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Trust, testing and tracing: How South Korea succeeded where the US stumbled in coronavirus response

As US tops 60k deaths, South Korea marks first day without a new local case.

Imagine that you're in a midsize city, the lock-down has been lifted and you finally go back to the office and see your colleagues for the first time in months.

The next morning, you wake up with a tickle in your throat. You also notice a bit of a headache, and more alarmingly, a mild fever. No need to panic.

You call the COVID-19 hotline to get information on local testing sites, walk to the nearest one, have a brief one-on-one visit with a doctor, and have your nasal or oral sample collected. The whole process takes less than 30 minutes. Later that evening, you get a text message letting you know whether you're COVID positive. All this for free or just under $20.

You aren’t extremely worried because the country is taking prompt action for each confirmed COVID-19 case to find and alert anyone who might've been exposed and isolating them immediately. The daily new case count in the entire country has mostly stayed in the single digits for a few days straight now.

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But if you do test positive, again no need to panic. If you're really sick, you'll immediately get admitted to a designated hospital, free of charge. If you are asymptomatic or only have mild symptoms but are worried about infecting your family and if you qualify, you can go to a designated quarantine facility for two weeks.

There you'll be given a personal necessity kit -- a kind of care package with everything you need to stay safe including gloves, masks, garbage bags, soap and even disposable thermometers -- and another box full of non-perishable food to last you through the quarantine, including basic foods and ready-made meals.

The government may even pay you a salary during the isolation. Throughout the isolation, a health official will regularly call you to check how you’re feeling and ask you if you’ve checked your temperature.

“We had a chance to contain this outbreak, but we didn’t,” said Ashish Jha, K.T. Li Professor of Global Health at Harvard T.H. Chan School of Public Health and Director of the Harvard Global Health Institute. “And as a result of that testing failure, over 60,000 Americans are dead and our economy has been shut down. It didn’t have to be this way.”

South Korea announced on Thursday it had the first day in months without a new diagnosed case of the coronavirus, other than four cases detected at the border from those coming into the country.

The first confirmed COVID-19 case in South Korea was reported on Jan. 20, just a day before the first confirmed case in the U.S. was reported.

But South Korea quickly activated a response system put in place during the Middle East Respiratory Syndrome, known as MERS, outbreak five years ago and expanded its testing capacity and contact tracing. MERS had a fatality rate of about 20% in South Korea, so many South Koreans knew instinctively how devastating a viral epidemic could be.

“This experience taught them to move quickly and early,” said Yong Suk Lee, deputy director of the Korea Program at the Freeman Spogli Institute at Stanford University. “Let’s track each individual and inform all the people so that they can be prepared and get tested. They communicated transparently with plain, factual, straightforward information.”

In the last 100 days, the American ally in the Far East has normalized daily life in the face of the coronavirus pandemic by a robust testing system coupled with an expansive contact tracing operation – all built on a foundation of massive amounts of data.

In the U.S., some states are acting to bring some features of life back to normal, but testing still lags far behind levels considered safe by medical experts, while medical staff continues to sound the alarm about shortages in supplies of the critical protective gear they need to do their jobs. Contact tracing programs are just ramping up.

The two democracies certainly have their differences, chief among them their size -- South Korea's population is about one-seventh of America's -- and the more decentralized nature of the U.S. federal system of governance. South Korea also has universal health care that has served as a backbone of the country's strong COVID response.

Experts with whom ABC News spoke said South Korea's greater success in fighting the outbreak came in part due to its ability to institute widespread coronavirus testing and contact tracing far earlier in the pandemic, cheap and effective care for those who got infected, and, perhaps most importantly, a greater cultural trust in the government whose transparent and consistent messaging prompted citizens to take more protective measures ahead of the virus and generally support more aggressive contact tracing methods in its wake.

