The Battles

The Unlikeliest Pandemic Success Story

How did a tiny, poor nation manage to suffer only one death from the coronavirus?

Story by Madeline Drexler

FEBRUARY 10, 2021

https://www.theatlantic.com/international/archive/2021/02/coronavirus-pandemic-bhutan/617976/?utm_source=newsletter&utm_medium=email&utm_campaign=atlantic-daily-newsletter&utm_content=20210210&silverid-ref=MzQzOTU3ODQ3MzAyS0

On january 7, a 34-year-old man who had been admitted to a hospital in Bhutan’s capital, Thimphu, with preexisting liver and kidney problems died of COVID-19. His was the country’s first death from the coronavirus. Not the first death that day, that week, or that month: the very first coronavirus death since the pandemic began.

How is this possible? Since the novel coronavirus was first identified more than a year ago, health systems in rich and poor countries have approached collapse, economies worldwide have been devastated, millions of lives have been lost. How has Bhutan—a tiny, poor nation best known for its guiding policy of Gross National Happiness, which balances economic development with environmental conservation and cultural values—managed such a feat? And what can we in the United States, which has so tragically mismanaged the crisis, learn from its success?

In fact, what can the U.S. and other wealthy countries learn from the array of resource-starved counterparts that have better weathered the coronavirus pandemic, even if those nations haven’t achieved Bhutan’s impressive statistics? Countries such as Vietnam, which has so far logged only 35 deaths, Rwanda, with 226, Senegal, with 700, and plenty of others have negotiated the crisis far more smoothly than have Europe and North America.

These nations offer plenty of lessons, from the importance of attentive leadership, the need to ensure that people have enough provisions and financial means to follow public-health guidance, and the shared understanding that individuals and communities must sacrifice to protect the well-being of all: elements that have been sorely lacking in the U.S.

America has “the world’s best medical-rescue system—we have unbelievable ICUs,” Asaf Bitton, executive director of Ariadne Labs, a Boston-based center for health-systems innovation, told me. But, he said, we have neglected a public-health focus on prevention, which socially cohesive low- and middle-income countries have no choice but to adopt, because a runaway epidemic would quickly overwhelm them.

“People say the COVID disaster in America has been about a denial of science. But what we couldn’t agree on is the social compact we would need to make painful choices together in unity, for the collective good,” Bitton added. “I don’t know whether, right now in the U.S., we can have easy or effective conversations about a common good. But we need to start.”

Over the course of three reporting trips to Bhutan since 2012, a word I heard innumerable times was resilience. It alluded to the fact that Bhutan has never been colonized, and to its people’s ability to bear hardships and make sacrifices. Resilience, I came to learn, is core to the national identity.

That mattered when the coronavirus began spreading early last year. At the time, Bhutan looked like a ripe target. It had only 337 physicians for a population of around 760,000—less than half the World Health Organization’s recommended ratio of doctors to people—and only one of these physicians had advanced training in critical care. It had barely 3,000 health workers, and one PCR machine to test viral samples. It was on the United Nations’ list of least developed countries, with a per capita GDP of $3,412. And while its northern frontier with China had been closed for decades, it shared a porous 435-mile border with India, which now has the world’s second-highest number of recorded cases and fourth-highest number of reported deaths.

Yet from the first note of alarm, Bhutan moved swiftly and astutely, its actions firmly rooted in the latest science.

On December 31, 2019, China first reported to the WHO a pneumonia outbreak of unknown cause. By January 11, Bhutan had started drafting its National Preparedness and Response Plan, and on January 15, it began screening for symptoms of respiratory ailments and was using infrared fever scanning at its international airport and other points of entry.

Around midnight on March 6, Bhutan confirmed its first case of COVID-19: a 76-year-old American tourist. Six hours and 18 minutes later, some 300 possible contacts, and contacts of contacts, had been traced and quarantined. “It must have been a record,” Minister of Health Dechen Wangmo—a plain-spoken Yale-educated epidemiologist—told the national newspaper Kuensel, with evident pride. Airlifted to the U.S., the patient was expected to die, but survived. According to an account in The Washington Post, his doctors in Maryland told him, “Whatever they tried in Bhutan probably saved your life.”

