2.1. Global Infectious Diseases and COVID-19
Infectious diseases refer to those “caused by pathogenic microorganisms, such as bacteria, viruses, parasites, or fungi; the diseases can spread, directly or indirectly, from one person to another” [20
]. These diseases can infect people by contact with other humans, animals, or other reservoirs infected by a pathogen or toxic substance. Additionally, communicable diseases refer to those that directly or indirectly spread between humans or between humans and animals. Thus, an infectious disease pandemic is an epidemic that has the potential to be easily transmitted and to affect the global population due to its highly infectious nature [21
Since the Second World War, the world has seen many innovative developments in vaccines and antibiotics; such advances have ensured that communicable and infectious diseases are reasonably controlled [11
]. An important study by the Institute of Medicine, “Emerging Infections: Microbial Threats to Health in the United States,” shed some light on the issues involved with novel infectious diseases [22
]. Soon thereafter, the WHO passed the resolution “Global Health Security: Epidemic Alert and Response” in 2001 [23
], which enabled the collection of information and enforcement of actions through cooperative work by inter-governmental agencies, non-governmental institutions, private organizations, and governments around the world.
In 2003, the SARS outbreak in China quickly spread fear of a pandemic that could cross borders and affect countries worldwide. Particularly, China failed to promptly and transparently disclose epidemic information. The Chinese government reported the outbreak to the WHO several months after the first confirmed case of SARS, thus delaying effective response measures by world organizations. Immediately, the WHO raised the alert that the SARS outbreak was of high risk, subsequently issuing a travel advisory notice (e.g., advising a travel ban to places where the epidemic had occurred) aimed at suppressing the spread of the disease. As a result of this experience with SARS, many countries worldwide recognized the importance of a global infectious disease governance system, which should stretch beyond the governance of each country [24
]. In 2005, the International Health Regulations were revised and expanded to include not only communicable diseases but also other possible threats (i.e., biological terrorism and events that induce international public health crises). Nevertheless, other highly contagious diseases have continued to emerge throughout the last two decades.
In the presence of healthcare emergencies, such as the infectious and coronavirus outbreaks discussed above, public healthcare should be available throughout the country not only with rapid response but also based on an equitable basis [5
]. The sense of equity involves a person’s perception of the input and output relationship which should not create tension or displeasure as a result of cognitive dissonance [26
]. Rousseau [27
] defined equity as a function of customer’s perception in a service encounter experience. Equity is realized when a person believes his/her outcome concerning resources invested is in harmony with that of others [28
]. Equity theory has become the theoretical foundation for service recovery as it helps create possible recovery approaches for service failures through recognition, procedures, and mutual interaction involving customer complaints [29
]. It is important that people perceive that a service is being provided equitably. Especially in a crisis such as the COVID-19 pandemic, it is imperative for people to perceive that urgent public healthcare is being provided equitably [5
]. Such perceived equity inspires people to be transparent about their activities (e.g., infection status, contacts, self-quarantine, etc.) that are the first line defense against the disease. This study examines the successes and failures of the Korean healthcare organizations in their efforts to contain COVID-19, from an equity perspective relating to healthcare services.
