Case Study - COVID

Travica COVID-19 Containment Strategies

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Containment Strategies for COVID-19 Pandemic

Bob Travica

University of Manitoba, Canada

[email protected]

(NOTE: Under review for publication)

Abstract

The exploratory study reported here investigated the manner in which different countries have responded

to the COVID-19 pandemic caused by the largely unknown and dangerous virus SARS-CoV-2. Based on

studying still limited and evolving evidence, a model of pandemic containment strategy was created. In an

initial validation, the model was able to differentiate between three strategies of containing COVID-19 –

Restrictive, Permissive, and Hybrid. The article frames a pandemic containment strategy as a mediator

between pandemic causes and consequences, along with a capability of the health system and a

government's response time. Cultural assumptions behind different strategies are also discussed.

Implications for further research and for practice are outlined.

Keywords: COVID-19, pandemic containment strategy, pandemic decisions support systems, pandemic

management, health informatics

1. Introduction

In December 2019, a new respiratory disease was detected in Wuhan, the capital of province Hubei in

China. Laboratory analysis discovered a new virus akin to SARS (Severe Acute Respiratory Syndrome).

Soon after, the new disease spread to other parts of China, neighboring countries and beyond. In the last

week of January, the Chinese federal government declared the state of national emergency, quarantined

Wuhan, and imposed elaborate restrictions on surrounding cities and across the country. The traffic,

business, and freedom of movement were all severely limited, while the infected persons were traced and

quarantined.

The new SARS-CoV-2 virus and the disease it causes COVID-19 (Corona Virus Disease of 2019)

generated an international health crisis. On March 11, 2020, WHO declared a COVID-19 pandemic. At

the moment of this writing in early May, over 3.7 million people around the world are affected by the

pandemic and the case fatality is around 7%. Figure 1 illustrates a dramatic escalation of the pandemic

between February 29 and April 5, 2020 in the select countries explored in this study. In the UK for

instance, there were 23 cases of infection on February 29 and 196,000 on April 5, with the case fatality

rate of 15% or 433 per 1 million inhabitants. (The correlation between the two fatality measures in the

sample is 0.92).

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Medical science does not know much about SARS-CoV-2. It matches by 95% the genome of the SARS

virus that caused the 2002-2004 epidemic with 7-15% case fatality. SARS-CoV-2 spreads human-to-

human with the reproduction number of 2.3 (one person infects 2-3 persons). This high transmissibility is

due to a high viral load early in the illness (Chen & Li, 2020). The pathogen is airborne and survives

outside a host on hard surfaces for up to 72 hours (van Doremalen et al., 2020). It attacks lungs and

mostly men over 65 years of age. Still, other organs may be affected and there is variation regarding age

groups across countries. Assessments of the COVID-19 severity based on Chinese samples suggest that

80% of cases get mild symptoms, 15% require medical help, and 5% end up in intensive care and possibly

die. (Wu & McGoogan, 2020) The death rate in the infected population is predicted to be between 0.2%-

0.8% (Marteen, 2020; Sanders, 2020). The prospective evolution of SARS-CoV-2 is uncertain.

Figure 1. The Escalation of COVID-19 in March-April 2020

(CFR= Case Fatality Rate, k=1,000, m=million; source: Johns Hopkins University dashboard,

www.worldometers.info/coronavirus/)

The sessional influenza (flu) was confused with COVID-19 by authorities as well as laypersons around

the world. However, the flu poses roughly 50% less danger than COVID-19 across different indicators

and can be prevented by vaccination. Granted, the COVID-19-caused mortality is still about 30,000

below the flu range of 291,000-646,000 deaths per season (Bean et al., 1982; CDC, 2017; WHO, 2020).

The speed of this virus' transmission is puzzling. A home party of 50 in a small Connecticut town became

a source of infection reaching even South Africa (Williamson & Hussey, 2020). Similarly, a business

meeting in Singapore generated a cluster that reproduced several overseas off-shoots (Figure 2).

Extensive mixing of people through business and tourism in the globalization era could have contributed

to Italy's severe outbreak (BBC, 2019; Xinhuna, 2020).

These alarming facts define one side of the COVID-19 pandemic as a research problem. The other side is

in the responses of the government and health authorities globally. These have been all but orderly or

coordinated. A delayed response marked the crisis start in China (Lai et al., 2020). In contrast, few

neighboring countries promptly activated defenses developed in previous epidemics (Ahn, 2020; BBC/a,

2020; Chang, 2020; Choudhury, 2020; Kupferschmidt & Cohen, 2020). However, a response delay then

became a rule in the westward lineup of countries. The authorities appeared passive, underestimating the

threat to public health and failing to prepare health systems. Instated of safeguarding the public, some

high visibility officials themselves fell victim to the disease (AFP/The Local, 2020; Goldberg, 2020). As

the patient volume ballooned, the health systems stalled and the authorities rushed to fire-fighting.

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Appeals for staying at home, washing hands, and helping in "flattening the curve" filled public discourse

(Krans, 2020). The World Health Organization (WHO) contributed to the confusion for it could not

determine until the last week in January whether the human-to-human transmission was possible.

Moreover, intending to avoid panicking, the WHO did not call the virus "SARS" (WHO/a, 2020). This

move could have dulled the alarm and bolstered the threat deniers.