In March, the Bhutanese government also started issuing clear, concise daily updates and sharing helpline numbers. It barred tourists, closed schools and public institutions, shut gyms and movie theaters, began flexible working hours, and relentlessly called for face masks, hand hygiene, and physical distancing. On March 11, the WHO tardily deemed COVID-19 a pandemic. Five days later, Bhutan instituted mandatory quarantine for all Bhutanese with possible exposure to the virus—including the thousands of expatriates who boarded chartered planes back to their homeland—and underwrote every aspect, such as free accommodation and meals in tourist-level hotels. It isolated all positive cases, even those who were asymptomatic, in medical facilities, so early symptoms could be treated immediately, and provided psychological counseling for those in quarantine and isolation.

Bhutan then went further. At the end of March, health officials extended the mandatory quarantine from 14 to 21 days—a full week longer than what the WHO was (and still is) recommending. The rationale: A 14-day quarantine leaves about an 11 percent chance that, after being released, a person could still be incubating the infection and eventually become contagious. Bhutan’s extensive testing regimen for people in quarantine, Wangmo added at a press conference, was “a gold standard.”

While President Donald Trump was railing against coronavirus surveillance, Bhutan launched a huge testing and tracing program, and created a contact-tracing app. Last fall, the health ministry rolled out a prevention initiative called “Our Gyenkhu”—“Our Responsibility”—featuring influencers such as actors, visual artists, bloggers, and sports personalities. When, in August, a 27-year-old woman became the first Bhutanese in the country to test positive for COVID-19 outside of quarantine, a three-week national lockdown followed, with the government ramping up testing and tracing even more, and delivering food, medicine, and other essentials to every household in the land. In December, when a flu clinic in Thimphu turned up the first case of community transmission since the summer, the nation again entered strict lockdown—and again, a full-throttle campaign prevailed against the virus, which has been all but snuffed out for the time being.

In tandem with this rigorous public-health response came swells of civic compassion from every level of society. In April, King Jigme Khesar Namgyel Wangchuck launched a relief fund that has so far handed out $19 million in financial assistance to more than 34,000 Bhutanese whose livelihoods have been hurt by the pandemic, a program extended until at least the end of March. The government created a country-wide registry for vulnerable citizens, and has sent care packages containing hand sanitizer, vitamins, and other items to more than 51,000 Bhutanese over the age of 60. The Queen Mother gave a frank address to the nation, calling on the authorities to ensure services for sexual and reproductive health, maternal, newborn, and child health care, and services for gender-based violence, which she deemed “essential.” Thousands of people signed up to leave their homes and families for extended periods of time to join the national corps of orange-uniformed volunteers known as DeSuung. Bhutan’s monastic community—highly influential in a Buddhist and still largely traditional culture—not only pointedly reinforced public-health messaging but also prayed daily for the well-being of all people during the crisis, not just the Bhutanese.

Government officials modeled the same altruism. During the country’s summer lockdown, Wangmo, the health minister, slept in ministry facilities for weeks, away from her young son. Prime Minister Lotay Tshering, a highly respected physician who continued to perform surgeries on Saturdays during most of the crisis, slept every night during the lockdown on a window seat in his office—a photo in the newspaper The Bhutanese showed his makeshift bed’s rumpled blankets and an ironing board standing nearby. Members of Parliament gave up a month’s salary for the response effort; hoteliers offered their properties as free quarantine facilities; farmers donated crops. When lights in the Ministry of Health’s offices burned all night, locals brought hot milk tea and homemade ema datshi—scorching chilies and cheese, the national dish.

“I have complained about ‘small-society syndrome’ and how suffocating it can get. But I believe it is this very closeness that has kept us together,” Namgay Zam, a prominent journalist in Bhutan, told me. “I don’t think any other country can say that leaders and ordinary people enjoy such mutual trust. This is the main reason for Bhutan’s success.”

While bhutan might be culturally unique, its experience offers several lessons for affluent nations.

First, hope that you are lucky and your country’s leaders are thoroughly engaged. Bhutan had trusted, smart, and hands-on direction from its king, whose moral authority carries great weight. He explicitly told government leaders that even one death from COVID-19 would be too much for a small nation that regards itself as a family, pressed officials for detailed plans covering every possible pandemic scenario, and made multiple trips to the front lines, encouraging health workers, volunteers, and others. His crucial role also sidetracked any political gamesmanship; in Bhutan, the opposition in Parliament joined forces with the ruling party.

