Devi Sridhar's 'Preventable' Review: The Countries That Handled COVID-19 Best

During a recent trip to London, I saw almost no one wearing a mask—except for American tourists, who were easily identifiable because they wore them even when they were outside. Restaurants have recovered and are packed; reservations are down only 13 percent from before the pandemic, compared with 40 percent in New York. For me, a visiting American comparing London to his homeland, the impression is that the city—and the country—has moved on from COVID-19.

But England has not moved on from its failed initial response to COVID-19 and the decisions surrounding it, which remain controversial. Starting in February 2020, the country pursued a libertarian strategy of trying to reach herd immunity, before lurching to a severe lockdown in late March. England cycled through lockdowns of varying severity over roughly the next year. People were ordered to stay at home, and nonessential businesses were closed; at times, it was an offense to leave your home without a reasonable excuse. The National Health Service (NHS) attempted an effort at test and trace from May 2020 to January 2021, but this proved to be completely useless.

I happened to be marooned in London throughout most of 2020, having arrived only days before the initial lockdown was imposed on March 23. I remember how empty London’s streets were during that period, except for the speeding ambulances. While I never caught COVID-19, my doctor did—perhaps because of the NHS’s lack of personal protective equipment and overall lack of preparedness for a pandemic. Prime Minister Boris Johnson nearly died from the virus. And it was recently revealed, in a scandal known as Partygate, that during lockdown, when group gatherings were forbidden, Johnson hosted parties in the prime minister’s residence at No. 10 Downing St. Wine was wheeled in from a nearby shop in a suitcase. Johnson survived a recent no-confidence vote by his own Conservative Party but so narrowly that his premiership remains threatened.

The debate in England about these COVID-19 policies is immensely sensitive—given the staggering number of deaths—and highly politicized, with the Labour press arguing the government did not do enough during COVID-19 and some of the Tory press arguing the government did too much by enacting lockdowns.

Devi Sridhar’s Preventable: How a Pandemic Changed the World & How to Stop the Next One is a notable contribution to the still-raging debate. Sridhar, a professor of global public health at the University of Edinburgh, is broadly associated with the Labour-aligned stance—that is, the need to suppress the virus even if this was achieved through the curtailment of individual liberties such as freedom of movement. She has advised Scottish First Minister Nicola Sturgeon, as well as the World Health Organization, on COVID-19 and is a divisive figure in the U.K. because of these associations and her support for strict border closures.

Preventable itself is a wide-ranging book. It is in part a work of advocacy for a more muscular response by governments to pandemics and a work of analysis, comparing different countries’ methods of trying to control the spread of COVID-19.

Because these different responses come not only from state capacity but also ideology, reaction to Sridhar’s book has been accordingly split. The U.K. progressive, anti-populist press is mostly supportive. The Guardian, where she is a contributor, was glowing. The Financial Times, which seems to advocate trusting the experts—particularly one as establishment as Sridhar (she co-wrote a book with Chelsea Clinton)—as an almost moral duty, was even more positive, getting straight to the political point in its review: “Preventable argues that … the poor leadership skills of populist leaders (such as Johnson, Donald Trump and Brasil’s Jair Bolsonaro) condemned some of the countries best equipped to fight the pandemic to failure in 2020.”

The story in the Tory press, which tends to be skeptical of COVID-19 lockdown measures—and Sturgeon—was very different. The Spectator, in an article titled “‘Please don’t do a hit job’: An interview with Devi Sridhar,” proceeded to do exactly that and was personal in its conclusion: “Now virtually the whole world—with the exception of hermit kingdom China—is living with Covid, being a former pin-up for Zero Covid is no longer quite such good box office.” A pre-publication article in the Spectator was even nastier, listing the book in a “guide to all the titles which won’t be flying off the bookshelves in the forthcoming months.” (It actually was a bestseller.) The article concluded: “With such an avalanche of epidemiological musing … remember the words of Christopher Hitchens: ‘Everyone has a book in them and that, in most cases, is where it should stay.’”

The truth however is that Sridhar’s book is highly nuanced and the author too intellectually heterodox and empirically oriented to be constrained by a single ideological perspective. There is no doubt she felt countries should have developed a COVID-19 control strategy. But unlike lockdown true believers, Sridhar is very candid that containment policies such as school closures involve trade-offs and can cause harm. As she writes, “School closures have far reaching and detrimental effects. Many children, especially in poorer countries, will never return to formal schooling again.”

It is tempting to now relitigate COVID-19 policy decisions made then by citing recent academic research questioning the efficacy of lockdowns. Both pro- and anti-lockdown camps have become amateur epidemiologists. Though they argue endlessly about science, neither side acknowledges the glaring political contradictions in each of their approaches: Zero-COVID adherents tend to be globalists who dream of a borderless world (for people, goods, services, and finance)—except when it comes to COVID-19, where free movement and activity must be tightly prescribed. Anti-lockdown populists pretty much feel the opposite in every respect.

