The father of the reporter of this journal is in his late 60’s and has an underlying medical condition. He is currently residing in the southeastern city of Daegu, South Korea. As the Coronavirus/COVID-19 issue has become serious over the past weeks, especially penetrating most parts of Daegu city, which led his whole family to the crossroads of having to make several decisions.

At first, the reporter thought if he should have his father stay in Seoul where his children live, since COVID-19 can be deadly to those over 60’s with an underlying disease. But staying in Seoul could be more dangerous because of his children who still commute to work. The reporter chose to have his father “Jip-cock” — (self-isolate at home) — in Daegu city for now. The next problem they faced was related to hospital treatment and the prescription of medicine. Hearing news that a majority of nurses in the hospital his father usually visits had been confirmed positive for the coronavirus, he had to delay his visit to the hospital, but his medicine was running out. He had to face two options: visiting the hospital to get his medicine with the risk of being infected, or waiting at home with the hope that the situation would get better, ignoring the risk of aggravation of his underlying disease.

Fortunately it became known that the Ministry of Health and Welfare temporarily allowed medical institutions to consult and prescribe over the phone from Feb. 24. They heard from the hospital that consultation was available over the phone and prescriptions were given by fax on appointment days. Next, they had to find a pharmacy. The previous pharmacy near the hospital where they usually received their medicines was quite far from home and there were many confirmed cases of infection in the vicinity. They had to find the nearest pharmacy around home, but most of the pharmacies they contacted did not receive prescriptions by fax or did not have the medicine they needed. In the end, they had no choice but to visit a large pharmacy near a general hospital. Here, they had to make a decision again between taking a bus or subway with a number of simple contacts, or taking a taxi where he could most likely have one close contact.

Not only the reporter’s family, but everyone in Korea faced similar dilemmas at every moment of the past weeks. These were painful days when one had to choose the second worst in order to avoid the worst. These were situations where someone was about to undergo cancer surgery, someone was about to give birth, or someone had a child who continued coughing. One high-risk mother delayed her regular medical check-up after her childbirth, but one terminally ill cancer patient received anticancer treatment at a hospital where some confirmed coronavirus patients were found. Some parents took their children to a pediatrician with anxiety, and others took care of their coughing children with folk remedies at home. Some stood in line in front of a mart in desperate need of face masks, but others gave up standing in line due to a great fear of getting infected there. Assessing the risks based on the circumstances where they were and information that they had, everyone chose response strategies. It is only the result that will determine which choice was the right one.

South Korea itself has also been in a dilemma, at the crossroad of tens of thousands of choices over “what way is the most protective of people’s lives and safety.” Once selecting an option in the current situation, the situation will have changed before long. Emergency measures implemented yesterday are of no use today, and new measures to be chosen today might bring about countless side effects tomorrow. In such a dilemma, they have to push forward anyway. Numerous fumbles were committed and followed by innumerable criticisms.

Notwithstanding, we the people of Korea and the government must continue to think critically about the situation. If COVID-19 is the “enemy,” then it means the crisis we are undergoing now is a “war.” We have to now choose something and give up other things in order to win. While medical personnel and patients are fighting to overcome this painful but progressive situation at the frontline, we, on the other hand, must not hate, ridicule, or blame others. Quickly but calmly, it is time to strategize. What we need are “novel strategies” against this novel infectious disease.

■ Unprepared “Mitigation” Strategy

When COVID-19 first entered Korea, our government's first strategy was "containment." A series of responses were ongoing under the containment strategy:preventing people from Hubei Province, China, from entering Korea; bringing back Korean residents from Wuhan, China, the city where the virus originated; conducting body temperature checks at the airport's arrival hall; hospitalizing those confirmed to have the coronavirus in quarantine negative pressure rooms; disinfecting and closing all the places suspected to have had confirmed cases of the virus; revealing the tracks of infected cases to the public; and 14 days self-quarantine, etc. These strategies were adopted based on the lessons from the domestic outbreak of Middle East respiratory syndrome (MERS) in 2015.