Figure 2. Example of COVID-19 Clusters Creation

(Source: Lew at al., 2020)

Bewildering variety of new policies have emerged. These range from declaring the state of national

emergency in Spain (Harris, 2020) to confronting the pandemic with special measures while,

paradoxically, taking SARS-CoV-2 off the list of high consequence infectious disease in the UK

(www.gov.uk). Borders closing and mandated quarantining have been deployed as well as plain advises

on staying at home and self-isolating, enforced by financial fines or by nothing at all. Wearing non-

medical facial masks has been mandatory in some states, while in others even the professionals that

directly face the public remained free to choose (provided they could purchase masks in the first place).

This confusing, complex situation triggers a question: Are there any patterns in this variety of efforts at

containing the COVID-19 pandemic? This question adds to the uncertainty of the COVID-19 pandemic

and its viral cause to frame the research problem of this exploratory study. Its purpose is to contribute to

research that may help understand strategies in containing this pandemic.

2. Literature Background

Due to the novelty of the phenomenon and lacking evidence, the literature on the pandemic is used

throughout the article rather than discussed in a single section. The exception is the information systems

(IS) literature that is addressed in this section. The focus is on health informatics research that emerged in

this century with links to medical and computer sciences. Mettler and colleagues (2012) proposed a

framework for health informatics research. Two of their directions are relevant for this study - ICT for

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epidemiology and decision support systems (DSS) in the health sector. The ICT for epidemiology that is

of interest refers to various digital technologies used for monitoring citizens' health and behavior. For

example, mobile telephones have been used in Canada for voluntary self-monitoring of citizens health

(Thrive Health, 2020). Asian countries have used smartphones with more force. In China, monitoring the

health state is mandatory (Ghaffary, 2020). A government-issued QR (Quick Response) code is stored on

the phone and it can be scanned by authorized personnel in public transport, shopping malls and other

mass public places in order to read the health status from an official database. The status is indicated by

colors of traffic lights (green for healthy, red sick, yellow for uncertain). This software is operationally

linked to two massively used e-payment systems, AliPay and WeChat Pay, which effectively serve as

credit card systems in China.

Hong Kong mandated wearing a wristband that alarms authorities when a quarantined person leaves the

home. In South Korea, the government broadcasts texting alerts citing the locations and physical

characteristics (without names) of the infected people moving in a particular geographical zone (Ghaffary,

2020). Moreover, street and building cameras/CCTV systems, and drones have been used in several

countries for ensuring that citizens respect the quarantine and safety regulations (mask wearing, social

distancing).

ICT have also been deployed for contact tracing that proved to be an important policy measure in fighting

the COVID-19 pandemic. The South Korean authorities learned about networking of citizens from their

credit card transactions. As this sort of payment is extensively used, a registered, infected credit card

owner is easy to trace regarding the locations visited, timing, and public transportation used (Ahn, 2020).

In turn, this evidence allowed for tracing the people who were in the vicinity of the infected person. In

Singapore, systems based on the smartphone allowed an infected owner to self-register anonymously, and

then the phone would send notifications to everyone the user has recently encountered (Ghaffary, 2020).

Another technological aspect of interest concerns design science. This exploratory study is the first phase

of a larger project whose ultimate goal is to design a decision support systems (DSS) for managing the

COVID-19 and similar outbreaks. This family of IS includes systems for data collection from the

authority and social media sources, surveillance/early warning, epidemic prevention, planning relevant

supplies, tracking an outbreak and its geographical spread, and modeling/forecasting outbreak trends. One

notable system is in China. In the aftermath of SARS, the Contagious Disease National Direct Reporting

System was developed with the goal of preventing SARS from returning. This system helped to prevent

avian influenza (H7N9) and pneumonic plague in Mongolia (Myers, 2020). The latter achievement

happened just ahead of the COVID-19 outbreak. However, the system failed at the COVID-19 case.

Myers cited Chinese experts that blamed the system's input: "The local health administration clearly made

a choice not to use the reporting system”. The first cases were entered into the system not before January

3, 2020.

Begley (2020) shed the light on design aspects and shortcomings of another notable DSS used in this

pandemic. Named after its developer, the Institute for Health Metrics and Evaluation at the University of

Washington, the IHME system has played a prominent role in the American government's daily policy

making. However, evidence shows that the IHME keeps changing wildly the predictions of pandemic

outcomes. Expert critics point out to design flaws, such as omitting the standard, epidemiological SEIR

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parameters (numbers of susceptible, exposed, infected, and recovered individuals). The IHME also

neglects interactions between the infected and other people, and the virus transmissibility. Instead, the

system relies on modeling the outbreak in China and Europe and fits historical bell-shaped curves to the

emerging American data. It is missing across country variation in containment policy measures as well.

Yet another notable DSS for pandemics is at the Imperial College in London. It accounts for standard

epidemiology parameters. Curiously, it put predictions of COVID-19-caused deaths as high as to 500,000

in the UK and over 2 million in the USA (Landler & Castle, 2020). The underlying assumption was that

the pandemic would spread unopposed. These predictions could have motivated governments in these two

countries to become more active in confronting the pandemic.

Evidence on these systems motivates this exploratory study to fill some gaps in strategies models behind

computing algorithms. In particular, the key standard epidemiology causes, virus characteristics, and

country-based variation in modeling dimensions need to be accounted for.

3. Methodology

This is an exploratory study, a part of a larger project motivated by the COVID-19 pandemic. The

research problem is: How do countries respond to the COVID-19 pandemic caused by the largely

unknown and dangerous virus SARS-CoV-2?

