Published on 11 August 2020
Writer: Aznita Ahmad Pharmy, Research Fellow, CARI
Editors: Jukhee Hong, Executive Director, CARI and Eleen Ooi Yi Ling, Research Manager, CARI

CARI Viewpoint: An effective COVID-19 response must be fact-based while the development of pandemic-related ASEAN common standards can increase efficiency

CIMB ASEAN Research Institute (CARI) organised the CARI Briefings webinar under its COVID-19 Economic Recovery Plan Series, titled “How Can ASEAN Bounce Back: Fostering Public Health Safety and Economic Resilience for a Borderless Community in ASEAN.” The session featured Datuk Dr. Noor Hisham Abdullah, Director-General of Health Malaysia and was moderated by Tan Sri Dr. Munir Majid, Chairman of CARI. The discussion centred on Malaysia’s management of the COVID-19 pandemic, the country’s cooperation with ASEAN in addressing COVID-19, as well as the challenges of balancing between public health safety and the survival of the economy.

During the briefing, among the key insights shared were:

1) The world is still struggling to contain the COVID-19 pandemic despite some early success

It’s been almost seven months since the World Health Organization declared the COVID-19 outbreak as a public health emergency of international concern but the pandemic shows no signs of slowing down. As of 8 August 2020, 210 countries are affected by the pandemic with 19.5 million confirmed cases and more than 724,000 deaths worldwide.

According to Dr. Noor Hisham, the pandemic is summed up in the following four situations of COVID-19 transmission around the world:

• 1st Situation:
  This is where the countries affected were alert, well-prepared and acted fast. These countries managed to avoid large outbreaks, flattened the curve and brought the situation under control due to strong and decisive leadership combined with a good communication strategy with the public.
• 2nd Situation:
  This situation is where Malaysia is currently at. In this situation, there was a major outbreak following cases of overseas returnees, as well as the outbreak from the high-risk groups such as the tabligh group. However, the situation has been brought under control with strong leadership and engagement with the public. From March until the present, Malaysia succeeded in bringing down the number of confirmed cases but it is still an ongoing process.
• 3rd Situation:
  In this situation, the countries managed to flatten the curve to single-digits, or down to zero documented cases but due to the easing of restrictions and standard operating procedures (SOPs), they are now struggling with a spike in cases. This can be observed in Hong Kong, Japan and Melbourne, Australia. This situation is a real concern for Malaysia and Dr. Noor Hisham hopes the country can learn from these countries to prevent a similar occurrence.
• 4th Situation:
  This situation is where the cases in the affected countries continue to rise rather than going down. The public health measures have failed to contain the infection due to the leadership, unclear and contradicting information resulting in a population that does not comply with the SOPs. The outcome of countries in this situation is unclear and remains a real concern as well.

The infection is akin to a wildfire. Once it has been sparked, it would be very difficult to contain. Public health measures will be inefficient and this is why the infection needs to be contained as soon as possible, said Dr. Noor Hisham.

2) An effective COVID-19 response must be based on science and supported by the government

a. Science over politics allows the execution of an effective COVID-19 response

The successful execution of the Ministry of Health’s COVID-19 approach so far is partly due to the government allowing the experts to do their job. “Certainly in our success, it is because the Prime Minister [of Malaysia] listens to the technocrats and civil servants, and that’s very important. Science has led, rather than politics,” remarked Dr. Noor Hisham.

For example, the MCO was a new initiative which needed a decisive decision by Tan Sri Muhyiddin Yassin. “We advised the PM and he dared to take that decision at that point of time in March. It was a drastic decision to lock down the whole country,” he said.

He shared the six approaches carried out by the Ministry of Health:

• Surveillance and public health intervention
• Evidence-based approach / WHO guidelines
• Diagnostic and testing
• Risk Communication
• Movement Control Order
• Isolation and treatment

b. Risk communication key to public engagement

From among the six approaches, risk communication is essential in engaging with the public and is implemented through the following methods:

• Fighting fake news: “We are not only fighting with the virus but we are also fighting the viral fake news in the media. It’s important for us to identify very early, in terms of risk communication to the public. The more we inform the public, the less fear there will be and they can handle the situation much better,” said Dr. Noor Hisham.
• Daily updates: Part of the government’s COVID-19 response in the earlier stage were two daily press conferences: the medical and non-medical. The non-medical press conference was given by Senior Minister for Security Datuk Seri Ismail Sabri Yaakob while Dr. Noor Hisham presided over the medical press conference.
• Social media: The MOH interacts with the public through various platforms such as Facebook, Twitter, Instagram and Telegram and has also set up a dedicated COVID-19 hotline for the public.

“I have been given the responsibility to look into the medical perspective and how we can engage with the public. We explain the issues and challenges based on medical facts, not based on rumours but science. It is important to get the public’s trust. Once we have the public trust, we hope the public will comply with the SOP and the advice given by the MOH,” he said.

c. Various stages of lockdowns activated in response to the developing situation

Being in the second situation of COVID-19 transmission, Malaysia has had some success but cannot afford to be complacent. “Looking at the distribution of COVID-19 cases detected in Malaysia until today, we have not won the war yet but certainly we have won a few battles,” said Dr. Noor Hisham.