The MERS’ strategies seemed to work for a while. Since the first confirmed case of coronavirus occurred on Feb. 10, more confirmed cases occured at a manageable level, around one to five per day. There also emerged the possibility of an  end of COVID-19, with no additional confirmed case for five days as of Feb. 11. The situation, however, was completely reversed when the 31st confirmed patient in Daegu city was recorded on Feb. 18. More confirmed cases were surging at the Church of Shincheonji, a secretive religious sect, and Cheongdo Daenam Hospital, based in and near Daegu, the fourth largest city of S. Korea. With a soaring 100 or 200 cases per day, the confirmed cases as of Feb. 27 reached a total of 1595. The death toll mounted to 13 as of Feb. 27, mostly from those with an underlying medical condition.

In time, the existing strategy was no longer effective. Rather, there had been serious side-effects. As a result of implementing the existing guideline related to the temporary closure of places where confirmed patients were found to have been, almost every emergency room in Daegu city was closed for a certain period of time. Every medical staff who contacted confirmed patients had to be self-quarantined for 14 days, which led to a sharp decline in the number of medical staff workers left for patient care in hospitals. Since it takes 30 to 40 minutes for a person to be tested by medical staff wearing protective gear, suspected patients had to wait in line in front of the selected clinics for a long time. The quarantine negative pressure rooms for confirmed patients prepared in advance became crowded with patients within a few days. It was in an instant that the fear over the COVID-19 spread all over the country.

The crisis alert was raised to a “critical level,” which is level 4, on Feb. 23, which was when the Korean government declared it would supplement the “containment” strategy with the “mitigation” strategy: Slowing down the pace of the spread of the disease outbreak to the maximum by the constant containment strategy, and minimizing the infection damages that have already happened, with the new mitigation strategy.

At the mitigation phase, several preventive measures of the containment phase are less effective, because mitigation is mainly focused on “treatment” with limited resources. Due to the overflow of confirmed cases, the willingness to devote lots of energy to conducting an epidemiological investigation and revealing the tracks of the infected fades away. Some of the patients fail to check into the negative pressure rooms due to the limited space and resources, so they have to check into other hospital rooms which become quickly emptied and temporarily designated as COVID-19 exclusive. As a result, some suspected patients have to wait at home monitoring their symptoms. Suffering from a surge of patients and a shortage of supplies, medical staff workers begin to take off their protective gear one by one. The Daegu city has now been driven into such a “mitigation” phase without any strategy.

■ The Right Mitigation Strategy: Reflecting on MERS and Swine Flu

The mitigation phase means that there is a pandemic of an infectious disease, which must be handled with workable strategies from now on. In order to reduce the number of casualties among the influx of confirmed cases, it is important to apply “the right kind of mitigation strategy,” as well as shifting from containment to mitigation. There will be a response suitable for COVID-19 somewhere in the broad spectrum between containment and mitigation. But where is it? In order to narrow down the issue, we need to remind ourselves of the memories related to the previous infectious diseases we have experienced before.

First, let’s see the 2015 domestic outbreak of MERS. After the first confirmed case on May 20, 2015, there were 186 confirmed cases and 38 deaths until the pandemic was declared over on Dec. 23, 2015. The authorities quarantined the Samsung Medical Center in S. Korea as a form of “Cohort Isolation” and fully operated only a few negative pressure rooms nationwide;  however, it turned out that such move was not enough at the time. A strong containment policy based on the lessons learned from this was applied to the current COVID-19 outbreak, only to lead to incapacitation within a month. COVID-19 was different from MERS. The former has a lower mortality rate, but a far stronger power of transmission than MERS. Unlike MERS emitting the virus the most when the infected person is in a serious condition, COVID-19 has the highest level of virus emission in the early stage of infection, making it very difficult to contain the spread of the virus. The plan to exterminate COVID-19, which spreads like wildfire, with limited quarantine and medical resources may have been impossible from the beginning.

If the MERS response does not work, then what about the response from the Swine Flu experience? After its domestic first case was reported on Apr. 28, 2009, the swine flu recorded an estimated 700,000 infection cases and 263 deaths in total until Apr. 1 of the following year, when the national crisis phase was lowered to “concern (blue),” also known as level 1. During this period, the number of patients had increased so rapidly that the World Health Organization (WHO) and the S. Korean authorities stopped counting the confirmed cases from July 16, 2009 and from Aug. 21, 2009, respectively. WHO declared the pandemic as Phase 6, its most severe phase, as of June 11, 2009, and S. Korea also raised its national crisis phase to “critical (red).” which is level 4, as of Nov. 3, 2009.

