By Dato' Dr Amar-Singh HSS
The world and Malaysia have come to a difficult crossroad in the coronavirus outbreak (COVID-19). The time has come to make some hard choices. We would rather not make these choices, but burying our heads in the sand is not going to make the problem go away. We would like to believe that we in Malaysia are protected or will be spared but to quote the WHO director: "No country should assume it won't get cases, that would be a fatal mistake, quite literally."
On the one hand there are those who are dismissing this outbreak as a minor problem and say we are overreacting and calling the rest of us alarmists. On the other hand there are those who are panicking in extreme ways. Both are not helpful to this outbreak. There are yet others who say that our country has a milder version of the virus and we will be OK. But there is no evidence of this from the virologists studying this virus and it is currently just speculation. Minor genetic shifts do not constitute a mutation.
The experience in Wuhan, China, the current explosive situation in Italy and the growing epidemic in the US and Europe should tell us that this may also happen in our nation. It is our early response and vigilance that has limited the spread in our country so far. But we can now see the numbers beginning to rise. If we do not put in place further measures, we may also have an explosive outbreak. This will not just overwhelm the entire health system but result in a substantial number of deaths of older individuals.
In Italy, as in Wuhan earlier, they are now having to make the hard choices of not offering care to those above 65 years, as there are just not enough ICU beds in hospitals. Malaysian government hospitals have collectively between 700-900 adult ICU beds. These are already full with ill patients most of the time. We do not have the capacity to deal with more ill patients if we have an outbreak like that in China and Italy. In addition, many healthcare professionals have also fallen ill with the coronavirus, diminishing the healthcare system's responsiveness.
We may not want to make these hard decisions because we are concerned of the damage to the economy, especially to those in the tourism, food and manufacturing industries. But this is a very short term and narrow outlook. If there is a massive outbreak in our country, the economy may be damaged for a much longer period of time.
In making tough decisions the key will be the sustainability of these measures. How long are we going to keep our borders ‘closed'? How long are we going to continue testing individuals at entry points to our country when most countries now have infected individuals? How long are we going to keep schools shut and ban all public gatherings and conferences? How long are we going to practice community social distancing measures?
There are three possible directions we could take, three possible hard choices.
The first is to carry on as usual. Put minimum restriction on society. Allow free movement of individuals and allow travel and businesses to continue as usual. This will allow the virus to spread widely and over time we can develop community herd immunity.
This, many believe, is a disastrous choice. The number that will die from this decision will be unimaginable. If 60% of Malaysians get infected and we have a 1% mortality rate (higher mortality in older individuals and those with chronic diseases) then between 150,000 to 200,000 Malaysians may die. Although a few have proposed this option, no one in their right mind can accept such a decision or course of action.
The second option is to continue as we are doing now. Isolation of all infected individuals. Vigilant contact tracing of infected individuals. Limiting travel to and from countries that are of high risk. Screening at entry points to our country. Advising the public on reducing risk of coronavirus by good social hygiene. Some minimal social distancing measures. All this is good and commendable but there is no evidence from countries which are now facing large outbreaks that these measures will be sufficient.
South Korea and China appear to have been able to contain massive outbreaks. But the authoritarian government in China and the highly disciplined people of South Korea were possibly major factors to enable a meaningful lockdown to break transmission and limit public panic behavior. So we can continue as we are now until we have a massive outbreak but will we be able to manage when it comes?
The third option is the one that I am advocating for. A preemptive strike. That is, we prepare as if an outbreak is imminent or already in place. This will be painful for all of us and it will have to be thought through and will require sustainability measures over time. It would be wise to listen to the discussions going on in Singapore on this.
Lawrence Wong, the Singaporean Minister for National Development, who is the co-chair of a multi-ministry task force set up to handle the coronavirus, said on 10 March that "As the virus spreads to countries everywhere, country-specific border control measures will become less relevant and effective because we are unable to shut Singapore from the world. We have to now shift our approach…. We will look at the whole range of social distancing measures."
Making this the choice will not be easy. What will it entail? We will need to shut down all mass gatherings of individuals in the country. All conferences should be postponed, all religious congregations should be asked to no longer meet in their mosques, temples or churches but to meet in a virtual context. We should seriously consider closing schools and teaching children online for a period of time. All non-essential travel should stop. We should discourage all travel outside the country and mass travel within the country (no tour bus travel in Malaysia). Businesses and companies that are able to have their employees work from home should encourage this to happen. Older individuals and those with chronic medical problems should consider keeping a stock of three to four weeks of their personal medication and food resources so as to deal with a period when they need to be completely socially isolated from the community.
I fully recognize that this third option is extremely socially distressing and difficult, especially for parents. There will be a significant economic impact. However, remember that we are doing this to protect all of us. While many will have a mild infection, the mortality can be high as high as 10-15% in our older loved ones and those with chronic illnesses. The data from Italy and other countries shows that even some young adults can become seriously ill.
Remember also that many poorer families do not have the resources to deal with such measures. This will be a time for Malaysians to come together and support each other financially and socially. Also recognize that it cannot be the responsibility of just the authorities alone to stop this outbreak; it is the responsibility of every single person in Malaysia.
Remember that this coronavirus (COVID-19) does not respect nations, borders, politics, politicians, religions, ethnicity, businesses, economics or opinions. It is spreading worldwide and will be with us for at least the next few months, perhaps until the end of the year. We must work together to stop it.
I leave you again with these words of wisdom by Michael O. Leavitt, a former Secretary of the US Department of Health and Human Services, spoken in 2007 at a pandemic influenza leadership forum: "Everything we do before a pandemic will seem alarmist. Everything we do after a pandemic will seem inadequate. This is the dilemma we face, but it should not stop us from doing what we can to prepare. We need to reach out to everyone with words that inform, but not inflame. We need to encourage everyone to prepare, but not panic."
(Dato' Dr Amar-Singh HSS is a Senior Consultant Pediatrician.)