South Korea’s Covid-19 success story started with failure – NewSimulationShoes

This story is one in our six-part series The Pandemic Playbook. Explore all the stories here.

DAEGU, South Korea — Jo Hye-min stepped off the train and into a situation she had only seen in movies: a completely, and eerily, empty station.

It was February 2020, when the threat posed by the novel coronavirus SARS-CoV-2 was only starting to become clear in much of the world. But the situation in Daegu was already dire: Hospitals were overwhelmed and on the brink of collapsing. Hundreds of people believed to have been exposed to the virus were being isolated in private rooms. A nurse’s association in Daegu issued a plea for volunteers to help.

“It felt like war had broken out,” Jo says, and the 28-year-old nurse enlisted. The national disease control agency called her at 10 pm, asking if she could be in Daegu by 9 am the next morning. She dropped off her cat with a friend and made the 60-mile trip from her home in Busan. When she arrived at the isolation facility, she was told it would be at least a month before she could leave.

Jo was joining a frantic, all-out effort by South Korean officials to contain a burgeoning epidemic.

A woman in her 60s, who would later become known as Patient 31, had tested positive for Covid-19. Public health authorities learned she was a member of a secretive religious movement and attended services in the days before being diagnosed, potentially exposing more than 1,000 people.

South Korean officials made a plan. They needed to test as many people as possible, as quickly as possible, to figure out how bad the outbreak was. Then they had to find out who might have come into contact with the infected people. And they needed all of those people — both the infected and the potentially exposed — to isolate themselves to prevent the virus from spreading any further.

It was a three-step protocol: test, trace, and isolate. And it worked. Within a week of Patient 31’s diagnosis, the country was performing the most Covid-19 tests in the world; it implemented perhaps the most elaborate contact tracing program anywhere; and it set up isolation centers so thousands of patients could quarantine.

As other countries saw their outbreaks spiral out of control, measures like these helped South Korea keep Covid-19 in check. On March 1, South Korea had about 3,700 confirmed cases; Italy, the first hot spot in Europe, had 1,700 and the US had just 32 cases, though its dismal testing meant the virus was likely spreading unsurveilled. By the end of April, Italy had topped 200,000 cases; confirmed cases in the US were already above 1 million. South Korea still had fewer than 11,000. Adjusted for population, South Korea’s first wave of coronavirus cases was about one-tenth as big as that in the United States.

Before the Covid-19 pandemic, the US was considered better prepared than any country in the world to stop an infectious disease outbreak. But the first months of the pandemic response in the US were marked by now-familiar stumbles. The virus escaped containment. While South Korea tested, traced, and isolated, the US struggled, a critical early failure that cost lives.

No country had a perfect response to the pandemic. Every approach came with trade-offs and caveats, and even success stories can go awry in the face of global, exponential growth. But around the world, nations took successful steps to limit the pandemic’s damage. We talked to Jo and other South Koreans as part of Vox’s Pandemic Playbook series, which will explore the successes — and setbacks — in six nations as they fought the virus.

South Korea’s early, decisive action was crucial. South Korea was one of the first countries where Covid-19 was seen outside of China, before much was known about the virus at all. It seemed at high risk for an unstoppable outbreak — and instead, it staved off disaster. To date, the US ranks 10th in its total cases per capita; South Korea ranks 145th. Though it has been slower to vaccinate its population than world leaders like the US, South Korea is still seeing fewer than 700 new cases per day on average; the United States, meanwhile, is averaging more than 70,000.

“South Korea was able to flatten the epidemic curve quickly,” researchers from Harvard and Seoul National University wrote in a review of the country’s response. Among the top reasons for its success: “conducting comprehensive testing and contact tracing and supporting people in quarantine to make compliance easier.”

Testing capacity quickly expanded. Contact tracing began. And at the isolation center, Jo settled into a new routine, calling up to 50 patients a day to check on them. If they fell sick, she had no treatment to offer. Nobody knew what would work. They had one option: test, trace, and isolate.

Patients lapsed into depression. They had nothing to do but watch TV and eat out of their lunchboxes; some people would vomit when they took their daily Covid-19 tests, administered through the nose. In the most extreme cases, a patient would stop responding to the nurses’ calls. A nurse in protective gear would enter the room and try to provide the person with more direct emotional support.

“I could see the patients started to lose it mentally and emotionally,” Jo said. “I was always on alert, and the emotional care was really difficult for me.”