By the time South Korea reported 204 confirmed cases on Feb. 21, the country had conducted a total of 16,400 tests. By the time the U.S. had 207 confirmed cases on March 4, it had performed 1,597 tests, 10 times fewer, according to the COVID Tracking Project.

“Politicians say that the United States has performed a greater number of tests than anywhere else in the world,” said Jennifer Nuzzo, Senior Scholar at the Johns Hopkins Center for Health Security. “While that may be true about the number of tests alone, that isn’t what we should pay attention to. On a per-capita basis, that’s not true.”

The U.S. reported more than 1 million confirmed cases and 63,019 deaths as of Thursday. South Korea has reported 10,765 confirmed cases and 247 deaths. That is .3% of the U.S. population testing positive and .02% dying from the virus. In South Korea, .02% tested positive and a tiny .0005% of the population have died from COVID-19.

To see how South Korea differentiated itself from the United States in its pandemic response, it's necessary to look back to the very beginning, to the time when South Korean leaders were warning of a possible crisis with just the first few positive cases, while some top American officials were alternating between ignoring it and calling it a hoax. President Donald Trump did place a limited travel ban on flights from China at the end of January but didn't declare an official national emergency until March 13. By that time, more than 3,000 cases and 55 deaths had already been reported in the U.S.

“At one point, South Korea had one of the fastest-growing epidemics in the world, but they’ve been able to keep their numbers quite low since the government acted early,” Nuzzo said. “Comparatively, the U.S. has struggled, in large part because we haven’t been able to test. There’s no replacement for government leadership defining what should be done and making it happen.”

Before testing, a question of trust in the government

Perhaps the most surprising difference in the countries' response was that South Korea never instituted a true lock-down the way the U.S. has in most states -- in part because the government assumed the people would properly social distance without a mandate. Businesses weren't forced to close, and borders weren't shut down to prevent people from coming in from abroad.

“People were willing to follow social distancing and voluntarily wear masks when they went out,” Lee said. “There was a lot of trust in how the government was responding. South Koreans have a collective spirit when confronted with disaster.”

From the very beginning of the outbreak, South Koreans diligently complied with the government directive to wear N95 masks in public, already having become accustomed to wearing masks due to air pollution. When the demand for the masks skyrocketed in mid- to late-February, the government quickly took over the distribution and rationed two N95 masks per week per person.

Even as the curve appears to be flattening and the country reopens, South Koreans continue to protect themselves by wearing masks whenever out in public.

In the U.S., many people have abided by, and vocally encouraged, social distancing measures on their own, but a segment of the population balked at what some called draconian government-imposed restrictions as states locked down. Across the U.S., residents went to parties and beaches, and in some places thousands gathered for "anti-lockdown" protests -- encouraged at one point by the president himself.

Adding to the confusion were changes in official U.S. health recommendations. In the U.S., the Centers for Disease Control and Prevention (CDC) initially discouraged the general public from wearing masks amid an extreme shortage at health care systems across the country. The CDC later reversed course and recommended people to cover up their faces even with make-shift masks, while some municipalities took extra steps to make face coverings in public mandatory.

Recently Vice President Mike Pence was photographed during a hospital visit not wearing a mask, contrary to what the hospital said was its policy. Thursday, Pence did wear a mask when visiting a ventilator factory.

Easy access to testing and health care

From local public health centers to drive-through testing sites around every corner, the easy access to testing has been one of the most important tactical success stories of South Korea's pandemic response, public health experts say.

Since the first confirmed case in January, the South Korea government quickly ramped up its testing operation, running thousands of tests within a month of the first case. This allowed South Korea to rapidly detect its mass outbreak when the virus spread through a church group in the large, southeastern city of Daegu.

By late February -- within two weeks of the outbreak in Daegu -- the country was testing tens of thousands of people a day. At the same time, the U.S., a nation more than six times the size, was only administering 300 to 400 tests per day.

“Testing is very important because it tells you where the problem is,” said Professor Michael Ahn of University of Massachusetts Boston, whose research focuses on technological innovations in public policy.