3.1 Research Questions and Techniques

The study addressed these research questions:

1. What public health policy measures are deployed in different countries, which can be used for

creating a model of containment strategy for the COVID-19 pandemic?

2. What is the role of ICT/IS in policy making?

3. Can a model of pandemic containment strategy differentiate between particular strategies?

These questions imply that the unit of analysis is country. The study has been limited geographically to

several Asian countries at the center of the epidemic, a part of Western Europe, and North America.

The availability and quality of evolving data make a paramount impact on analysis and findings of this

study. Evidence on the pandemic is growing chaotically and still insufficiently within the academic

domain. There are some medical studies (in the form of preprint or expert letter) as well as an extensive

news media coverage addressing the period since November 2019. The main data feeds used in the study

came from the Johns Hopkins University dashboard, Worldometers, WHO's statistics, and Bhatia &

Minute Physics' visualization site. These sources supply mutually close statistics. The triangulation of

sources enabled a basic validation of the data.

Due to the simultaneity of the evolving phenomenon and the investigation of it, data collection

intertwined with a mixed-method analysis. Potential variables were shaped in the process described in the

section below.

As for the terminology used it this study, the term "strategy" refers to a mix of deliberate and emerging

goals, plans and ad hoc decisions (altogether, policies) created by health and political authorities. In

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addition, the labeling of the strategies denotes a variation in "forcefulness" of different strategies, and no

political or other connotation should be implied.

3.1 Creation of Variables and Strategy Model

During the course of analyzing daily dashboards on the COVID-19 outbreak and the relevant literature, I

was continuously checking the pandemic outcomes, such as the number of confirmed cases, the number

of deaths, daily increase of confirmed cases, and the recovered cases. As for antecedent constructs

capturing the aspects of containment policies, they emerged from studying the medical and media sources

and commencing with China's outbreak. The policies included the staying at home order, cancellation of

large public events and mass gatherings, closure of workplaces, libraries and museums, travel restrictions,

airport screening, isolation of cases, and contact tracing (Lai et al., 2020). Moreover, Taiwan's policies

included border control, case identification, and mandatory quarantine of suspicious cases (Wang et al.,

2020).

The list of policy aspects was revised several times based on qualitative coding, by following logic of

convergence and divergence influenced by evolving practice. For example, the imposed limitations have

been called "lockdown", "shut down", "stay at home order", "quarantine", and so on. As all these have to

do to with reducing freedom of movement, I placed them in the same broad category of Lockdown. These

categories were validated by facts on the ground, which were surfacing as the pandemic has been

progressing internationally. In other words, it was sensible to infer that the authorities across the world

have dealt with similar problems and responded similarly in kind although not in extent. In addition to

this roll-up movement in analysis (category creation), a drill-down movement was also performed in

order to exhaust detailed policy measures within each category.

A model of containment strategies emerged gradually and was recursively refined. An evolving pattern of

policy aspects solidified by the end of March 2020. Analysis moved to framing these as analytical

constructs with plausible mutual relationships indicated and corroborated by the unfolding practice.

Consequently, I assumed that the constructs constituted a model of pandemic containment strategy (PCS

model). Another assumption was that the underlying notion to all of the model's dimensions was

forcefulness with which the pandemic is confronted. A higher forcefulness implies more limitations on

usual freedoms of citizens movement and on conducting business activities, and the other way around.

The PCS model was implemented in Microsoft Excel and initially validated by making educated

assessments of the variables' values on a three-point scale. The model yielded different total scores from

rating select countries on the modeled dimensions. The ensuing conclusion was that the differing scores

indicated pandemic containment strategies. As this sort of validation is apparently limited, it can be

considered just as a step stone in understanding the complex, evolving phenomenon of confronting the

COVID-19 pandemic.

4. Findings

This section discusses the PCS model and findings on governments' response timing, and health system

capabilities.

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4.1 The PCS Model

The PCS model is depicted in Figure 3, and a description of its dimensions and their relationships follow.

Declaring Special Regime. This dimension emerged from the China evidence and was confirmed in other

countries. It refers to invoking special legislation in extraordinary circumstances aiming at mobilizing

social forces and resources toward containing the COVID-19 pandemic. A special regime can be in the

form of a national state of emergency (China), national health emergency (USA), and an ad hoc

legislation on granting special powers to the executive branch of government (some European countries).

This aspect is related to all other aspects in the PCS model.

Figure 3. Pandemic Containment Strategy Model

Social Distancing. This dimension refers to a government's advice or lawful orders to maintain a physical

distance from other persons. Social distancing can apply to shared public spaces (streets, parks), stores,

restaurants, public transport and workplaces, where a prescribed physical distance is supposed to be

maintained between individuals sharing the same space. As well, schools' moving to distance education

and closing of pre-school institutions are the methods of separating members of younger age groups from

one another. The cancellation of mass events (sport, arts, entertainment, funerals) is also a form of social

distancing. Simulation modeling found this aspect to make a significant difference in reducing outbreak

outcomes (Lai et al., 2020). Social Distancing impacts on the business limitations and can be enforced by

digital technologies.

Early Detection. This dimension refers to a government-imposed checkups in order to identify and isolate

infected persons. Even before COVID-19 grew into a pandemic, this method was applied in South Korea,

Singapore, and Taiwan (Ahn, 2020; BBC/a, 2020; Kupferschmidt & Cohen, 2020). Checkups were

performed on airports, bus and train stations, streets, shopping malls, etc. Simulation models found this

aspect to make a significant difference in reducing outbreak outcomes (Lai e al., 2020). Early Detection is

a consequence of declaring a heightened special regime and it can be enforced by digital technologies.

