Stethoscope: Better organising principles during Covid-19 third wave

This article first appeared in Forum, The Edge Malaysia Weekly, on October 12, 2020 - October 18, 2020.
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As Malaysia fights off a third Covid-19 wave, we must remind ourselves that this will not be the last wave in our long war against the virus. What are the lessons from the first 10 months of fighting Covid-19, and what should be our organising principles for this wave and future ones?

By now, we know that basic measures can work well against Covid-19, as proven by our success earlier. The strict Movement Control Order (MCO) of March to May helped flatten the infection curve, but it came at great economic and psychological cost, and is now rightly considered a nuclear option.

Masks, hand hygiene, physical distancing and the 3Cs and 3Ws of the Health Ministry are now widely understood and reasonably complied with. The ministry has also learned valuable lessons in resource allocation and priority-setting, and doctors are more experienced at treating patients with the disease.

Conversation has rightly shifted to more complex measures. The enforcement of the standard operating procedures (SOPs) of the Conditional MCO and Recovery MCO must improve, with visible sanctions on errant leaders and without double standards. Political considerations must take a back seat to public health imperatives. Health experts must regain their stature and decision-making privileges similar to the first phase, and not be crowded out by the security agencies.

Prisons are overpopulated and must be decongested, and we should release low-risk offenders and those who have not yet been sentenced, as Colombia, France, Indonesia and Iran have done. Migrant health is crucial, as they form large parts of our society and economy.

Malaysia needs a basket of solutions for the vaccine, but that should be considered an endgame to be pursued in parallel to other public health measures. These are fundamental requirements for any pandemic response, and they will help us prevail against the current wave and also future waves of Covid-19.

How to do better?

Start with humility. Now, Malaysia needs a more refined national conversation about the long-term strategy and overarching organising principles to fight Covid-19 in the next few years. These organising principles will help us become more proactive and systematic, instead of reactive and uncoordinated. I offer three organising principles.

The first is to avoid hubris. Malaysia has been very successful against Covid-19, especially when compared with the national crises in Brazil, Philippines, Indonesia or India. This could result in a sense of complacency among political leaders in Malaysia, leading to a sense of invincibility or imperviousness. We are not out of the woods yet; the old “political normal” will only threaten the lives of the rakyat.

Global responses to Covid-19 have upended traditional perceptions of the soft power of countries. Countries considered to be powerful and well-resourced like the US and the UK are increasingly struggling in the fight against Covid-19. Other countries have just stayed under the radar and quietly gone about their work, like Mongolia and Rwanda, which have performed excellently.

Therefore, a sense of humility is crucial for any strategy for the next few years. This will force us to learn lessons from countries that have performed even better than Malaysia, such as Vietnam, Thailand, South Korea, Taiwan and Hong Kong. For example, Vietnam, a country of 96 million and three times more populous than Malaysia, only had 1,100 cases and 35 deaths (as at Oct 7). What can we learn from its investments in public health infrastructure, de-politicised public health leadership, decisive decision-making and powerful crisis communications?

Malaysia has beaten the first wave of Covid-19, but the war will be long and arduous. Although we should be reassured that we have the tools and capacity to succeed, we must not take our initial success for granted. The price of health security is eternal vigilance and humility.

Decide decisively

The second organising principle is decisive decision-making. There are good reasons why decisions can sometimes be late, such as scientists and epidemiologists wanting as much data as possible. There are also bad reasons why decisions can be late, such as complacency or paralysis by fear of backlash or wrong decisions. We can eliminate these bad reasons in several ways.

One, public health has always advocated the precautionary principle, and that should be an important organising principle for all decisions. For example, we can decide on Targeted Enhanced MCO (TEMCO) areas in two new ways. The threshold for a TEMCO should be lower and the burden of proof smaller. Furthermore, if there is a high index of suspicion that an area will become a red zone and this is supported by mathematical models, a TEMCO can be declared while waiting for all test results from contact tracing to come back (which can take several days). If most results are negative, the TEMCO can be lifted.

Two, decisions can be decisive if we commit to using if/then algorithms, with the caveat that we must be judicious in creating them. In the early days, it was announced that districts would be classified as red zones if there were more than 41 active cases. Being named a red zone triggers a specific set of actions, such as roadblocks or reduced opening hours for shops. This can be considered an if/then algorithm, which will reduce the energy, time and bureaucratic coordination needed to make decisions, which will in turn speed up decisions. Of course, the algorithm itself must be improved over time, without being unstable or unpredictable.

Three, inter-ministerial coordination must be consistent and predictable. Consistency is key, especially in the simple things: when universities are closed but primary schools remain open, it is clear that the ministries of education and higher education must coordinate. After 10 months of fighting Covid-19, the decision-making pathways must be predictable and understood by all relevant stakeholders.

We should not be seeing turf wars, egos or petty fights for the limelight. Unfortunately, this requires political will, which is in short supply in Malaysia. This is all the more reason for sustained public pressure to achieve inter-ministerial coordination.

The perils of indecisive decisions are clear. During rapidly changing pandemics, we have a tiny window of opportunity to make good decisions. Even a good decision implemented just one day late has the potential to trigger a sudden chain reaction, putting governments on the back foot, from which they may never recover. Therefore, decisive decisions are crucial.

Avoid MCO 2.0 at all costs

The final organising principle is to avoid MCO 2.0 at all costs. There are two specific ways this should be done. One, Malaysia must implement a basket of solutions, recognising that all solutions are inadequate if applied individually. All solutions must be on the table at the same time: for example, expanded testing, precautionary mandatory (not voluntary) quarantines for returnees from high-risk areas, and more liberal use of TEMCOs. Fighting a pandemic requires multiple solutions all at once, and not just relying on the misleading promise of finding individual magical solutions.

Two, Malaysia must allow more levels of government to make decisions, and decentralise decision-making power to state, district and municipal governments. Malaysia is a highly centralised country, which was an advantage in the initial stages of a pandemic marked by chaos and uncertainty. However, as time went by, other organisations and levels of government gained more knowledge, experience and confidence in making decisions.

There are advantages to this decentralisation. State, district and municipal governments are closer to the ground, and can better read public sentiment and their acceptance of risk levels. Decentralising decision-making is an important form of contingency planning and government continuity, especially when half our federal cabinet can be exposed to Covid-19 in just one meeting.

Decentralising also allows state, district or municipal governments to self-TEMCO if they deem necessary, which is a more accurate and timely decision than one made in Putrajaya and will reduce our risk of a second nationwide MCO in the long run.

A smooth and predictable journey

After 10 months of battling Covid-19, we should have already articulated our organising principles. Malaysia should not yo-yo between harsh and lax restrictions in its fight against Covid-19. Rather, we should find surgical methods and targeted interventions that balance lives and livelihoods, rather than wield blunt public health instruments like a nationwide MCO.

Deploying the right intervention at the right time and place requires humility and decisive decision-making. That will help us to avoid a second nationwide MCO. These organising principles can help guide us through the next few years smoothly and predictably, especially if they are backed by political will.


Dr Khor Swee Kheng is a physician specialising in health systems, health policies and global health

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