One could read and critique Sridhar’s initial policy advice—favoring a more aggressive response to the pandemic, including tight border controls, social distancing, and the banning of nonessential travel—with the benefit of hindsight, but this would not be a very fruitful approach or a good use of the reader’s time. For one, Sridhar changes her thinking in response to changing evidence. As an example, she updated her analysis of the cost and benefits of school closures as more data came in showing the developmental harm closures caused to children and the limited risk of COVID-19 transmissions from schools.

More broadly, it is a fact that countries differed in the efficacy of their initial policy response to COVID-19 even if these policies didn’t always work in the long term. Some, like Taiwan, were able to contain the virus and had low early death rates. Others, such as the United States, which devotes more resources to health care than any other country in the world, could not mount an effective response at all.

Indeed, the core of Preventable, and what I believe will be its lasting contribution, is how and why countries responded to COVID-19 differently. Rich countries did not necessarily handle the pandemic better than poor ones, showing that something else is at work besides money. The specifics are complex, which is why the book exceeds 400 pages.

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Sridhar’s framework is essentially political. “[W]ith the right politics and leadership, much of the suffering and death [from COVID-19] was largely preventable,” she writes. It is worth looking more closely at the initial policy successes of some countries and failures of others, as detailed in Preventable.

South Korea. South Korea’s response to COVID-19 was informed by its recent experiences with another virus: MERS (Middle East respiratory syndrome) in 2015. That experience did not go well: South Korea had the largest outbreak outside of the Middle East. As a result of MERS, South Korea put policies and planning in place for pandemics that proved critical when COVID-19 hit.

South Korea’s plans did not rely on a national lockdown, and schools were largely kept open, though social distancing was deployed. Instead, Sridhar writes, “the core of the South Korean response has been the test/trace/isolate system … and by March 2020 it had the highest per capita test rate in the world with results back within twenty-four hours.” In comparison, she notes, during this period the U.K. was only offering testing in hospitals.

If someone tested positive, South Korean public health teams traced that person’s activity over the previous week using phone and credit card data and closed-circuit TV. They were then asked to isolate at home or in specialized isolation centers, where their symptoms were continuously monitored to see if they required hospitalization. South Korea, according to Sridhar, attributed its low death rate to this monitoring system. The low oxygen levels stemming from COVID-19 may not be detectable by patients themselves, and so often in the United States patients showed up at hospitals when they were already gravely ill.

Sridhar terms the South Korean model, which is based on testing rather than lockdowns, “reasonably effective.” But, as she points out, it also involved something else: trust in the government and that it wouldn’t misuse the personal data it had gathered.

Senegal. Senegal is another one of the book’s case studies of success and one barely known in the global north. As of March 2021, it ranked second, right after New Zealand, in FP Analytics’ COVID-19 Global Response Index.

“President [Macky] Sall knew to go early, go hard and keep it simple,” Sridhar writes. Once COVID-19 was confirmed in the county, Sall closed schools and air travel and shut down large gatherings. This applied to mosques, with many choosing to worship from home.

Sridhar praises the country’s messaging efforts, including the use of religious leaders and musicians who released a single about beating the virus, “Daan Corona.” Senegal’s success also built on a more traditional disease management and surveillance infrastructure developed for infectious diseases such as Ebola.

As Sridhar writes, “What Senegal’s story shows is that even in the context of limited resources and scientific uncertainty, certain countries reacted quickly and effectively to prevent a crisis.”  Senegal’s success rested on leadership, messaging, testing, but also financial support for those who were impacted by COVID-19 restrictions and had no way to earn a living, allowing them to isolate.

Italy. Two regions in Italy, Lombardy and Veneto, make for a clear case study within the same country of differing COVID-19 policy responses and their impact. Veneto took a strict containment approach accompanied by mass testing. Lombardy’s focus was on treating cases once they occurred rather than trying to prevent them. The results of these different strategies: Lombardy’s case fatality rate was three times that of Veneto, as of April 2020.

In Sridhar’s telling, these outcomes were not surprising, and what happened next in Lombardy was almost inevitable: As the pandemic worsened and Lombardy became a death zone, it implemented almost medieval extreme lockdown measures. There was almost no exit from or entry into afflicted areas. She was not surprised by this turn of events: Around the world, before vaccines became widely available, “mitigation strategies [allowing the virus to spread] … have always resulted in lockdown measures.”

New Zealand. New Zealand was distinctive in the Anglophone world for successfully pursuing a COVID-19 elimination strategy—of trying to eliminate the virus altogether rather than just flattening the curve through containment. (Australia attempted this, too.) To accomplish this, New Zealand closed its borders to everyone but citizens and long-term residents, who themselves were forced to quarantine in hotels if they chose to enter the country. In March 2020, the country entered a state of emergency with a stay-at-home lockdown.

The elimination strategy was successful: The country went 102 days without cases. But Sridhar also points out that it was not “without its challenges,” which she itemizes: Not everyone cooperated with lockdown and test and trace; lockdown took a psychological toll; and the closed border ruined tourism and separated families. Despite these misgivings, Sridhar titles her section on the country, “The Paradise of New Zealand.”