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Lockdown. This dimension refers to limiting freedom of citizens' movement by the government decision.

This is a compound dimension whose specific facets include ordering/advising citizens to stay at home,

quarantining (at home, in a state-run institution), curfew (in various extents), public transport reduction or

suspension, and traffic limitations. In some countries, the term "lockdown" is used in a generic sense

approximating the term "pandemic strategy" used in this study. Consequently, evidence suggests variation

in labeling specific lockdown measures. For example, "stay at home order" uttered in the USA may be

synonymous with "mandated quarantine" in some European countries. This study, however, treats these

two as distinct policy measures.

In most Western countries, both the quarantining and stay at home policies have been implemented. Also,

the assumption is that each varies across countries. For example, the "stay at home order" in the USA or

Canada is factually an advice compared with such an order in Singapore where it is reinforced by a fine.

Likewise, the quarantine aspect may be differentiated based on the location and/or age (e.g., in Serbia,

persons over 65 years of age had to stay at home at all time). Lockdown is related to Social Distancing

and Business Limitations, and it can be enforced by digital technologies.

Police/Military Enforcement. This dimension refers to an official deployment of state organs of force,

typically the police and possibly the military. These are authorized to enforce restrictions, such as the

lockdown and social distancing. The police ordinarily welds discretionary power in maintaining public

order, but in a special pandemic regime its authority can be increased (for example, enforcing testing for

infection or performing curfew). Some form of police involvement has bee universal. However, when the

military gets directly involved in civic life with discretionary powers, this represents a significant change

in public life. The military deployment has been limited to a number of countries (e.g., China, South

Africa).

Borders Closing. This dimension refers to banning entry to the geographical space of a country, with the

active involvement of borders guards. The ban applies to foreign nationals, while returning nationals have

usually been monitored at the entry point and ordered to undergo timed self-isolation – a form of social

distancing applied in Canada, among other countries. As policy on closing borders has usually exempted

commercial cargo traffic (e.g., within the EU), this exemption should not be accounted for in assessing

the extent of Borders Closing.

Business limitations. This dimension refers to limiting business hours or closing businesses by a

government decision. Service businesses facing customers (dentists, beauty saloons, bars, branches of

retail) are the first on the list. For example, stores and restaurants in Wuhan were closed down, while in

other countries their operation was limited to delivering teak-out orders. Limitations on business hours

has also been used as a policy measure. Offices and factories were shut down in some countries, while not

in others. Working from home has been encouraged in many countries in order to support policies on

social distancing. Evidence suggests that limitations on business may increase as the pandemic

progresses, while the effectiveness of this measure varies across countries. Business Limitations is likely

to be related to Lockdown and Social Distancing.

Contact Tracing. This dimension refers to using manual or automated methods for determining networks

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of infection from a person tested positive to the persons that he/she contacted. Just in Wuhan, 1,800 teams

worked on contact tracing relying on technological means (Kupferschmidt & Cohen, 2020). In South

Korea, Taiwan, and Singapore (as already mentioned), the virus carriers have been treated as the person

of interest in police investigations. Contacts that such a person made were meticulously traced in order to

access them for infection testing purposes. In conjunction with the early detection, contact tracing has

been considered a key to successful containment of the pandemic in the Far East (Ahn, 2020). In contrast,

Western countries have shun away from this sort of intervening into the private space during the first

wave of the pandemic. However, as it progresses, a pragmatic interest of restoring economy and normal

life might legitimize contact tracing. In technologically challenged parts of the world, contact tracing is

performed in a manual manner.

Technology Enforcement. This dimension captures capabilities of modern digital technologies in fighting

the pandemic by monitoring citizens' behavior. As discussed in the beginning of the article, smartphones,

wristbands, CCTV systems, and drones have been used for monitoring citizens' behavior and compliance

with measures of containing the COVID pandemic. Relationships of Technology Enforcement with other

dimensions have already been cited in this section. Based on empirical evidence, Technology

Enforcement is expected to have the most developed relationships with other dimensions, second only to

Declaring Special Regime. The bolder line between Technology Enforcement and four related dimensions

is supposed to indicate this.

4.2 Three Strategies

All the dimensions in in PCS model share logic of control, limitations or restrictions of freedom of

movement and conducting business – forcefulness as a unifying concept. The provisionary ratings of PCS

model's variables yielded three patterns of different total scores (Table 1). These are considered to

represent three strategic approaches that I call Restrictive, Hybrid, and Permissive. Figure 4 depicts

locations of these three strategies.

The Restrictive Strategy emerged in China. It is characterized by high limitations on freedom of

movement and on business as well as a strong government lead in policy making and reinforcement (note

the high ratings in Table 1). It engages a state of national emergency and deploys the police and possibly

military in reinforcing the policies. Authorities engage in close tracing of contacts of infected persons in

order to access potential virus carriers. Various means are used to this end, including advanced digital and

mobile technologies. Quarantining is forced onto different levels, from the city down to the family level.

In China, the Restrictive Strategy has been efficient, taking about three months to contain COVID-19 (the

state of emergency in Hubei lasted from January 23 till April 7), and keeping the case fatality rate under

10% (refer to Figure 4).