However, the atmosphere of the swine flu’s “critical” phase at the time was quite different from that of the COVID-19. If one caught the flu, he/she was able to go to a local clinic for treatment or just struggle at home. Even if he/she went to a big hospital because he/she was serious, he/she would not check into a negative pressure room or meet any medical staff equipped with D-level protective gear like spacesuits. Schools still stayed open in spite of some vacancies in classrooms and so did workplaces with people still commuting day and night. Rallies, weddings, funerals, concerts and exhibitions were also held as scheduled.

Won’t this COVID-19 crisis subside some day like back then, when we are able to cope well enough and at the same time maintain our daily lives? But COVID-19 is too different from the swine flu. There were two powerful weapons in the war against the swine flu: Antiviral agents and Vaccines. In April, 2009 when its first confirmed patient appeared in Korea, the antiviral agents were already available. The swine flu vaccination also started to be available as of Nov. 11, 2009. While antiviral agents relieved the symptoms of the infected, dropping the amount of virus emission, vaccines created herd immunity. As a result, the number of suspected swine flu patients graphically showed a sharp decline from the peak in the first week of November that year. The number of antiviral agent dosages per day, deaths, and cluster outbreaks, all declined sharply during a similar period. However, there is no such a weapon for the war against COVID-19, and even the possibility of getting hold of it anytime soon is not that high.

It is okay to carry out the MERS containment strategy if resources are limitless, and the swine flu’s mitigation strategy if there is a powerful weapon. In the case of COVID-19, the resources such as medical staff, supplies and beds are limited with no cure and vaccine yet. Under such a circumstance, the authorities must minimize the public anxiety and the impact of COVID-19 on the medical system and the economic, social, and cultural sectors. What is the “novel strategy” against this challenging novel infectious disease? Experts suggest largely three things: First, solve the bottleneck effectively with the prioritization of resource utilization such as medical staff, supplies, beds, etc.; second, set a stronger “social distancing” strategy; lastly, continue to manage other risks that could be higher during any pandemic period, no less than COVID-19 itself.

■ Novel Strategy No. 1: Prioritizing

The first strategy in “prioritizing resource utilization to solve the bottleneck” is required for the following questions: Is it necessary for every confirmed patient to be hospitalized only in the quarantine negative pressure rooms, in spite of the lack of beds? Is it necessary to close an emergency room and make all the medical staff self-quarantined for 14 days every time one confirmed patient is found to have been there? Is it necessary to conduct testing by those with D-level protective gear in limited negative pressure facilities, which takes 30 to 40 mins per capita, in a situation of long waiting lines? There is now similar confusion in practice, in the regions of Daegu and North Gyeongsang Province, S. Korea. Some principles have already collapsed and the others are barely holding out.

Putting behind us our regret and reproach like “what if we had prepared more,” we need to accept the fact for now, that resources are limited. “In a situation where the quarantine phase needs changing rapidly from containment to mitigation, all the previous strict standards of diagnosis, quarantine, hospitalization, treatment, discharge, etc. must be completely readjusted. Otherwise, the bottleneck could function as a trap,” said Lee Wang-jun, M.D., chairman of the board of Myongji Hospital based in Gyeonggi Province, S. Korea, at the Experts’ Emergency Symposium for Response to COVID-19 on Feb. 19.

However, the standards must be treated with caution and not be taken so loosely. Therefore, a thorough prioritization and readjustment of resource utilization standards, under a consistent principle must be implemented, so as to relieve social anxiety. Let’s take bed assignment as an example. The confirmed coronavirus patients by now have been assigned each bed by order of arrival, regardless of symptoms or risk levels. If the total 100 beds were full of minor, low-risk patients, the next 101st critical, high-risk patient would have to wait at home until one of the beds got empty. Such has happened in practice in the regions of Daegu and North Gyeongsang Province, with the death of a 74-year-old while waiting for hospitalization at home on Feb. 27. As additional deaths occurred in the middle of waiting for hospitalization, on Mar. 1 the government came up with a plan to have minor patients check into temporary “Daily Healthcare Center(s)” in each region.