Under the Korean CDC guidelines and because of South Korea's universal health care system, those presenting with respiratory symptoms and a fever, international travel history, and potential close contacts with a positive patient, are guaranteed access to free tests. Even those without symptoms can get tested just as easily and pay their own fees, costing about $140.

The coronavirus has been circulating around both countries for a few months, but only in the last two weeks did the U.S. surpass the Asian nation in per capita testing rate, according to an analysis of official figures compiled by Our World in Data. As of Thursday, with at least 6 million tests administered in the U.S., one in every 53 people in the country has been tested so far. In South Korea, with a total of 619,881 tests, one in every 83 people has been tested so far.

In the U.S., public labs and private, commercial labs alike have been plagued by testing backlogs and capacity issues, allowing only those people at the highest risk to get tested in some places. States are racing to increase their testing capacity, and calling on the federal government for help. California Gov. Gavin Newsom announced last week that the state is drastically ramping up its daily testing capacity to a minimum of 60,000-80,000, and the Los Angeles Mayor announced on Wednesday that the city would offer free coronavirus tests to all residents, regardless of symptoms.

Experts said it's also important to consider the test-positivity rate -- meaning the percentage of tests performed that turn out to be positive. In the U.S., it's been around 15% to 20%, while it’s been close to 1% - 2% in South Korea, according to public data reviewed by ABC News. This suggests that the U.S. is only testing people who already have a high likelihood of being infected, meaning that the U.S. is missing those with milder symptoms or no symptoms, Nuzzo said.

Top U.S. health officials have said that more than 25% of those with the coronavirus may have mild or no symptoms, though they can still infect others.

In South Korea, universal health care also allows people to walk into any designated testing site or care facility without the fear of cost. But in the U.S., even as many states and cities plan to roll out free testing, the cost of care should the person test positive and the hurdles of going through their health care providers covered by their insurance have continued to slow down widespread testing efforts.

"In Korea, if you’re potentially exposed to the virus, the government is going to cover everything starting with testing,” Lee said. In the U.S., "just getting testing alone is challenging and expensive. And people think, 'What will be the cost of my health bill if I go through this?' We’re not provided a clear understanding of health care costs."

Then, in South Korea, government-supported quarantine efforts, which helped separate COVID patients from their family members, even for those showing mild symptoms, played a key role in preventing household spread of the virus. About 80% of clusters have occurred in families, according to a World Health Organization report that looked at the spread of the virus in China.

Aggressive and systematic contact tracing

Few people in South Korea have gone outside the Korean CDC’s guidelines to get tested voluntarily and cover their own fees, in part because South Koreans are better informed of their potential exposure to the virus in the first place, experts say.

It's the result of an aggressive contact tracing operation, which integrates GPS data, credit card data and surveillance footage as well as other information from 28 different data sources to perform real-time analysis to quickly and precisely identify those who might have come into close contact with a COVID-19 patient, according to health experts.

South Korea was able to quickly launch an aggressive contact tracing effort because of a legal basis and infrastructure for the operation that had been established during the MERS outbreak.

The system, developed within weeks of the first mass outbreak in February, has allowed the South Korean government to pinpoint those who might have gotten exposed to the virus and proactively offer them tests or quarantine support, officials say.

In the U.S., states have begun pushing forward aggressive contact tracing operations only in recent weeks. California announced last week that it is building a massive army of 10,000 volunteer contact tracers as part of its efforts to prepare for future reentry, and Massachusetts recently hired more than 300 people to begin tracing in the first week of the program and an additional 2,200 volunteer traces to help with the effort. Some other states, like Connecticut and Colorado, are using tech-based systems to help COVID-patients self-report and manage data.