Sweden. Sridhar contrasts New Zealand’s approach with that of Sweden, which is typically held up as the poster child for the success of a laissez-faire or anti-lockdown approach. Underlying its hands-off approach to COVID-19 was the public health authorities’ belief that “the only sustainable way to deal with this kind of respiratory pathogen would be to let it flow through the population and avoid the economic and social costs of lockdown.”

Hence, Sweden did not pursue lockdowns or test and trace for that matter. Schools and restaurants stayed open and so did the border. These policies were in stark contrast to the containment measures deployed by other Scandinavian countries.

Did the Swedish lax approach work? Sridhar writes: “The debate is polarized.” In her analysis, Sweden’s “gamble” did not pay off. “Swedes paid a heavy price in that lives were lost unnecessarily. And, as the year progressed, Sweden went the same way as its Scandinavian neighbors—into suppression,” she writes.

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Among the analyses in Preventable of COVID-19 responses across countries and regions, one consistent finding is that poorer countries that took the approach of aggressively trying to contain the pandemic—such as Greece or the Czech Republic—fared better than richer countries, such as France, that were more hands-off, at least initially.

It is true that many of the countries that handled the first wave well, such as South Korea, New Zealand, and Senegal, struggled as time went on. But their strategies bought time until vaccines were available. And their economies were not as devastated as those of countries with laxer policies, according to Sridhar: “[T]hose countries that responded effectively and controlled the virus, like Taiwan, South Korea, Denmark and Norway, had faster economic recovery compared with countries like Britain, Spain and Sweden.”

But there is a puzzle in these overall patterns of response. It is clear from Sridhar’s telling that countries that undertook a coordinated national response involving test and trace and isolation handled the initial outbreak much better than the disorganized response of the United States and the U.K. Yet it is the latter two countries that were first able to develop effective vaccines.

Is this just a coincidence?

There is a reason to think not. The answer to this puzzle is found outside of Preventable, or even epidemiology writ large, and instead is provided by a niche area of political science studying economic development and varieties of capitalism.

Chalmers Johnson in his book MITI and the Japanese Miracle describes two economic systems, plan-rational vs. market-rational economies, a distinction common in the literature on the varieties of capitalism. Plan-rational economies are characterized by their governments’ focus on planning, with economic growth the overarching goal. (The Soviet Union was “plan ideological,” according to Johnson, so not part of this grouping.) In plan-rational economies, the state has a developmental orientation, and there is a great deal of state intrusion into the economy. Market-rational economies, in contrast, are centered on market efficiency, with the government playing primarily a regulatory rather than a planning role.

For Johnson, Japan was the exemplifier of the plan-rational system, with the United States the standard-bearer of the market-rational system. There are strengths and weaknesses in each system.

When there is a crisis where there is no consensus about what the long-term goal should be, and therefore how to plan for it, the plan-rational system stumbles. The market-rational system is better at coming up with new answers. Johnson writes that “the great strength of the market-rational system lies in its effectiveness with dealing with critical problems. … [Its approach] helps to promote action when problems of an unfamiliar or unknown magnitude arise.”

Johnson doesn’t discuss pandemics, but his dual-system typology, which is found elsewhere in political science, applies in this case. Plan-rational economies were distinguished by their planning and state effectiveness at controlling the pandemic—but only initially. In contrast, the more flexible market-rational U.S. and U.K. systems came through when it came to developing vaccines.

This typology of plan rational vs. market rational doesn’t map precisely to countries’ responses to the pandemic, but it roughly does, with COVID-19 control standouts of Taiwan and South Korea falling into the camp of plan rational.

The typology can be seen again in countries’ behavior once vaccines were developed. The United States and U.K. reverted to type—or rather, continued as type—with no planning for the next crisis. There were to be no more Operation Warp Speeds in the United States. In alignment with market efficiency, the U.K. made aggressive moves to rapidly sell off its vaccine manufacturing and innovation center, which had proved so useful in vaccine development. (Kate Bingham, who led the U.K. vaccine task force, denounced the government’s overall approach.)

And China, too, continues on its pre-chosen path. Even though vaccines are now readily available, it insists on pursuing a zero-COVID strategy, an authoritarian policy imposed at great cost.

The question is whether the United States can broaden its market-efficient economic approach, which has many strengths, to include planning capabilities, too. As Preventable demonstrates, planning was critical for early pandemic control, though in the long run it was not sufficient. Both approaches are needed. If the United States had added a bit more planning to the mix, many lives could have been saved during the initial outbreak.

The risks facing the United States going forward go well beyond just pandemics. Coronaviruses aren’t the only threat emanating from China. China poses unprecedented economic and military challenges to the United States. It is moving to a new economic model, one that combines state planning with market forces. By expanding its own economic model, the United States can respond more effectively to these new threats. Losing this competition is preventable.