The government said it will vacate the nationwide public hospitals and local medical centers to secure up to 10,000 beds. Securing more beds, however, does not solve the whole problem(s). “Medical service is a communication system. More secured beds are good for nothing without a system of secured channels of communication.” said Lim Seung-gwan, head director of Gyeonggi Provincial Medical Center Ansung Hospital, S. Korea. It means each patient must be placed in a medical institution suitable for his/her symptoms.

Lim maintained his stance concerning COVID-19 that we must not only separate seriously infected patients from minor ones, but also consider to separate patients with mental illness and those with severe disabilities who have been confirmed, as well as pregnant women, infants and blood dialysis persons, etc. who need special care.

Questions have been raised about emergency room shutdowns, medical staff’s self-quarantine and inefficient testing methods. As the COVID-19 issue has grown serious, it happened that all of the emergency rooms, where the confirmed and suspected patients were found to be, came to a shutdown. At most hospitals that wanted to avoid such a situation, emergency patients with symptoms similar to the coronavirus’ like fever and cough but not yet confirmed as infected with the corona virus were rejected, leading to secondary damages. “At this point, the above is not an ideal measure but instead the maximum utilization of our resources. Also, instead of an unnecessary shutdown, due to a suspected case, quarantine must first be put in place and then performing the normal emergency treatment must continue, following the infection safety rules until his/her test result comes out. For example, in case he/she is tested positive, shutdown should be allowed but the treatment should be resumed as soon as possible, provided the facility is sufficiently disinfected.” said Heo Tak, emergency medical doctor at Chonnam National Univ. Hospital, based in South Chonnam Province of S. Korea and chairman of the board of The Korean Society of Emergency Medicine.

There are divisions among the medical professionals concerning the standard of self-quarantine of medical personnel who gets in contact with a confirmed infected person. “The possibility of being infected is low if all the patients and medical staff workers wear masks. Rather than quarantining for 14 days, treating other patients while closely monitoring their symptoms can prevent other damages caused by COVID-19,” said Lee Sung-soon, head director of Inje Univ. Ilsan Paik Hospital based in Gyeonggi Province of S. Korea, at the Symposium of Feb. 19. He also said, however, “Infection within a hospital and of medical staff is very scary. We must consider the COVID-19’s feature that it can spread without any symptoms.”

The medical staff’s protection level at the testing stage has to be seen in the same context as above. Time, space, and medical personnel are all insufficient to fulfill the standard during MERS and Severe Acute Respiratory Syndrome (SARS). When testing in an open space by those with protective gear, the medical staff worker and his suspected patients may be at high risk of being infected. To solve this, experts actively discussed 3rd plans during the last week, such as testing at home, utilizing of negative pressure phlegm collection booths that are usually used for tuberculosis tests, etc. Likewise, “drive-thru” testing where the suspected patients can be tested in his/her car without getting out, and so on. Some of them have already been implemented in practice.

■ Novel Strategy No. 2: Stronger “Social Distancing”

The subject of the second strategy “social distancing” is both the quarantine authority and the public. When the government persuades the public with specific plans and the public cooperates with the government with trust, things take effect. Social distancing is a representative strategy of “mitigation” that is frequently mentioned at the pandemic phase. It has been chosen at present, which is why rallies, events and gatherings are cancelled and temporary shutdown of businesses and schools are recommended, resulting in most people now working from home.

Kim Jin-yong, infectious disease medical specialist at Incheon Medical Center, S. Korea, suggests “nonpharmaceutical interventions” which are stronger than the existing “social distancing.” 〈Community Mitigation Guidelines to Prevent Pandemic Influenza — United States, 2017〉 compiled by the U.S. Centers for Disease Control and Prevention(CDC) indicate the methods of nonpharmaceutical interventions needed for seasonal flu and novel flu pandemics, respectively — (Figure 1). Kim said the government must persuade the public to be in concert with the strong level of home quarantine referred to in the CDC’s guidelines.