But much of the contact tracing efforts in the U.S. have been focused on individual surveys and voluntary disclosure, not the real-time collection and analysis of mass data like in South Korea. Whether the U.S. can or will implement a similar system remains a question, determined more by the cultural difference that comes from the decentralized government system in the U.S. and privacy concerns that can be resolved from setting legal boundaries like South Korea has, than the actual technology, according to Ahn.

South Korea "is somewhat more centralized, and also it's a smaller country with less population,” Ahn said. “However, in American context too, you can have the legal basis and safety features in place. We have the technology and we have the data. It's America, right?”

Privacy concerns have been raised in South Korea, but the public consensus has mostly been favorable towards the contact tracing efforts, especially after the government's initial contact tracing effort using patient surveys faced difficulties earlier in the outbreak when some members of the church group in Daegu refused to voluntarily reveal their contacts.

Katherine Baicker, dean of the University of Chicago Harris School of Public Policy, said contact tracing, with the help of large-scale public cooperation with voluntary data collection through technology, can be done without violating individual confidentiality.

“There are ways to assess the health risk posed by specific businesses in specific areas,” Baicker stated. “We could begin to reopen more of the economy safely if we focused on those businesses that provided the greatest benefit at the lowest risk.”

Preparing for a second wave

Screening and quarantining for travelers arriving into South Korea is more thorough than ever.

Every person coming in through the airport -- with or without symptoms -- is either tested immediately on site or within three days of entry depending on their length of stay. If they test positive, the patient is moved to a hospital or care facility. If they test negative, the person is still moved to a government-designated facility for 14 days, where they have to report their physical condition through an app -- another measure to which many Americans would likely object.

Most of the new cases reported in the past few days have come from those entering the country, according to the South Korean government’s daily status update.

Meanwhile, the U.S. issued a Presidential Proclamation prohibiting foreign nationals who have visited countries across Europe, China, and Iran in the past 14 days from entering the U.S. The proclamation doesn’t mention U.S. citizens, and for those who do arrive from other countries, there is no uniform testing system other than the CDC guidance to stay home and monitor temperature for 14 days upon arrival.

More generally, as the pandemic appears to subside in South Korea and more and more people are coming out on the street, officials say the South Korean government is still on high alert and working to prepare for a potential second outbreak in the fall, echoing warnings from top U.S. officials like Dr. Anthony Fauci, the nation's top infectious disease expert.

As part of those efforts, the South Korean government has also just begun antibody testing, which can determine if someone has been exposed to the virus in the past.

Korean CDC director-general Jung Eun-kyeong said during a press conference this week that getting a sense of how wide the spread of the virus in the community was, including those not already discovered through the mass testing, is critical in determining how much of the population remains vulnerable to a second wave.

“We need to know what percentage of the population has developed antibodies against COVID-19 to figure out the real spread of the virus,” Jung said.

The U.S. is also fielding mass antibody testing, but the effort can be scattershot and the reliability of some of the tests have been called into question.

South Korean Deputy Health Minister Kim Ganglip said during an interview with South Korea’s Yonhap News that the public’s loosening attitude toward social distancing amid the flattening curve is the biggest risk factor in causing another outbreak.

What to know about coronavirus:

  • How it started and how to protect yourself: Coronavirus explained
  • What to do if you have symptoms: Coronavirus symptoms
  • Tracking the spread in the U.S. and worldwide: Coronavirus map
  • "An increase in outdoor activities could become the kindling for a large-scale transmission," Kim said, urging people to practice social distancing guidelines until May 5.

    It's a fear shared by U.S. health experts, as they watch U.S. beaches fill up and nail salons, among other businesses, reopen in parts of the country.

    But should a second wave happen, Ahn said, South Korea is still better positioned to quickly detect and respond to it. The U.S., he said, needs to catch up to their ally's effort, and fast.

    “If you don't do this and open up, knowing how contagious the disease is, then we are going to come back to a citywide or nationwide lock-down,” Ahn said.

    ABC News' Josh Margolin, Joohee Cho and Kate Hakyung Lee contributed to this report.