By Dato' Dr Amar-Singh HSS
The coronavirus (COVID-19) outbreak has affected every single Malaysian in an enormous way. It has torn the fabric of our society and changed the way we live. We want this to end. We wish we could reset this year and start again. But in many ways we are just beginning to address this outbreak in our nation and the world. There's much more to do before we can get out of a global crisis and return to some sanity in our day-to-day life. We are all in this together and hence we should be keen to know that we are taking the correct steps. Transparency and honesty are vital at this time.
Angela Merkel, Germany's Chancellor, estimates that 60-70% of her population will be infected by the coronavirus and said "….. since World War II, there has been no greater challenge to our country that depends so much on us acting together in solidarity".
Jacinda Ardern, Prime Minister of New Zealand, in declaring a 4 week lockdown at a very early stage of their epidemic, said "Everything you will all give up for the next few weeks, all of the lost contact with others, all of the isolation, and difficult time entertaining children - it will literally save lives. Thousands of lives." She went on to ask her people "I have one final message. Be kind. ….What we need from you, is support one another. … We will get through this together, but only if we stick together. Be strong and be kind."
We are in an unprecedented time in the history of our nation and the world. There is no roadmap forward. We will have to write as we go along and that will be hard.
Currently we have made a significant and meaningful stand. We are not Italy, we have done better than much of Europe in our control measures. But the worst may be ahead.
There are three things that we need to emphasise, that would enable us to move forward. Three corners or points of a triangle that are critical for us to endure this period and deal with this epidemic (see the figure). If even one is broken, we will not be able to halt the epidemic.
Firstly we need to continue our physical (social) distancing measures to stop virus transmission. We can achieve this with our movement control order (MCO). Without it we would have a roaring outbreak on our hands. As it was announced today, it has been necessary to extend the MCO a further two weeks and we hope it does not need to be extended further.
Every Malaysian has a part to play here. If even a small portion of our community (10%) disregards the MCO, then we will be in crisis. As an example, see the graph below that shows the impact of just one person or one group on the entire epidemic in Malaysia. This is not to blame any individual or group but show us how each of us can make a significant difference in stopping this epidemic or inflaming it. The infection introduced into the tabligh convention accounts for more than half our national outbreak and continues to have ramifications in our country and is a super-spreading event for many neighbouring countries.
This sort of wide spread infection can happen in many other situations without the MCO. It can happen in a conference, a wedding, a funeral, a large religious meeting, a mass celebration or eating together in a community. It only takes one infected person to spread it to others and, so on. Every Malaysian must take the MCO seriously and play their part so that we can end this restriction order early.
The second arm of our defence is testing. We need to identify all infected persons and quarantine them. I have spoken earlier about this but would like to highlight a little more on what is happening currently. The graph below shows the ‘test returns’ and ‘positivity rates’ each day for COVID-19, based on calculation on data obtained from MOH press releases. I am indebted to two Malaysians I have met online during this epidemic for thinking through this data with me and offering valuable insights (they have chosen to remain anonymous). The data is limited by the very large number of pending tests and we have no idea of private testing numbers. But the high positivity each day (10-20%) indicates that we are still doing too few tests. You have to cast your net widely to pick up cases when the epidemic is spreading in the community (see my earlier article). Note in contrast that only ~ 3% of South Korea's coronavirus tests result in confirmed cases, ~ 1% in Australia but ~16% in Italy. The higher the positivity the weaker the testing strategy. The testing per million population graph from "Our World in Data" group also shows where we fare compared to others (caution that some data is older and countries may have improved).
The public need a clear idea on how many tests were completed each day (daily test returns) and how many were positive (positivity rates). We also need this data by each state and district so that everyone will be aware of their risks and act accordingly. At this time the Ministry of Health (MOH) is very stretched but many individuals would be happy to support the work of processing data. Such data from MOH would increase public confidence in our testing.
I want to remind us constantly that there is increasing data that we could be spreading the coronavirus without realising we are infected. One study to support this suggested that 86% of all infections were undocumented and were the infection source for the majority of cases identified. Another study suggests that many countries in the world are only picking up 10-30% of cases currently.
As many have articulated, in these times you have to treat every person you meet as coronavirus positive.
Finally we need to support our healthcare professionals (HCPs). They need our support to ensure they have adequate PPE, that their daily needs are met, that their families are cared for. It is very hard for HCPs to keep going at this exhausting pace without community support. No national or MOH coordination will work effectively at this time. We require local community initiatives, i.e. adopt a hospital or health district. We need for community leaders with recognised integrity to lead these local community initiatives so that HCPs don’t get overrun with food alone. I have watched how our former deputy health minister and current member of parliament, Dr Lee Boon Chye, galvanise support for Hospital RPB Ipoh. He has a track record of reliability and honesty, hence many have rallied to his call to meet the practical needs of HCPs at Hospital RPB Ipoh. The group that he coordinates liaises with the hospital management, identifies pressing needs and meets them quickly. All hospitals and health districts will need this. Hospitals that are currently poorly supported should not be shy to speak up.
We must work together to strengthen these three key measures. This is not just the role of government, MOH, CSOs but the role of all Malaysians. To paraphrase the words of Angela Merkel, there has been no greater challenge to Malaysia than the coronavirus outbreak and it all depends on us acting together in solidarity.
(Dato' Dr Amar-Singh HSS is a Senior Consultant Paediatrician.)