The strategy was not without its costs, and not all of its components may be universally applicable; Americans especially already have a deep distrust of the government and government surveillance. And South Korea has made mistakes. In some cases, public officials leaked patients’ personal information. Civil rights advocates say the government unconstitutionally overreached to track people’s locations. Clusters continue to pop up, and businesses still operate at limited capacity.

But the country’s response saved lives. Thousands of health care workers and millions of everyday South Koreans made the sacrifices necessary to prevent the kind of mass death seen in much of the Western world. To date, fewer than 2,000 South Koreans have died from Covid-19. The country has never issued an official stay-at-home order; subway trains and buses have been mostly packed with commuters, and people have been working in their offices as usual since last spring. Masks are commonplace, but otherwise, Covid-19 has not altered the fabric of everyday life in South Korea the way it has in much of the Western world.

Five years earlier, an outbreak of the MERS virus, which appeared to be even more lethal than Covid-19, led to strict social distancing protocols. The country took action after that crisis so it would be better prepared for the next outbreak.

“I think back then, Koreans didn’t realize that new infectious diseases can be a threat to all of us,” Park Young-joon, a top official at the Korea Disease Control and Prevention Agency (KDCA), says. “These experiences led to a change in attitude.”

They were determined never to be caught off guard again.

After a deadly failure, South Korea reformed its public health system

In December 2019, about two dozen of South Korea’s top epidemiologists and health officials gathered at the KDCA for a training exercise. The scenario: A hypothetical coronavirus had originated in China, and a family of four was bringing the new respiratory virus into South Korea from Hong Kong.

After the exercise, an internal review singled out the importance of using GPS and credit card data to track contacts with the infected patients. Another idea proposed during the simulation would also prove prescient: The country should develop testing materials that could be quickly adapted to any new coronavirus.

The country committed to running these pandemic war games after it was threatened by two of the most frightening respiratory pathogens to appear in the 21st century.

During SARS-1, in 2003, South Korea was considered a model for its decisive response. Just three people died.

Then came MERS, an even deadlier coronavirus, in 2015.

A man in his late 60s visited several Seoul-area hospitals and health clinics before he was diagnosed with MERS. He was likely the country’s patient zero, and he infected other patients and medical workers over a 10-day period. The outbreak, the largest outside the Middle East, led to 186 confirmed cases and 38 deaths, and highlighted weaknesses in the country’s contact tracing and quarantine programs.

A year earlier, a very different disaster — the sinking of the Sewol ferry that killed more than 300 people — sparked outrage at government incompetence. South Koreans were losing faith in the government’s ability to handle a crisis. In the wake of MERS, public officials were criticized for failing to apply the lessons of SARS-1. People wanted something done.

“People freaked out,” Kelly Kim, general counsel at Open Net Korea, a civil rights group, says. “If something bad happens, they always blame the government and ask the government to do something about it. The easiest thing is making a law.”

The government passed a total of 48 reforms after MERS, all toward the goal of being better prepared for the next pandemic. The country committed to a playbook: test, trace, and isolate. Crucial changes were made to the system for contact tracing — the process where health workers talk to infected people and get a list of those they were in recent contact with, and then work outward, asking those contacts to get tested and isolate themselves.

But that system only works if the patients are forthcoming. During the MERS outbreak, one man had reportedly lied to health workers about his presence at a conference attended by 1,000 other people.

“It put the whole country into this crisis,” Park Kyung-sin, a professor at Korea University Law School, says. “The lesson was clear: Location tracking has to be done on a mandatory basis.”

The post-MERS changes passed by the national legislature authorized federal agencies to access credit card transactions, cellphone location data, even CCTV footage if needed. People could be fined for breaking quarantine. The number of infection control staff and isolation units was increased.

There was a culture change, too. Public health officials started running the periodic outbreak simulations to test their readiness. And Park Young-joon read daily status updates on emerging diseases.

A few weeks after the pandemic simulation, one of those reports came from Wuhan, China, noting an outbreak of aggressive pneumonia. At first, he didn’t take the reports of an unknown respiratory virus too seriously. But then he learned the Chinese government was locking down the entire city. That was when he first believed it would spread to South Korea.

“I realized this disease was different,” he says. “We felt it was just a matter of time.”

When Covid-19 hit, South Korea put its new protocols in action

There were still only four confirmed Covid-19 cases in South Korea on January 27, 2020, when government health officials gathered representatives from more than 20 medical companies in a conference room in Seoul’s biggest train station.