Second, invest in preparedness. Bhutan set up a health emergency operations center and a WHO emergency operations center in 2018, and had also invested in medical camp kit tents, initially thinking they would be deployed in disaster-relief zones; the tents were repurposed to screen and treat patients with respiratory symptoms. In 2019, the country upgraded its Royal Centre for Disease Control lab, equipping it to handle not only new and deadly influenza viruses on the horizon, but also SARS-CoV-2. Most presciently, in November 2019, the WHO and Bhutan’s health ministry staged a simulation at the country’s international airport. The scenario: a passenger arriving from abroad with a suspected infection caused by a new strain of coronavirus. All these measures reflect what Bitton sees as a dynamic, system-wide self-awareness. “You could call it humility; you could call it curiosity,” he said. “It’s this idea of, wow, we have a lot to learn.”

Third, act fast and buy time. “The countries that responded early and before the virus got entrenched—in particular, before it got to the vulnerable populations—seem to all have done better,” Jennifer Nuzzo, a senior scholar at the Johns Hopkins Center for Health Security, told me. Bhutan’s system of community-based primary care had sowed the concept of prevention, and its free universal health care and testing meant that logistics and supply chains were already in place.

Fourth, draw on existing strengths. When Bhutan added five more PCR machines to its testing stock, up from just one, it needed people to collect samples from the field and operate the devices. So it shifted technicians from livestock-health and food-safety programs, and trained university students. When it became clear that one ICU physician was not enough, it instructed other doctors and nurses in clinical management of respiratory infections and WHO protocols. “This is the lesson from Bhutan,” Rui Paulo de Jesus, its WHO country representative, told me. “Utilize the resources you have.”

Finally, make it possible for people to actually follow public-health guidance by providing economic and social support to those who need to quarantine or isolate. Nuzzo calls these “wraparound services.” But Tenzing Lamsang, an investigative journalist and editor of The Bhutanese, believes the term doesn’t do justice to Bhutan’s deeper policy impulses. “Bhutan’s approach as a Buddhist country, a country that values Gross National Happiness, is different from a typical technocratic approach,” he told me, noting that its pandemic plan covered “all aspects of well-being.”

Other countries illustrate many of these approaches. Senegal acted early, barring international arrivals and imposing regional travel restrictions, enforcing curfews and business closures, and launching an economic and social resilience program to make up for lost income among the poor; after barely skirting the 2014–16 Ebola outbreak in West Africa, it also bolstered staffing for an emergency operations center and conducted mock drills. Rwanda blanketed the country with random testing and contact tracing, relying on the same lab technologies used for tracking HIV cases. Vietnam declared an epidemic on February 1, 2020, and deployed its provincial governments to swiftly detect infections, close nonessential businesses, enforce social distancing, and monitor border crossings.

There are certainly plenty of caveats around the idea of trying to replicate Bhutan’s values or transplant its strategies. As Nuzzo pointed out, political systems vary significantly, and one nation’s assumptions might not thrive on alien terrain. Moreover, coronavirus transmission can take wild turns. And until Bhutanese are vaccinated, the kingdom will need to play a flawless game of containment. “As Buddhists,” a Kuensel editorial in September reflected, “we learn that this reality changes every moment.”

For now, though, Bhutan has helped define pandemic resilience. “What I learned from Bhutan is that the health sector alone cannot do much to protect people’s health,” de Jesus told me. Lamsang agreed. Pandemic resilience, he said, came from “things that we don’t count normally, like your social capital and the willingness of society to come together for the common good.”

It is tempting to dismiss Bhutan or other small, communitarian countries as irrelevant models for the United States. To be sure, Bhutan is no paradise. It has its share of quarantine dodgers and anti-vaxxers, “maskholes” and “covidiots,” all duly called out on social media. And like every other nation, when this crisis is over, it will have to reckon with long-standing problems—issues including youth unemployment and the effects of climate change.

But its victory, at least so far, in staving off the worst of the pandemic might give Bhutan the confidence and drive it needs to tackle these other challenges—and on its own terms. After all, that’s another aspect of resilience: moving forward when the crisis has passed.

MADELINE DREXLER is a Boston-based journalist and a visiting scientist at the Harvard T. H. Chan School of Public Health. She is the author of Emerging Epidemics: The Menace of New Infections and has written extensively in recent years about Bhutan.