Managing COVID-19 in four small countries: Initial response to the pandemic in San Marino, Montenegro, Malta and Cyprus

•Small countries with centralized health systems were fast at adapting to the pandemic.•Expansion capacity was limited if there was one main central healthcare institution.•Tourism dependency led to tensions between infection control and economic considerations. The aim of this paper is to compare the impact of the COVID-19 pandemic on four small countries in the southern half of Europe with similar public health systems: San Marino, Montenegro, Malta and Cyprus, the latter two being island states. There are advantages and disadvantages in being a small nation amidst this crisis. The centralized public health administration means that small countries are faster at adapting as they learn and evolve on a weekly basis. However, small countries tend to be dependent on their bigger neighbours, and the networks they belong to, for trade, food, medical supplies as well as policies. The risk threshold taken by a small country for the transition strategy has to be less than that taken by a bigger country because if things go wrong in a border region, there is less resilience in a small country, with immediate impact on the whole country. The blow to the tourism industry, which plays a main role especially in small countries, negatively impacted the economy, and it has been a feat to reach a balance between allowing the flow of inbound tourists and keeping the local infection rates under control.