[Figure 1]Abbreviation: NPI = nonpharmaceutical intervention.
Source: the U.S. Centers for Disease Control and Prevention(CDC). Community Mitigation Guidelines to Prevent Pandemic Influenza — United States, 2017

As a result of mathematical modeling in “A Study on the Design and Development of an Integrated Monitoring System for Early Warning of Infectious Diseases” by the Government-wide R&D Fund for Infectious Diseases Research (S.Korea), the strategies of “nonpharmaceutical interventions” in which the entire nation is involved had a much greater effect than the “reduction of the long-distance population movement by public transportation.” The sooner the infected and those coming in contact with them were quarantined together, the more significantly the total number of the infected would decrease. That is why the whole family needs preemptive isolation if a person has slight suspected symptoms, under the circumstance where all are unable to be tested at once.

■ Novel Strategy No. 3: Managing Secondary Damage

Some insist that it is also necessary to reconsider the risk evaluation of COVID-19 itself. It means we should think it over if the outsider a.k.a. COVID-19 that came in through our gates is the real enemy that is trying to kill us all. The point is that, under the circumstance where it is not possible to prevent all coronavirus cases, trying to eradicate them all cases may threaten considerable secondary damage, we need to recognize that the virus is one of the risk factors in our lives to some degree. It is in a similar context that we still drive a car, despite the risk of car accidents, and that the elderly and the infirm with a flu do not stay at home throughout the year despite the risk of acute respiratory failure.

Regarding the tragedy that has happened at the emergency rooms of hospitals during the recent weeks, Seo Ju-hyun, emergency medical specialist at Myongji Hospital, said, “A patient with a heart attack was rejected by many emergency rooms in and around his city just because he came from China, so that his heart stopped for a while, he was barely alive afterward. Another patient with a stroke had to confirm the test result for coronavirus first before taking the medical treatment just because he was in Italy a month ago, with his urgently needed surgery delayed. An eight-year old boy with pneumonia symptoms like coughing and feeling heavy in his heart went to an emergency room but failed to check in. He had to unbearably and painfully wait for his coronavirus test result to come out negative before any treatment, so, waiting in a cold container building throughout the night, just because he had visited one of the areas where the virus prevailed.” Seo added, “Such matters seem to account for much more cases of health aggravation and death now than COVID-19 does. There are countless bacteria and viruses in this world, all of which are impossible to eradicate. I don’t know if it is reasonable for all the medical staff and the public to be obsessed with COVID-19 only.”

Tak Sang-woo, research professor at Seoul National Univ. Institute of Health & Environment in S. Korea, gave an example and said, “A person riding a scooter with a face mask but without a helmet. That person judges the risk of COVID-19 infection to be more significant than that of an accident. Each one has different understandings about the risk, which causes confusion. Far more data about COVID-19 risk has been created than a month ago. The quarantine authority must provide objective grounds, based on the data with which individuals can evaluate the risk.”

The effect of these “novel strategies” cannot be guaranteed. If you have fear, doing nothing could be another solution. In the graph by the U.S. CDC — (Figure 2), during the pandemic outbreak without vaccine and treatment, the curve shape of “no intervention” is very different from that “with intervention.” Let's note that this graph shows the number of the infected, not the number of the confirmed. “No intervention” may be what the Japanese government has chosen at present. If S. Korea chose the way of “with intervention,” the goal is to lower the peak of the curve to the lowest and reduce the half-filled area—the total damage scale—to the least. We will be able to judge if the decisions are right and the strategies are effective at the end of the pandemic. It is all of us who draw the graph curve until the end comes.

[Figure 2]Source: The U.S. CDC. Community Mitigation Guidelines to Prevent Pandemic Influenza — United States, 2017 (Adapted from: CDC. Interim pre-pandemic planning guidance: community strategy for pandemic influenza mitigation in the United States—early, targeted, layered use of nonpharmaceutical interventions. Atlanta, GA: US Department of Health and Human Services, CDC; 2007)

translated by Daok Cook
translation supervised by Franz Maier, Sumi Paik-Maier