Bickley et al. Globalization and Health (2021) 17:57 https://doi.org/10.1186/s12992-021-00677-5 RESEARCH Open Access How does globalization affect COVID-19 responses? Steve J. Bickley1,2†, Ho Fai Chan1,2*† , Ahmed Skali3, David Stadelmann2,4,5 and Benno Torgler1,2,5† Abstract Background: The ongoing COVID-19 pandemic has highlighted the vast differences in approaches to the control and containment of coronavirus across the world and has demonstrated the varied success of such approaches in minimizing the transmission of coronavirus. While previous studies have demonstrated high predictive power of incorporating air travel data and governmental policy responses in global disease transmission modelling, factors influencing the decision to implement travel and border restriction policies have attracted relatively less attention. This paper examines the role of globalization on the pace of adoption of international travel-related non- pharmaceutical interventions (NPIs) during the coronavirus pandemic. This study aims to offer advice on how to improve the global planning, preparation, and coordination of actions and policy responses during future infectious disease outbreaks with empirical evidence. Methods and data: We analyzed data on international travel restrictions in response to COVID-19 of 185 countries from January to October 2020. We applied time-to-event analysis to examine the relationship between globalization and the timing of travel restrictions implementation. Results: The results of our survival analysis suggest that, in general, more globalized countries, accounting for the country-specific timing of the virus outbreak and other factors, are more likely to adopt international travel restrictions policies. However, countries with high government effectiveness and globalization were more cautious in implementing travel restrictions, particularly if through formal political and trade policy integration. This finding is supported by a placebo analysis of domestic NPIs, where such a relationship is absent. Additionally, we find that globalized countries with high state capacity are more likely to have higher numbers of confirmed cases by the time a first restriction policy measure was taken. (Continued on next page) * Correspondence: [email protected] Steve J. Bickley, Ho Fai Chan and Benno Torgler contributed equally to this work 1School of Economics and Finance, Queensland University of Technology, 2 George St, Brisbane, QLD 4000, Australia 2Centre for Behavioural Economics, Society and Technology (BEST), 2 George St, Brisbane, QLD 4000, Australia Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Bickley et al. Globalization and Health (2021) 17:57 Page 2 of 19 (Continued from previous page) Conclusions: The findings highlight the dynamic relationship between globalization and protectionism when governments respond to significant global events such as a public health crisis. We suggest that the observed caution of policy implementation by countries with high government efficiency and globalization is a by-product of commitment to existing trade agreements, a greater desire to ‘learn from others’ and also perhaps of ‘confidence’ in a government’s ability to deal with a pandemic through its health system and state capacity. Our results suggest further research is warranted to explore whether global infectious disease forecasting could be improved by including the globalization index and in particular, the de jure economic and political, and de facto social dimensions of globalization, while accounting for the mediating role of government effectiveness. By acting as proxies for a countries’ likelihood and speed of implementation for international travel restriction policies, such measures may predict the likely time delays in disease emergence and transmission across national borders. Keywords: Coronavirus, COVID-19, SARS-CoV-2, Globalization, Travel restriction, Border closure, Health screening, Survival analysis Background limit potential virus import and spread through more so- The level of complexity around containing emerging and cially connected populations [14, 15]; greater economic re-emerging infectious diseases has increased with the globalization may indicate slower policy adoption due to ease and increased incidence of global travel [1], along legally binding travel and trade agreements/regulations, with greater global social, economic, and political inte- economic losses, and social issues due to family relations gration [2]. In reference to influenza pandemics, but that cross borders [16–21]. Greater political nonetheless applicable to many communicable and globalization may indicate greater willingness to learn vector-borne diseases, the only certainty is in the grow- from others and/or maintain democratic processes of ing unpredictability of pandemic-potential infectious dis- decision making in global coordination efforts, either ease emergence, origins, characteristics, and the way potentially delaying the implementation of travel re- biological pathways through which they propagate [3]. strictions. Travel restrictions may also have minimal im- Globalization in trade, increased population mobility, pact in urban centers with dense populations and travel and international travel are seen as some of the main networks [22]. Moreover, the costs of closing are com- human influences on the emergence, re-emergence, and paratively higher for open countries than for already transmission of infectious diseases in the twenty-first protective nations. For example, more globalized coun- Century [4, 5]. tries are more likely to incur financial or economic pen- Emerging and re-emerging infectious diseases have alties (e.g., see [23, 24]) when implementing health presented major challenges for human health in ancient policies which aim to improve the health of local popu- and modern societies alike [6–10]. The relative rise in lations such as import restrictions or bans on certain infectious disease mortality and shifting patterns of dis- food groups/products and product labelling. ease emergence, re-emergence, and transmission in the Globalization, after all, is known to promote growth and current era has been attributed to increased global con- does so via a combination of three main globalization di- nectedness, among other factors [11]. More globalized mensions: economic integration (i.e., flow of goods, cap- countries – and, in particular, global cities – are at the ital and services, economic information, and market heart of human influence on infectious diseases; these perceptions), social integration (i.e., proliferation of modern, densely populated urban centers are highly in- ideas, information, culture, and people), and political in- terconnected with the world economy in terms of social tegration (i.e., diffusion of governance and participation mobility, trade, and international travel [12, 13]. One in international coordination efforts) [25, 26]. See Table 1 might assume that given their high susceptibility to in- for examples of data used in the estimation of each fectious diseases, globalized countries would be more (sub)dimension of the KOF globalization index we use willing than less globalized countries to adopt screening, in this study. quarantine, travel restriction, and border control mea- Globalization appears to improve population health sures during times of mass disease outbreaks. However, outcomes such as infant mortality rate (IMR) and life ex- given their globalized nature, globalized countries are pectancy (LE) regardless of a country’s level of develop- also likely to favor less protectionist policies in general, ment (i.e., developed, developing, or underdeveloped) thus, contradicting the assumption above, perhaps sug- [27, 28]. Links between the dimensions of globalization gesting that counteracting forces are at play: greater so- (i.e., social, political, and economic) and general popula- cial globalization may require faster policy adoption to tion health are less clear cut [29]. For less developed Bickley et al. Globalization and Health (2021) 17:57 Page 3 of 19 Table 1 Dimensions and sub-components of Globalizationa Dimension Sub-Component Examples of Data Points Economic Trade Trade in goods and services, trade partner diversity, trade regulations, trade taxes, tariff rates, and number of trade agreements. Financial Foreign direct investment, portfolio investment, international debt, reserves