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Figure 4. Three Pandemic Containment Strategies in Global Space

(Source: JHU Dashboard on March 15, 2020)

A massive mobilization of human and material resources in China resembled a state of war. Two

dedicated hospitals were built in Wuhan in about a week time, health care workers from all over China

poured to Wuhan, and massive contact tracing was deployed (Kupferschmidt & Cohen, 2020). Some

other countries in Asia and Africa have followed this strategy. One contextual factor to be noted is the

scale of things inherent to China. Wuhan numbers 11 million inhabitants, which is a mid-size city in the

Chinese terms, while equaling the size of some countries in Europe. Organizational size has been

recognized in organization theory as a correlate of organizational structure (Blau & Schoenherr, 1971).

Table 1. Pandemic Containment Strategies

Containment Dimension Restrictive Permissive Hybrid

Declaring Special Regime H M H

Social Distancing H L M

Early Detection M L H

Lockdown H L L

Police/Military Enforcement H L M

Borders Closing H M H

Business Limitations H L L

Contact Tracing H L H

Technology Enforcement H L H

SCORE 26 11 21

Scoring scale: L (low)=1, M (mid)=2, H (high)=3

The Permissive Strategy has emerged in the European Union, the UK, and the USA (looking at the

federal level, variation between states is likely). It implies lower limitations on freedom of movement and

business. Authorities rely on behavioral advice and on citizens' voluntary compliance. Pandemic policies

are being added and adjusted in accord with the evolving situation. Examples are variation in Social

Distancing (the number of people allowed together, locations, occasions), borders control, traffic

reductions, business hours regulation, the scope of testing, and the use of facial masks. While the

Restrictive Strategy declares a state of national emergency, the Permissive Strategy deploys some softer

legal framework. In general, it is low across a number od the PCS dimensions. The border closing may be

country-specific, such as within the EU. It is yet to be seen how efficient this strategy is (see Figure 5).

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Germany provides an exceptional example of a successful containment. A big, developing case is the US,

given the size of the population and several densely populated cities that cannot be controlled as tightly as

with the Restrictive Strategy.

The Hybrid Strategy was applied in S. Korea, SAR Hong Kong, Singapore, Taiwan, and Japan. This

strategy imposes mid-level limitations on freedom of movement and doing business (Chang, 2020;

Choudhury, 2020), giving an impression as if not much has changed in public life (Blackwell, 2020). It

combines some policies typical for the Restrictive Strategy (e.g., close contract tracing, mandated

quarantine for infected persons as well as self-quarantining of for contacts) with a more liberal approach

to regulating physical movement and business. This strategy appears comparable, if not superior to the

Restrictive Strategy (Figure 5) in terms of efficiency and effectiveness.

Figure 5. Death Cases in Countries Paradigmatic for Three Strategies

(Source: Bhatia & Minute Physics, 2020, April 27, 2020)

Death rates have been much smaller than those in countries following the Permissive Strategy (see Figure

1). Taiwan's hike was just 27 confirmed cases (population of 23.4 million, high density), thus representing

a success outlier. Singapore (population of 5.6 million, very high density) has been a success outlier

regarding the case death rate under 1%. The Hybrid Strategy is premised on the early detection of ground-

zero contagion, its thorough treatment, and on a highly capable health care system. This means that the

government response time is short. Both these aspects are discussed in following sections.

In summary, the dimensions in the PCS model were assessed in a manner that provided an initial

validation of the model's capability to differentiate between three containment strategies. They are

differentiated on the extent of strategy forcefulness.

4.3 Health System Capability

Evidence used in this study indicated a number od medical aspects that have played a role in containing

the COVID-19 pandemic. For instance, the testing timing and scope, and the availability of specialized

equipment proved to make a difference in the outcomes of the pandemic. The Hybrid Strategy countries

demonstrated that a health care system mitigates outbreak outcomes, while Italy and Spain showed, rather

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dramatically, what happens in a contrasting scenario. There were insufficient hospital capacities, testing

kits, personal protecting equipment and intensive care equipment, while mortality soared beyond 10% of

confirmed cases. (Sills & Millan, 2020; Speciale et al., 2020).

Evidence from France and the UK has been consistent regarding the hospitalization challenges and death

rates. Perhaps the most remarkable indicator of a lacking preparedness is that even health workers in the

Permissive Strategy countries could not defend themselves against COVID-19 (Minder & Peltier, 2020).

Hospitalization and testing problems also challenged the USA for weeks. The only exception within the

Permissive Strategy is Germany. It has demonstrated a higher capability of the testing timing and

capacity, and managed a significantly smaller death rate.

All this evidence points out to a mediating role of health care systems in the pandemic. This line of

reasoning has led to formulating a dimension of Health System Capability as part of studying strategies of

containing the COVID-19 pandemic. Although a health care system works under guidance of government

authorities, these two differ inasmuch as the health care sector differs from the political sector of society.

Therefore, Health System Capability is a separate influencer of pandemic outcomes, independent of

containment strategy.