According to him, Malaysia’s COVID-19 strategic plan is divided into a few battles, the first one being the battle of the Movement Control Order (MCO).

• Movement Control Order (MCO): The MCO consisted of MCO 1, 2, 3 and 4. During the MCO, Malaysians were advised to stay at home. This artificial environment was imposed with the intention of bringing down the number of infections from those returning from abroad and controlling the local transmission of COVID-19. This was necessary due to the spike in infections caused by the tabligh group and Malaysians returning home from abroad.
• Enhanced Movement Control Order (EMCO): Apart from the MCO, the Malaysian government also implemented the Enhanced MCO (EMCO) whereby an area was put under lockdown and everyone in the area (locals, foreigners, legal and illegal migrants) were tested for COVID-19. Those who tested positive were sent to the hospital while those who tested negative but had been exposed to the positive cases were quarantined.
• Conditional Movement Control Order (CMCO): Once the strategy showed signs of flattening the curve, the government needed to change its strategy to protect lives, as well as livelihoods seeing that the lockdown cost the country US$572 million (RM2.4 billion) a day. The CMCO allowed not only essential services but other economic sectors to resume their activities but with SOPs in place. The social and education sectors, however, remained closed. During this time, there was a spike in cases among legal and illegal migrants but the authorities managed to bring down the curve further.
• Recovery Movement Control Order (RMCO): Seeing the numbers go down during the CMCO, the government decided to allow the social, education and sports sectors to reopen but with the caveat that they comply with the SOPs. “The SOPs are very important because we need to manage the risk of every sector,” said Dr. Noor Hisham.

While the initial response to the RMCO was positive, that success led to complacency which led to a new spike in cases. The authorities moved swiftly by reactivating public intervention to bring down the cases. “This is what we are doing because we found new clusters, this is the burning ember. If we fail to control this burning ember, it will start to spark a wildfire and once the wildfire has taken off it will be very difficult for public health intervention to be effective,” he explained.

d. Targeted COVID-19 testing instead of mass testing

A country’s testing rate should not be used as a benchmark to the effectiveness of its COVID-19 response as mass testing may not necessarily be the solution for every country.

“Today our total individual sample is 983,297 individuals. We have done more than 1.5 million tests but some tests were duplicated. The positive rate from the tests is 0.92%, which means that for every 100 patients that we test, we only pick up hardly one patient,” said Dr. Noor Hisham.

He revealed that Malaysia’s case fatality rate to be 1.39%, which is much lower than the global rate of 3.29% while the country’s recovery rate stands at 96%. As of 4 August, Malaysia had 1 new confirmed case, 193 active cases and 125 deaths.

“Looking at our tests, we are doing about 29.99 per 1,000 population, almost equivalent to South Korea,” remarked Dr. Noor Hisham. He added that the country has raised its testing capacity but instead of testing everyone, the testing strategy involves testing targeted high-risk groups. The testing strategy appears to be working as they have succeeded in flattening the curve from 3,000 active cases to 193 cases as of 4 August.

“The testing is important. We started in December whereby we enhanced our labs to be ready to test for the virus. We started with 1,000 tests in January. Now, we are capable of doing 37,500 tests a day. We also started the training for the public and private labs in January and we have 56 labs today,” he added.

3) ASEAN provides an important platform for countries in the region to work together to fight COVID-19

The COVID-19 pandemic has resulted in most of ASEAN countries facing similar challenges and therefore, the need for all ASEAN member states to work together.

“We continue to engage and make decisive decisions. Most important was the Special ASEAN and ASEAN+3 Summit on COVID-19 held via videoconferencing on 14 April 2020. ASEAN was proactive in coordinating this effort,” said Dr. Noor Hisham.

“We shared our experiences and we have also invited the delegation from China. We learned from their experiences, the do’s and dont’s and certainly, I think this is an important platform for us to work together as a team in the ASEAN region,” he added.

According to Dr. Noor Hisham, ASEAN’s response to the pandemic includes:

• the ASEAN Emergency Operations Centre Network, ASEAN Risk Assessment and Risk Communication, both based in Malaysia;
• ASEAN Biodiaspora Virtual Centre for Data Analytics and Visualisation, in the Philippines; and the
• Regional Public Health Laboratory Network based in Thailand.

He remarked that ASEAN’s attitude towards the COVID-19 pandemic is guided by the WHO as all ASEAN countries are members of the international public health organisation.

“We are in a shared struggle to protect both lives and livelihoods. It is how we strike a balance between lives and livelihoods. Our strategy from MCO was more towards [protecting] the lives, controlling the virus. But once we manage to flatten the curve, we look into [protecting] the livelihood. This is a very fine balance and we need to look into the situation analysis for respective countries,” Dr. Noor Hisham commented.