2.2. Cases of COVID-19 among Healthcare Facilities in Korea
Korea has a history of responding poorly to infectious diseases (e.g., SARS, H1N1, and MERS). In 2012, Saudi Arabia was the first country to experience the MERS outbreak. Korea was the most detrimentally affected country by the virus as many Korean global firms have operations in Saudi Arabia. In Korea, the first MERS case was confirmed in 2015 and its rapid spread resulted in a significant number of casualties which heightened anxiety that swept throughout the country. Furthermore, the serious blow caused to the national economy clearly revealed the weakness of Korea’s infection crisis management system [10
]. The Korean government’s limited response capacity regarding MERS and its poor communication to its citizens weakened people’s trust in the government’s infection crisis management policies to the point where many started believing that the national epidemic prevention system could easily collapse [31
]. There were 185 confirmed cases of MERS among those who traveled to the Middle East, 38 of whom died in 2015. The causes of the high mortality rate could be attributed to the limited capacity of the healthcare delivery system for handling the new virus, shortage of epidemic prevention equipment for medical first responders, and the moral hazard among patients [10
After painful experiences in dealing with past diseases, the Korean government was determined to establish an effective infrastructure to deal with future epidemic emergencies, with KCDC as the control tower. The new infrastructure includes an increased number of negative-pressure isolation wards, real-time systems for data and transparent information collection and analysis, and modernization of the healthcare system. Since the MERS crisis, the Korean government has reinvented a national healthcare delivery system equipped with advanced digital technologies and expanded the facilities specifically designed to deal with infectious diseases (e.g., the creation of negative pressure wards) [10
Thus, KCDC was well prepared to respond effectively to epidemic emergencies when the COVID-19 crisis occurred. When COVID-19 began to spread, the Korean government raised the response level to serious (the highest) on 23 February 2020 and promptly established the Central Disaster and Safety Countermeasure Headquarters, headed by the Prime Minister to bolster government-wide responses to the virus with KCDC as the command center [32
According to the Korea Economic Daily [33
], the rapid spread of COVID-19 around the world, especially in China, Italy, and in the United States, and the subsequent spike in the number of deaths, has brought global attention to the prevention model and early response operational strategy implemented by Daegu city, the epicenter in Korea. Daegu took aggressive actions with speed to prevent the collapse of its healthcare system without placing the city in a lockdown [34
]. The city government performed aggressive screening, testing, and quarantining of patients in the communities that were confirmed to have, or suspected of having, infected citizens.
According to KCDC [32
], Daegu city did not implement this approach at the onset of the COVID-19 outbreak in Korea (18 February 2020). Daegu and the North Gyeongsang province (where Daegu is located) were heavily criticized for the exponential growth rate of infected patients as ground zero. This region accounted for 70% of the confirmed cases in Korea, caused primarily by the Shincheonji Church gatherings (worship services where people sat on the floor shoulder-to-shoulder) and the mass infections that occurred among the first medical responders while providing care services. The city government performed screening tests of the entire congregation of the Shincheonji Church, isolated severely ill patients, and secured enough quarantine beds for those in need of treatment and isolation. To achieve this, Daegu operated a public-private partnership (PPP) network (composed of the Emergency Response Advisory Group, the Daegu Medical Association, and three infectious disease management support groups), which served as the control team for the COVID-19 epidemic [35
The PPP collaboration network deployed several response strategies against COVID-19. First, private hospitals were converted into isolation hospitals. A group chatroom for the control team was created, through which experts held discussions about the situation throughout the night. Through these discussions, the Daegu Dongsan Hospital and the Ministry of Defense were contacted and asked to secure as many beds as possible at the Daegu Armed Forces Hospital and Daejeon Hospital. At that time (18–25 February), there were only about 30 available negative pressure wards in Daegu, and some confirmed patients died while waiting to be admitted into a hospital.
Second, the entire congregation of the Shincheonji Church was tested, and those who had symptoms were identified. On the night of 18 February 2020, 70% of confirmed cases of COVID-19 were members of the Shincheonji Church. The Daegu secured information on the 3000 members of the Church, identified them, and ordered 544 symptomatic patients to remain in self-quarantine for two weeks. A leading physician at the Kyungbook National University stated that “the rate of confirmed cases reached 80% among patients who showed symptoms; so, if we had not prompted early isolation of those Shincheonji Church members who showed symptoms, Daegu might have been in the same situation as Europe or the United States” [33
Third, members of the Daegu Medical Association provided care to those patients in self-quarantine via video calls using 100 outgoing-call-only smartphones provided by Daegu city, hence eliminating the previously existing void in the response system. These response activities represent innovative strategies implemented in the initial stage of the Covid-19 invasion (e.g., aggressive testing, almost immediate test results, contact tracing of infected persons, and prompt treatment of severely ill patients). The mortality rates in New York, USA (6.44%) and in Madrid, Spain (12.62%) are much higher than that in Daegu, Korea (2.76%) as of 1 June 2020 (see Table 1
). These high mortality rates indicate that their patient monitoring and healthcare facilities operations were not systematic. It is evident that “the most potent operational strategy amid the lack of a cure is not search and destroy, but identification and isolation of symptomatic citizens” [33
Fourth, drive-through screening centers were developed for the first time in the world, supported by a world-leading ICT infrastructure [36
]. The Yeungnam University Medical Center, in the vicinity of Daegu, had admitted a COVID-19 patient on 19 February 2020, which resulted in the closing of the emergency room (ER) and prompted self-isolation of its medical staff. Based on this experience, the Medical Center decided to establish a drive-through screening center, which eliminated the risk of shutting down ER and self-quarantining first responder medical staff. Moreover, the existing screening center was inefficient in handling the large crowd of people needing testing in a small space. Thus, this was another innovation in need that led to the strategy of developing drive-through testing centers. Laura Bicker, a BBC correspondent in Seoul, referred to the drive-through testing centers as “such a clever idea and so quickly set up”. Sam Kim, an economics reporter at Bloomberg, mentioned that Korea “once again proved to be among the world’s innovative nations,” and Ian Bremmer, president of the Eurasia Group, a think tank in the US, stated that “innovation drives resilience” [37
]. Innovative operation strategies are critical in fighting such a formidable global pandemic as COVID-19.