4.4 Response Timing

An early intervention in preventing and controlling a pandemic is as important as preparations for

confronting an enemy in a war. Lai and associates (2020) found that "early detection and isolation of

cases was estimated to prevent more infections than travel restrictions and contact reductions". Had China

implemented containment measures earlier, the COVID-19 outbreak could have been significantly

reduced in magnitude and geographical range. Likewise, had the Chinese authorities delayed even more

the response, the pandemic would have been far worse (Lai et al., 2020). According to some sources, the

first cases of COVID-19 appeared in November 2019 (Bryner, 2020; Ma, 2020). Subsequently, infections

escalated from 180 (December 27, 2019) to 381 (January 1, 2020), while Wuhan’s health authorities cited

just 41 as late as January 11 (Ma, 2020). Many countries provided a similar evidence when overwhelmed

hospitals and infected staff revealed a latency in responding to the outbreak. Consequently, a dimension

of Response Timing was created to represent another influencer of the pandemic outcomes.

Estimating Response Timing is complicated by determining the start point for measuring the period

before a response occurred. One can be January 23, 2020, when the WHO announced that the new

respiratory disease detected in Wuhan could transfer between people. A day before, the Chinese

government imposed tight restrictions on Wuhan and surrounding cities. Both events should have been

eye-opening for health and government authorities around the world. When did these authorities start

responding to the outbreak challenge?

China's neighbors applying the Hybrid Strategy reported the first cases almost immediately (see Table 2,

column "1st Report"). Other countries where the Permissive Strategy emerged did so only a month or

more later. This is one measure of Response Time. Table 2 also displays an optional measure. Focus on

column "1st Hike" that specifies the number of cases and the increase relative to the previous day. I

defined hike as a daily increase of 100 or more confirmed cases relative to the previous day because a

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visual inspection of country curves suggested that this number usually coincided with a larger slope

increase. Thus, the period between dates in columns "1st Hike" and "1st Report" can serve as another

measure of Response Timing. For the four Asian countries, this period is between 4-6 weeks, while for

other countries it is just 3-11 days. This means that the Asian countries started early to control the

outbreak and kept it at lower levels for longer periods. In contrast, when this period is short it indicates

that a country responded when the outbreak had already been well underway. This measure confirms that

governments following the Permissive Strategy were late in responding to the COVID-19 outbreak.

Table 2. Government Response Timing

Country 1st

Report

Cases 1st Hike Cases

China 21-Jan 548 ? ?

Singapore 23-Jan 1 5-Apr 120 (+45)

S. Korea 24-Jan 1 21-Feb 100 (+27)

Taiwan** 24-Jan 2 18-Mar 23 (+13)

Japan 26-Jan 2 25-Mar 114 (+45)

Italy 21-Feb 17 25-Feb 131 (+38)

Germany 26-Feb 10 4-Mar 220 (+154)

Canada 26-Feb 6 15-Mar 163 (+109)

Spain 28-Feb 17 5-Mar 141 (+104)

France 29-Feb 43 5-Mar 376 (+284)

UK* 1-Mar 13 12-Mar 343 (+268)

US 3-Mar 68 9-Mar 376 (+311)

Note: *UK's hike compared to March 10. **Taiwan's peak ever was 27 daily cases.

(Source: Johns Hopkins University dashboard)

Note that the third possible method of assessing Response Timing is de jure – the date of issuing major

decrees and policies on containing the outbreak relative to January 23, 2020. It was not used here but it

could be an additional way of validating the Response Timing measurement.

4.5 Cultural Foundations of Containment Strategies

Differing cultural assumptions underpin the strategies of confronting the COVID-19 pandemic model

presented in this article. Deciding on mask/no mask enforcement, getting the police and military on

streets and in what capacity, executing close contact tracing and such measures are not just pragmatic

choices that the governments can make arbitrarily. Imposing a highly restrictive measure in a liberal

political context may yield results on a short run, but this would cost a loss in citizens' loyalty. Likewise,

counting on a stay at home order without putting teeth behind this measure would do little in a national

culture valuing Confucian understanding of social hierarchy as a warrant of social stability and safety.

Particularly in the current situation of lacking global leadership and coordination, national responses to

the pandemic are likely to reflect respective cultural roots.

The Restrictive Strategy puts collectivistic or communitarian cultural beliefs and behaviors before the

individual (Hofstede et al., 2010; Trompenaars & Hampden-Turner, 1998). So for example, in the current

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COVID-19 pandemic, a person wears a mask in order to protect others from being infected by him/her.

This behavior is not natural in a culture espousing the Permissive Strategy that puts the individual above

the collective and thus focuses on protecting the individual first. A "sense of responsibility and collective

action" pervades in a collectivistic culture, as noted by an international team of experts that evaluated

China's response to the outbreak (Kupferschmidt & Cohen, 2020). At the a social group level, the

Restrictive Strategy presupposes the interest of protecting a nation to interests of smaller social units

(administrative localities, economy sectors, religious congregations, etc.). For instance, religious services

are promptly banned across denominations. In contrast, the Permissive Strategy addresses the freedom of

religion practice more carefully and at the advisory level. While the faithful may be appreciative of such a

policy, church masses and burial ceremonies become the sources of infection (Parke, 2020). Negotiations,

power struggle and dynamic policy adjustments are the whole mark of the Permissive Strategy. Contrary,

a staple of the Restrictive Strategy is centralized decision making and policy creation..

The Permissive Strategy prioritizes individual freedoms. This sets the bar for the extent of limitations on

free movement, early detection of infection, contact tracing, wearing a facial covering, and possibly other

policy measures. Control power of information technologies is being curbed by concerns of privacy

advocates in the USA. Alerts sound when Apple and Google try to develop a system using the

smartphone and Bluetooth software for tracking the people that come close to the smartphone's owner and

identifiable by their exposure to the infection (Ghaffary, 2020). In contrast, the Restrictive Strategy

deploys intensively such technologies. Implicitly, it presupposes national interest to individual freedoms.