The message was simple: We need tests for this dangerous new virus, as soon as humanly possible, and we will approve yours quickly if it works.

After the MERS scare, the government budget for infectious diseases nearly tripled in five years, spurring a boom in the biotech sector. Some of that new funding was spent on research and development for testing kits.

A week after the train station meeting, on February 4, South Korea approved its first Covid-19 test. The same day, in the United States, the Food and Drug Administration okayed a testing kit designed by the Centers for Disease Control and Prevention.

The US test would prove unreliable, setting efforts back by weeks. South Korea’s was swiftly validated at more than 100 laboratories. Companies were soon shipping thousands of test kits to labs and hospitals across the country.

By March 1, South Korea was performing more than 10,000 tests every day. The US couldn’t even manage 100. When adjusting for population, it wouldn’t be until mid-April — when South Korea’s outbreak was under control — that the US would finally overtake Korea in total tests performed.

The surge in testing capacity came just in time. Patient 31 was about to figure into the country’s first known superspreader event, which would stretch Korea’s ability to rapidly test for Covid-19, trace the contacts of infected people, and isolate them.

On February 17, the patient, a woman in her 60s, tested positive for Covid-19 and was interviewed about her recent movements. Korean officials quickly realized they had a crisis in the making.

The woman had traveled between Seoul and Daegu, the country’s fourth-largest city, in the days before testing positive. She also attended services at the Shincheonji Church of Jesus, an insular Christian group based in Daegu.

Park Young-joon, as the head of epidemiological investigations at the KDCA, was quickly dispatched to Daegu. The government set up testing centers all across the area, including drive-through sites that could perform three times as many tests as regular clinics. After public pressure, the church group handed over a list of its members for contact tracing. Conscripted military personnel were called in to help.

Within days, hundreds of church members had tested positive. Park Young-joon decided the best way to contain the outbreak was to isolate everyone who may have been exposed. Thousands of people, tracked down through security footage and phone data, were urged to self-quarantine. The government struck a deal with Samsung and LG to transform their training dormitories into isolation centers for people deemed at higher risk. Noncompliance came with a hefty fine: more than $8,000 US.

The call went out to nurses like Jo Hye-min, pleading for volunteers to staff the isolation centers. More than 3,000 patients would enter the facilities during the month of March.

The country’s outbreak quickly leveled off. After averaging more than 500 new cases every day during the first week of March, the rate of daily new cases slowed dramatically. Over the first week of April, South Korea saw about 500 new cases total.

“We did an impossible task,” Jo says. “It was as though we built the Great Wall in a week.”

But Covid-19 wasn’t gone.

The next big scare arrived a month later, in early May: a cluster of infections linked to the Itaewon nightclub district. The clubs had reopened on April 30 — and by May 6, several cases were confirmed among people who had partied at one of them.

Jang Hanaram, a member of the military doing contact tracing work in Seoul, was put on the case. Jang says he was soon working 24 hours a day while sleeping in the bunk bed in his office. His days were a blur of phone interviews: He estimates that at the height of the effort, he was making more than 200 calls without a break.

Tracing contacts from the Itaewon outbreak added an extra degree of difficulty: Some of the nightclubs were favored by the LGBTQ community. There is still a lot of discrimination against LGBTQ people in South Korea, and people were not always forthcoming about where they’d been and whom they’d been in close contact with for fear of being outed or outing others.

One man, Jang says, lied to him during a contact tracing interview. But he and his team had other options. He could pull the man’s credit card and GPS data instead.

“Even when people weren’t so cooperative, we can find out where this person went and when,” Jang says.

By the end of May, using cellphone location data, South Korean authorities had identified nearly 60,000 people who had spent at least 30 minutes in the vicinity of the Itaewon nightclubs between April 30 and May 6.

Those people were simply urged to get tested. But another 1,200 deemed to be at higher risk of exposure were required to self-quarantine while being monitored by the government. Those patients checked in with health workers over a smartphone app; the government also sent them groceries and toiletries, and offered them psychological counseling.

Ultimately, the Itaewon cluster was linked to just 246 cases, and overall caseloads stayed well below what was seen in Daegu. The country didn’t see a second significant wave until late August, ignited by the protests of another church group.

But the extraordinary phone surveillance required to identify the 60,000 possible contacts in Itaewon has come under scrutiny from civil rights advocates, who saw some of their fears about the powers granted to the government in 2015 coming true.

“This was not the use envisioned by the people who passed the law after the MERS outbreak,” Park Kyung-sin says.