Finally, creative applications of the national ICT infrastructure and rapid development of mobile apps by young entrepreneurs have helped analyze the details about confirmed patients and their contacts (e.g., locations, people contacted, and travel patterns before their infection confirmation). KCDC [32
] collected and released relevant information (e.g., regions, pockets of high infection density, and places visited) on COVID-19 patients in real-time. Such transparency regarding the handling of COVID-19 patients encouraged citizens to voluntarily participate in physical distancing and personal hygiene. This is another strategy that has helped Korea effectively manage the crisis when compared to other nations such as Italy and the US. In Korea, after KCDC disclosed the movements of the first COVID-19 patient in Daegu on 18 February, all the places the patient had visited were immediately shut down and disinfected; moreover, the government analyzed security footage (e.g., CCTV from the entrance of the church) to help identify and isolate anyone who might have come into contact with the patient. Local governments sent out emergency alert text messages to provide real-time updated information so that the population of other provinces and cities could be advised not to visit the infected locations.
summarizes the current (as of 1 June 2020) state of the cities with the greatest number of confirmed cases among countries most affected by COVID-19, and the innovative operational strategies implemented by Daegu to respond to the COVID-19 pandemic. Daegu, the epicenter of COVID-19 cases, is currently in the process of being transformed into a smart city. It is noteworthy that the city/area where an explosive outbreak of COVID-19 cases occurred had higher mortality rates than that of the country as a whole.
summarizes statistics of the number of confirmed COVID-19 infection cases, deaths, and mortality rates among the top 10% of 169 countries, including Italy, China, and South Korea, as of 7 September 2020. The table also indicates average statistics for the entire 169 countries.
shows the mortality rates of the top 10 countries for COVID-19 infection, including South Korea, as of 7 September 2020 (including the average for the entire 169 countries as a group). The bars in the figure show the number of deaths per 100,000 population. In the early phase of the coronavirus spread, South Korea recorded the second highest number of infected persons after China. However, as shown in Table 1
and Table 2
and Figure 1
, Korea initiated aggressive strategies for testing and contact tracing based on its well-established public health infrastructure. Thus, the country has been able to flatten the curve of infected cases which resulted in relatively low rates of deaths/infected cases and mortality (deaths/100,000 population) [44
The crisis caused by a pandemic can lead to issues of equity in the public healthcare service [46
]. Particularly, failures in providing equitable public healthcare and in community participation in the decision making process should not be repeated. Thus, it is necessary to analyze the successes and failures experienced in the current situation (i.e., the first wave) as a preparation for the possible onslaught of the second wave of the pandemic. To conduct an in-depth analysis of the causes and consequences of the COVID-19 virus spread in Korea, we examine the operational procedures and strategies implemented by several healthcare facilities. Many seriously ill patients with the virus were diagnosed or infected in ER. Even in a normal day, ER operates at the disaster level [47
]. The COVID-19 pandemic severely tested the agility, flexibility, and resilience of ER operations at every hospital. The following five cases are investigated based on the information released by KCDC [32
2.2.1. Hospital A
Hospital A is an 808-bed tertiary general hospital located in Seoul with 2000 employees. The hospital provides care to an average of 600 inpatients and 2000 outpatients daily. The first COVID-19 case in this hospital was confirmed on 21 February 2020, and was consequently quarantined for two weeks until 5 March. A careful contact tracing of the patient resulted in 14 additional confirmed cases within the hospital. The first confirmed case in the hospital was a patient aide who helped patients move from the ward to the lab. Prior to the diagnosis, it was found that this aide had helped 207 patients. After the diagnosis of the first confirmed case, the hospital’s ER and outpatient clinics were closed and quarantined.