4) Questions and Answers

During the ensuing questions and answers session, the following topics were discussed.

a. Tension between those prioritising lives and those prioritising livelihoods

When discussing COVID-19 measures Tan Sri Dr. Munir pointed out that there must have been great tension between those who wanted to control population movement and those who wanted to open up the economy and asked Dr. Noor Hisham how these opposing views were resolved.

“Well, certainly it was very challenging at the initial parts but nonetheless, we have a good structure whereby we discussed all issues during the meeting. I had to defend based on facts and science. We argued everything in the meeting and then the decision was made based on facts. During that meeting, we had only one intention – to break the transmission of COVID-19 infection in the country.”

It was and remains crucial for the MOH to collaborate with other ministries in its COVID-19 response. For example, they needed to work with the immigration department for border control and the police for the enforcement of roadblocks.

“If you compared us in January-February with us today we are more prepared in terms of our health facility and our coordination with other ministries. For example now, the moment we identify an outbreak, we will straight away go to that locality and lockdown that locality instead of having a blanket lockdown in the whole country,” said Dr. Noor Hisham.

b. ASEAN common standards and travel bubbles

The idea of an ASEAN common standard for several areas including contact tracing to allow the safe resumption of intra-ASEAN travel has often been mentioned and Tan Sri Dr. Munir ventured to get Dr. Noor Hisham’s take on this.

• ASEAN common standards: ASEAN could provide a platform to establish common standards. “If we can, we should create a benchmark and standards agreeable to all the member states. Rather than all the countries performing duplicate services,” said Dr. Noor Hisham.
• Bulk vaccine procurement: ASEAN could work collectively to procure the COVID-19 vaccine. Bulk purchase by ten countries would bring down the cost of the vaccine.
• Travel bubbles: Malaysia is currently in discussion with Singapore and Brunei. The country is looking at the number of cases in the two countries. “We will look into mutual agreements by both sides that we can agree upon,” said Dr. Noor Hisham.

c. The possibility of Malaysia being a COVID-19 vaccine manufacturing hub

On the possibility of Malaysia being a manufacturing hub for the COVID-19 vaccine, Dr. Noor Hisham shared the following thoughts:

• Malaysia’s manufacturing capacity: Malaysia has the capacity to be a manufacturing hub for the COVID-19 vaccine. However, the country would require clinical trials data before committing to any decision. Malaysia had discussed with China including vaccine-related issues. If there is strong evidence to suggest the vaccine works, Malaysia would volunteer to be the hub for manufacturing for ASEAN countries but the government needs to study on patent issues before taking conclusive actions.
• Current findings: Studies conducted in the UK and China showed that after three months only 70% of those infected with COVID-19 had antibodies. The MOH’s own study from among one of the local clusters showed that after three months, only 20% of those infected had antibodies. These studies show that after eight weeks, the antibodies inside the body start to decline, which means that a recovered COVID-19 patient may get re-infected.
• More questions than answers: With many questions with regards to the vaccine development at the moment, Dr. Noor Hisham said the MOH would like to see data from the Phase 3 clinical trial first, and to ensure that it is safe and reliable before making any decisions.

5) Conclusion

a. Science over politics, facts over rumours

The COVID-19 pandemic has shown the importance of having a supportive government that listens to the advice given by public health experts. “Malaysia is fortunate to have a government which gives space to professionals to drive the fight and purpose for the measures against the COVID-19 pandemic. We can just look around us and see how countries which do not do so have failed,” said Tan Sri Dr. Munir.

b. Everyone needs to cooperate to mitigate the COVID-19 pandemic

Dr. Noor Hisham emphasised that containing the COVID-19 virus requires cooperation from several parties such as the Immigration Department, police and army personnel as well as the public. Getting the public to comply with the SOPs requires gaining the public’s trust and this is obtained with clear, accurate and continuous sharing of information.

c. Region-wide measure requires strong leadership

On a regional level, ASEAN initiated several measures that aim to enhance experience and information sharing but if the region was to go further by developing common standards or benchmarks, it needs to be driven by a single country to prevent duplicate work. When one country leads in a certain area, other countries can focus on other equally important areas. Coordination is essential to allow countries to work together and avoid the duplication of work.

d. Countries must remain vigilant to fend off next wave of COVID-19 infections

Having a second or third wave of COVID-19 infection remains a real concern and Dr. Noor Hisham said the country has learned from the past few months and is more prepared than before with the understanding on the importance of first and fast implementation. He said countries should also heed the lessons learnt from affected countries and those that managed to keep it under control like New Zealand which strengthened border control and enhanced the local economy.

“We want everything to resume back to normal, but [on the condition of] with the SOPs in place. If we comply with the SOPs, that is how we mitigate as well as manage the risk of COVID-19. We are sure we can manage the risk as long as the public complies with the SOPs. We need strong social responsibility, social discipline and social compliance. If we have that in place, I think we can succeed,” concluded Dr. Noor Hisham.

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