While effective states are well-placed to tackle their problems, an efficient response to the pandemic is also about how laxly or strictly these states implement their authority, capacity and legitimacy

More than one million people have died and over 81 million have been infected so far in the United States, the highest such figure in the world. This is despite the fact that the US ranks eleventh in healthcare in the world, according to 2021 research by the Commonwealth Fund which studied healthcare systems of eleven high-income countries.

Similarly, France which ranked at No 8 has suffered over 25 million infections, the fourth highest in the world, and 142,506 deaths, the tenth highest in the world.

And Italy whose healthcare system also ranks among the best – the country is not covered in the Commonwealth study though – has recorded around 15 million infections, ninth highest in the world, and 159,784 fatalities, eighth highest in the world.

On the other hand, a country like Pakistan which ranks way down the rankings of global healthcare measures – a 2020 Lancet study put it at 154th position among 195 countries – has recorded just 15 lakh cases and 30,000 deaths.

Liberia, a country with the least healthcare access and a population of over 5 million has had just 7400 cases and 294 deaths. 5747 people have recovered.

This disproportionate disparity in the Covid infections between some of the countries with advanced healthcare systems and those with poor medical facilities has exercised the minds of experts all over the world.

This differentiation, however, doesn’t apply uniformly across the world. Some countries with modest medical infrastructure like India have also fared badly. The country ranks second in terms of infections after America with 43 million cases and third in terms of deaths (521388 cases).

Table of Contents

India and China

Most of India’s infections and fatalities occurred in the deadly second wave caused by the Delta variant of the Covid strain in April and May 2021. According to a reply by the National Centre for Disease Control (NCDC) to a Right To Information application by a reporter of Hindustan Times, 166,632 fatalities took place during the wave: 120,770 people died in May and 45,882 in April, the two months with the highest Covid mortality since April 2020. In June 2021, 69,354 Covid fatalities were recorded which included reconciled deaths, that the authorities had failed to mention in April and May data.

China with one of the best healthcare infrastructures in the world has witnessed one of the lowest infections and fatalities: 156,143 and 4638 respectively. One reason for this success is that China follows Zero covid strategy. The strategy consists of two stages: one, the suppression phase in which the virus is eliminated locally using aggressive public health measures like stringent lockdowns. This is followed by sustained containment measures during which normal economic and social activities resume and public health interventions are used to contain new outbreaks before they spread widely. The goal, as is obvious, is to reduce the infection to zero.

This strategy has been used with varying success by Australia, Atlantic and Northern Canada, China, Hong Kong, Macau, New Zealand, Singapore, Scotland, South Korea, Taiwan, Tonga, and Vietnam. But with the advent of more transmissible Delta and Omicron variants, some countries have given up on the strategy and sought to live with the virus which is hoped to evolve into a less virulent variant. But China, Taiwan, Hong Kong, and Tonga haven’t abandoned the pursuit of zero Covid.

Paradox looms large

India and China’s examples, however, don’t detract from the overall global Covid picture which largely shows that the major developed countries have been at the receiving end of the virus.

One reason for this is the higher proportion of old age population in the developed western countries. For example, adults 65 and older account for 16 percent of the US population but 80 percent of COVID-19 deaths in the country during the first wave in April 2020. In the state of Idaho 94 percent of COVID-19 deaths were among those 65 and older, the highest in the US then. Similarly, in April 2020 over 95 percent of deaths from Covid-19 in Europe were of people over 60.

By February 2022, 93 percent of all Covid-19 deaths in the United States were among people over 50.

This is also borne out by the recent Omicron wave in Hong Kong which has one of the best healthcare systems in the world. Of the 5,906 COVID-19 deaths during the omicron wave, 96 percent were among people aged 60 and above.

A riddle veiled in mystery?

There has so far been no conclusive study that explains this disparity. For public health professionals, this has been the biggest conundrum of the pandemic. However, a study carried out by United Nations University World Institute for Development Economics Research has tried to crack the puzzle. It says only the “effective states” can handle their problems, including the epidemics, well. The study describes effective states as those having greater authority to provide order and security, greater capacity to provide public services, and greater legitimacy to make citizens accepting of their decisions.

But the developed nations which witnessed massive outbreaks of Covid infections and thousands of deaths already possess all these attributes. Then why did they fail?

The research has an answer: The states with greater effectiveness have largely been found to have resorted to lighter restrictions. They have also been found slower to enact containment policies. The weaker states such as the Central African Republic, Somalia and Yemen closed and cancelled public events more quickly than states considered to be more effective.

The study also blames the contiguousness of some of the effective states to the regions with high infection rates. This made southern Europe, comprising highly effective states, a high-risk area during the first wave of the pandemic.

The proportion of elderly in the population remains a distinct factor, according to the study. In countries like Japan and Germany, 20 percent of the population is 65 and above. In Uganda or Mali, on the other hand, it’s just around 2 percent.

So, while effective states are well-placed to tackle their problems, efficient response to the pandemic is also about how laxly or strictly these states implement their authority, capacity and legitimacy and make important policy decisions.