The Hybrid Strategy is in agreement with this approach since collectivistic values still make a salient part

of cultures in South Korea, Singapore, Taiwan and Japan (cf. Hofstede et al., 2010).

The Permissive Strategy acknowledges that the official social hierarchy must be voluntarily accepted and

held accountable, when attempting to impose new limitations on citizens; otherwise, the power

relationship breaks down. With the Restrictive and Hybrid strategies, however, legitimacy of social

hierarchy is a given. This cultural aspect can also be understood in terms of Hofstede's power distance –

the expectations and the acceptance of an unequal distribution of power in society. According to his

measurements, most Western countries are lower on power distance, while the Asian countries of interest

here are high (Hofstede et al., 2010). The implication of these differences is that the Western citizen is

typically less willing to accept the government dictum in the pandemic situation than the Eastern citizen.

Temptations of freedom during this pandemic show up in the case of USA as well. The federal

government first ignored the disease and described it as less dangerous than the sessional flu. When it

finally became engaged and began imposing restrictions, some state governments pushed back as they

were concerned with the consequences of business loss. Then, the actors turned the tables in the phase of

lifting limitations since late April ("reopening the economy/country") as the federal governors pushed for

it but some governors moderated the pace while facing an impatient citizenry. At the individual level,

freedom to "act as one pleases" and engage in "leisurely and fun-related activities" belong to a cultural

dimension of indulgence (Hofstede et al., 2010). The USA and other Western countries but Germany are

high on indulgence. Consequently, the government-imposed limitations ranging from a mandated stay at

home to face covering are counter-cultural, and so the authorities must continuously calibrate these. This

calibration has also to do with cultural assumptions and values of historical time.

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Based on empirical investigation, Trompenaars & Hampden-Turner (1998) have argued that the

American understanding of historical time is sequential. Think of a resolute process-like, step-by-step

progression toward an end-point. This culture is also focused on the present and immediate future and

encourages a short future time horizon. These cultural characteristics translate into a pandemic strategy

conceived as a process with dated landmarks to be reached in a proximate future. In American culture, the

future is assumed to be controllable since each step executed leads to the preconceived end, even though

the obstacles are in a largely unknown natural world. "The future is short-term, something controllable

from the present" (p. 134). However, as there are multiple processes in the complex constitution of the

American federation, these are rarely in sync and collide more often than not. Power negotiations, power

coalitions forming, battling and over-powering are the consequences playing out in the political domain.

A zig-zag policy making at various levels of government becomes a landmark in the pandemic situation.

At times, the limitations/freedoms see-saw looses a touch with reality and becomes a chip in political

games. The Permissive Strategy comes across as a complex and complicated endeavor with uncertain

ends, in spite of all the effort of controlling the future.

Contrast these characteristics with the Chinese culture. Shared beliefs are that the past, present and future

are equally important and not connected. Add to this a long-term time orientation (Hofstede et al., 2010;

Trompenaars & Hampden-Turner, 1998) and nearly three times smaller indulgence than the American's

(Hofstede et al., 2010). Implications are that the Chinese culture nurtures endurance and patience. These

cultural characteristics fit with a pandemic strategy conceived as an uncertain period of unknown

longevity, which requires perseverance from everyone.

The Hybrid Strategy combines freedoms with limitations to get the two into a balance that yields

desirable pandemic outcomes. Forced quarantining, strict contract tracing enabled by advanced digital

technologies, and other new limitations have been pulled out of a SARS rulebook, while there was no

general shutdown and a number of businesses continued operating in a special regime ((BBC, 2020;

Wang et al., 2020). The countries following this strategy harbor national cultures that mix Asian and

Western beliefs and behaviors. Japan started absorbing Western influences since the Meiji Period that

started by the end of the 19th century. Other countries in the region have experienced periods of Western

control in various forms. In modern times, educating the youth in the West has provided the intake of

Western influences that alloyed with local traditions.

There are more cultural similarities than differences between the Hybrid and Restrictive Strategy

countries. Koreans, Japanese, and Singaporeans believe that the past, present and future are connected.

This makes them different from the Chinese culture and similar to Western cultures. However, both the

Hybrid and Restrictive Strategy have roots in a similar understanding of historical time as the rewards to

present actions are expected in a distant future (somewhat less so in Singapore), which differentiates them

from the West. Also, these are collectivistic cultures (Japan being more balanced) and they exhibit a

higher power distance (Hofstede et al., 2010). They owe common cultural roots to Confucian traditions

planted where the Chinese people have been in majority or China made impacts through its long history

(Hofstede et al., 2010). As the authors put it: "People in these countries accept and appreciate inequality

but feel that the use of power should be moderated by a sense of obligation" (p. 80). In addition, all these

countries value the indulgence less than the countries adhering to the Permissive Strategy (Hofstede et al.,

2010). These cultural roots may explain why citizens of the Hybrid Strategy countries are willing to

accept the limitations imposed by authorities.

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A strength of each strategy, becomes a liability scaling up is unchecked. Freedoms that mismatch the

level or health risk pave the way to the pandemic escalation and prolongation. Likewise, restrictions that

mismatch the level and longevity of citizens' endurance may become counterproductive. Enduring under a

prison-like duress takes stamina and mental costs as a Wuhan survivor's account demonstrates (Jing,

2020). The rest of the 11 million in Wuhan and 50 million in the Hubei province may have had different

experiences but probably not any lighter. Excessive expanding of Permissive Strategy boundaries cost

dearly Italy and Spain with regard to pandemic outcomes. These countries started with the Permissive

Strategy and then were compelled to move to the Restrictive Strategy.

