- is a false dichotomy. A public health crisis, they say, costs an economy far more than lockdowns and supporting furloughed workers and struggling businesses.

In May, two economists, Richard Holden from the University of New South Wales and Bruce Preston from the University of Melbourne, did some grim algebra. They estimated that a lockdown would cost Australia around 90 billion Australian dollars ($59 billion), while the cost of an unchecked outbreak would have been more than AU$1 trillion. Although the figures will differ from country to country, the same logic applies.

"If the reproduction rate of the virus is above 1, then it's growing exponentially, it's out of control. And then there really isn't a trade-off," Holden said.

An unchecked second wave would profoundly impact economies that are already reeling and mean that disruptions to lives and livelihoods last for much longer.

"It might be the wrong conclusion," Insead's Fatas said. "It might be that we switch to a world where we are afraid of something which is not there. But if a second wave was large, I think psychologically, it would create an inertia and a persistence of the memory of this virus that would change the way we work. I wouldn't say forever. Nothing is forever. But for years, not just for months."

Fatas and Reinmoeller say governments will have to learn to do things that run counter to their instincts. They will have to let debt rise, have difficult conversations about how to tax wealth and how to support workers. They will also need to stop trying to find easy answers to a crisis that offers few. Countries racing to get out of lockdown for short-term economic advantage need to understand that the post-pandemic world will not reward who can get businesses open first, but who can do so with demonstrable competence and humanity.

"This is what is starting to emerge: The East is cautious, and the West is wild," Reinmoeller said. "The different pace in stepping out of the lockdown could give rise to two different economic areas: the 6-feet-distance economy where safety comes first, and the 'safety third' economic areas."

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