2.2.2. Hospital B
Hospital B is a 251-bed general hospital with 644 employees located in Seoul. It was closed for two weeks, from 8 to 22 March, due to a patient’s dishonesty. The patient was a resident of Daegu City but falsified his home address when hospitalized. After being diagnosed with COVID-19, the patient was isolated. The hospital shut down its outpatient center, some wards, and ER. The particular concern which this patient caused was the fact that the person had visited the artificial kidney unit, contacting many high-risk patients. Although there was no additional positive case found, the hospital was quarantined for two weeks.
2.2.3. Hospital C
Hospital C is a psychiatric hospital (housed on floors 8–11 in a high-rise building) in Daegu with 286 inpatients and 72 employees. The first positive diagnosis of COVID-19 was made on 26 March, after which the number of confirmed cases increased at an alarming rate. This case happened because the first patient was originally at a convalescent hospital (located on floors 3–7 in the same building) where the first positive case was tested on 20 March and spread quickly to133 patients. When the first case was confirmed at the convalescent hospital, the building management firm failed to disinfect the entire building and consequently the virus spread to Hospital C. Hospital C conducted virus tests on its own employees but did not screen all patients because all the employees were tested negative. There were 196 infected patients as of 20 April and the hospital was closed. KCDC conducted a thorough investigation of Hospital C and found that the mass infection occurred because of the failure to screen all patients [32
]. Further, due to the nature of the psychiatric hospital (i.e., closed wards in confined spaces), the infection spread rapidly, and subsequently the number of infected cases increased at an accelerated rate.
2.2.4. Hospital D
Hospital D is a 700-bed general hospital located in Seongnam City, in the vicinity of Seoul, with 1400 employees, including 140 specialists in 26 specialty areas. The hospital serves an average of 5000 patients daily. One patient was discharged after treatment in the hospital and returned to receive outpatient care. The same patient became very ill and was brought to ER and diagnosed with COVID-19 infection on 5 March. Consequently, a mass infection of the virus occurred among healthcare providers within the hospital (43 confirmed cases). Hence, the hospital was closed from 6 March to 12 April (38 days). Hospital D provided incomplete information to KCDC, as a person in need of isolation was omitted from the list [32
2.2.5. Hospital E
Hospital E implemented proactive measures to suppress the spread of COVID-19. All patients and their respective caregivers were required to fill out a paper-based health questionnaire upon admission. However, there were concerns about having the patients complete the questionnaire, which might take too much time while they were crowded in a limited space. In order to reduce crowding and minimize hospital-acquired virus infections, a mobile health questionnaire was delivered by the hospital. The questionnaire asked patients to precisely list all travel to foreign countries, visits to regions or facilities with confirmed cases, and any symptoms of fever or respiratory difficulties.
Hospital E reported that (https://www.yuhs.or.kr/en/
), between 12 and 19 March, an average of 6136 people submitted the mobile health questionnaire each day. On average, the questionnaire took 1 min 29 s to complete (8.9 s for each of 10 items). Further, Hospital E sent the mobile health questionnaire to visitors scheduled for outpatient services or testing at 6 AM on the day of the appointment via KakaoTalk (Korean SNS) or text message. Once the patient had completed the questionnaire, a quick response (QR) code was generated. If the patient had self-reported COVID-19-related flagging, a red QR code was assigned, and no flagging was noted with a black QR code. Only visitors who had the red QR code were issued with proper stickers and allowed to enter the hospital.
The patients with the red QR code were required to undergo an additional evaluation at the hospital entrance. Based on this evaluation, they were either directed to a designated safe care facility or were not allowed to enter the hospital for treatment. Moreover, visitors who were not able to use a mobile questionnaire or were not aware of this requirement were provided with the paper-based questionnaire at the entrance. The implementation of this mobile questionnaire was an effective measure to reduce hospital-acquired infections, among the patients and between employees and patients (hospital press release; https://www.yuhs.or.kr/en/
presents a summary of problem causes and response strategies employed by the sample hospitals.