This transitioning in Spain and Italy indicates uncertainties of the Permissive Strategy. Grave pandemic

outcomes and high profile infections in the UK speak of the same (e.g., the heir to the throne, the Prime

Minister, Health Minister, and health secretary caught COVID-19). A particular aspect can be at play in

British culture. Even at the time of this writing, the health authorities keep COVID-19 off the list of high

consequence infectious disease (HCID), although it was there from January until March 19, 2020. This is

so despite the fact that this disease meets 4 of 5 HCID criteria (www.gov.uk, 2020). The cultural

background may be in the assumption of a "herd immunity" (Conn & Lewis, 2020) and a related principle

of natural selection akin to Social Darwinism, applying the principle of national selection in a society

(Davis, 2020).

In summary, cultural differences regarding national vs. particularistic interest, individual freedoms vs.

social responsibility, social hierarchy, power distance, indulgence, and historical time constitute the

cultural foundations of the three pandemic containment strategies. The Permissive Strategy is bound to

particular uncertainties. A strength of each strategy, becomes a liability scaling up goes unchecked.

5. Discussion and Conclusion

In this article, I reported on an exploratory study of the COVID-19 pandemic, which is part of a larger

project. The study has been limited by the quality of data available as the unfolding developments have

not allowed for a broader literature genesis. The study was exploratory and the validation of the PCS

model is merely initial. The sample of countries was rather small although representative of typical

country responses to the pandemic. Still, the study's findings may be interesting and useful.

In addressing the first two research questions, policy measures for confronting the pandemic in select

countries were identified and used for creating a model of pandemic containment strategy (PCS model).

This model is one key finding. It contributes to the health informatics literature by juxtaposing health

policy with a technology variable that is involved in several relationships with other variables in the

model. This property captures the available evidence (Ahn, 2020; Ghaffary, 2020) and opens up a venue

for prospective research. In addition, the model overcomes a disconnect between policy measures and the

social context (Begley, 2020; Landler & Castle, 2020), which is one shortcoming found in pandemic

information systems, by assuming that a policy extent has ultimately a cultural grounding.

In addressing the third research question, the PCS model differentiated between three strategies –

Restrictive, Hybrid, and Permissive. These strategies make another key finding. The underlying

assumption behind the model's constructs and variables is that a pandemic containment strategy imposes

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17

new limitations on free movement (everyday life conduct) and business (economic activities). Some

limitations always exist in an organized society but these are additional limitations, specific to an

emergency. A pandemic containment strategy is a change to the regular state of affairs, and differences

between national strategies is in a forcefulness with which governments impose such a change. Focusing

on the proportion between new limitations and ordinary freedoms is another way of thinking about this.

The more extensive the newly imposed limitations, the more forceful is the strategy. Or, the larger the

scope of freedoms preserved, the less forceful is a strategy. Figure 6 depicts these trade-offs, where

positioning of the borderline between ordinary freedoms and new limitations determines the strategy type.

Figure 6. Freedoms and Limitations Trade-Offs in Containment Strategies

(P=Permissive, H=Hybrid, R=Restrictive Strategy)

The trade-offs visual in Figure 6 also shows dynamics of pandemic containment strategies. The normal

proportion of ordinary freedoms and limitations is defined by the solid angled bar. The dashed bars

represent expansions of new limitations according to the three strategies. Strategies may evolve with the

situation on the ground. A strategy that is initially defined as permissive may be switched to restrictive by

expanding new limitations. This happened in Italy and Spain, which their public health disasters forced to

severely limit ordinary freedoms (the dashed bar P moved to the right and became the R-bar). Japan and

Singapore went through different dynamics. In mid-April, these countries experienced a sudden increase

in cases (Rich, 2020) and had to adjust their Hybrid strategies by reinforcing social distancing. This

translates into two moves in the visual tool: First, the H-bar moved to the left toward the permissive zone,

and then it retracted back and moved toward the restrictive zone. Finally, when the pandemic gets under

control and subsides, the R-bar moves left toward the Hybrid, Permissive and, eventually, ordinary

borderline.

The discussion in preceding sections has addressed all the components of a comprehensive model of

pandemic management, which will drive a larger research project. As shown in Figure 7, the PCS model

is one component in this larger model along with dimensions of Health System Capability and Response

Timing. All three are conceived as mediating variables that make a difference on the impacts of virus

characteristics (e.g., reproduction number, severity) and demographics (e.g., age, population density) on

the pandemic outcomes. The Pandemic Management Model also includes the component of national

culture as an antecedent to containment strategies.

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Figure 7. Research Model for Pandemic Management

Future research needs to advance the PCS model's validation based on analyzing row data and a bigger

sample of countries. The future research should also test the PCS model at the state/province level in a

single country whose organization allows for variation in approaches to pandemic containment (e.g., the

USA, India, Nigeria). Furthermore, prospective research needs to test the Pandemic Management Model.

Its distinctive contribution is the cultural aspect. The ultimate goal will be to design and develop a DSS

for pandemic management that will advance design science for health informatics and contribute to

practitioners' decision making in epidemic/pandemic situations.

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