Privacy advocates worry about how much information the government can get — but it’s a “lonely fight”

South Korea’s epidemic response is distinct from that of the US and almost every other country in the world in one important way.

In the US, disease investigators must rely on interviews and, in theory, opt-in phone tracking apps, though those have struggled to attract enough users to be effective. In South Korea, cooperating with contact tracing isn’t done out of altruism, though everybody we spoke to stressed that South Koreans do feel a strong sense of civic responsibility. It’s the law — and if you refuse to comply, the authorities can get your financial or location data anyway. No such legal obligation exists in the US.

“The right to collect and use very personal information was an essential part of the [2015] legislation,” Park Young-joon says.

South Korea’s government has stretched that authority as far as it can go during the current emergency — beyond what is legally permissible, according to some civil rights lawyers we spoke with.

During the Itaewon outbreak, for example, the public health authorities didn’t just notify the people who had come into close contact with the patients who later tested positive. They used phone location data to alert anybody who was in the area of their potential exposure, which South Koreans focused on privacy rights saw as a serious overreach.

Park Kyung-sin explains the difference with an analogy about how police might investigate a crime: Normally, investigators get a warrant to follow specific people, targeting specific phone numbers.

But what South Korea did in Itaewon, he says, was more comparable to the National Security Agency surveillance exposed by Edward Snowden. Anybody who was within a certain area, no matter the individual risk of exposure, had their location data scooped up by the government.

“When that’s done against your consent, that is a problem,” Park Kyung-sin says. “We are not really fighting the law but the use of the law.”

One man who lied to contact tracers after the Itaewon outbreak was a teacher who worried about the consequences if people found out he was gay. Because he misled investigators, he was arrested and sentenced to six months in jail.

A couple of months after the Itaewon outbreak, Park Kyung-sin and his colleagues at Open Net Korea filed a constitutional challenge against the government’s use of the 2015 laws, asking for restrictions on mandatory location tracking and clear commitments from the government about deleting information.

And yet, broadly speaking, the public has accepted the measures. About nine in 10 South Koreans said in May 2020 that they supported disclosing patient location information. Attitudes may be changing as the pandemic drags on — Park Young-joon said he and his colleagues have noticed a decline in support — but most people continue to comply.

“Most Koreans are willing to compromise their privacy for their life,” Kelly Kim at Open Net Korea, the civil rights group, says. For privacy advocates, “it’s been a really hard fight, a kind of lonely fight.”

South Korea’s system worked because it acted early

South Korea’s citizens don’t regard the country’s response as perfect. They have endured their share of strife.

Park Jeong-uk, a pub owner in Seongnam, saw his monthly revenue drop by 50 percent during a small wave of cases in August. A winter surge that necessitated more social distancing measures was even harder. He had to let two part-time workers go, and has taken out bank loans he’ll have to start paying back soon. He lost a lot of sleep.

But he’s feeling pretty optimistic these days.

“Despite the shortcomings, I agree the Korean government did their best, given the circumstances,” Park Jeong-uk says. “And Koreans did an excellent job cooperating with the government. Most people trusted the government and followed the protocols.”

In some ways, South Korea simply may have lucked out. It is almost like an island, sharing only a militarized land border with North Korea, making it easier to isolate and monitor incoming travelers. Its people were better acquainted than most with social distancing measures, having lived through MERS. There is generally a lot of government surveillance that may have inured people to their private actions being fodder for public health monitoring.

Contact tracing alone isn’t a panacea. The US struggled on the first step in the test-trace-isolate process, when the first CDC testing kit failed, and that allowed the virus to spread undetected. By the time testing was closer to adequate levels, infections were so widespread it would have been extremely difficult to conduct comprehensive contact tracing, especially without the extraordinary tools available in South Korea.

Testing, tracing, and isolating is a good way to put out small fires, as the preferred metaphor among epidemiologists goes. Once the whole forest is ablaze, it loses its utility.

But that is also the point. South Korea saw a small fire spring up in Daegu in February 2020 and focused the full power of the government on stamping it out — then watched to ensure no new sparks would create a conflagration. Those efforts succeeded.

“We’ve been training for this,” Jang Hanaram says. “We are in this together; our community comes first. Koreans have really stepped up.”

Jun Micheal Park is a documentary photographer and filmmaker from Seoul. He has extensively covered South Korea’s Covid-19 response.

This project was supported by the Commonwealth Fund, a national private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy.

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April 15, 2022 NewSimulationShoes News