Article by Dr. Musa Mohd Nordin, published in malaymail.com:
NOV 1 — Soon after China declared the first case of Covid-19 to the world on 31 December 2019, the evolving pandemic has since been mired in a contestation of science, pseudoscience and politics.
The world has since witnessed some of the worst forms of human behavior and political governance. These ranged from the abject muzzling of scientists and healthcare professionals, censorship and secrecy in China to denialism, conspiracy theories and disinformation from the highest of political office in the US.
Despite the global experience with 8 pandemics in the 20th and 21st century, namely 1918 Spanish flu (40-50 million died), 1957 Asia flu (1.1 million died), 1968 Hong Kong flu (1 million died), 1981 HIV/AIDS (25-30 million died), 2002 SARS (770 died), 2009 H1N1 pandemic flu (200 thousand died), 2014 Ebola (11,300 died) and 2015 MERS-CoV (850 died); no country’s preparedness plans was up to mark to prevent, control let alone contain a looming pandemic.
Even the WHO was not spared of harsh criticisms of its delayed declaration of Covid19 as a Public Health Emergency of International Concern and its inept handling of China’s obfuscation of Covid-19 data.
The mix of scientific uncertainties of the novel SARS-CoV-2, charged with pseudoscience and politics in the presence of global pandemic unpreparedness, have been so catastrophic for both lives, livelihoods and economies.
Apart from the stellar achievements of a few nations, namely New Zealand and Taiwan, most countries including Malaysia has faltered in varying degrees in their crisis management of the Covid-19 outbreak. This brief examines the inter-play of science and politics, civil and political governance in a few select milestones in the Covid-19 timeline in Malaysia.
The first painful lesson began early in the pandemic when the Jemaah Tabligh was “allowed” to stage their Ijtima’ (gathering) in Malaysia from 28 Feb – 1 March 2020 at the Sri Petaling mosque. We were then into 2 months of the outbreak and the MOH should have by then, been well cognisant of the potential catastrophe of a mass event, hosting 14,000 participants in closed and confined spaces with both fiery religious sermons and intimate brotherly conversations, the 3Cs.
Malaysia was then in the midst of a political upheaval and both sides of the political divide were pointing fingers at the other for granting permission to the Ijtima’ organisers. But as the Malay proverb goes “gajah sama gajah bertarung, pelanduk mati ditengah tengah” – the citizens became the victims of the politicians’ hostile squabbles.
This Ijtima’ event was a super-spreader incubator which triggered the second wave of Covid-19 in Malaysia. It became South East Asia’s hotspot spreading to Brunei, Cambodia, Singapore, Thailand, Vietnam, the Philippines and Indonesia.
Another unfortunate failure of our pandemic science was the belated recognition of the index cases number 131 and 135, only detected one week after the Intima’ had ended. The infamous Tabligh cluster registered 3,375 cases which made up 38.9 per cent of the total Covid-19 cases in Malaysia till its cessation on 8 July 2020. It contributed 34 Covid-19 deaths (23 per cent) and it spawned 2 sub-clusters causing 121 cases. It has spread deep into the community with five generations of transmission.
By early June 2020, we had largely flattened the epidemic curve. This reprieve represented a window of opportunity to put in place mid and long term plans as to how to push the numbers lower, maintain them and co-exist with the virus until effective and safe therapeutics and vaccines can be found.
It meant continued vigilance with masking, distancing, hand washing, avoiding the 3Cs, an expanded program of testing, tracing, quarantine and strict border controls to prevent case importation.
Unfortunately, the rakyat, civil and political leadership let loose their guards and were celebrating their Covid-19 victories. The rakyat abusing their new found MCO freedom, brandishing confetti, superlatives and awards to their Covid heroes. A senior minister in the government declared;
“It was a good omen (nasib baik) that the Pakatan Harapan government was not ruling, otherwise there would be more deaths due to Covid-19”
Meticulous public health planning and astute political stewardship was critical to plot the roadmap of our Covid-19 exit strategy to protect our health, lives, jobs, economy and our future. But apparently they hardly planned for any of this and after 10 long months had only formed nine sub-committees to look at mid-term and long-term plans to manage Covid-19.
They were all jolted out of our celebrations by the explosive numbers of new cases registered in the Benteng Lahad Datu (LD) cluster in Sabah and Kedah’s Tembok cluster in Alor Setar. They were lulled into a false sense of confidence by their earlier victory over the Migrant Workers cluster in detention centers which recorded 649 cases for the 2 month period from 21 May to 23 July 2020. I am suspicious that they were hoping that these detainees and prisoners were a marginalised cohort and would not attract as much public attention. And considering they were either in detention centers or prisons, the enclosed space would prevent transmission to the outside world and that they would very quickly develop herd immunity.
These detention ambience were the perfect 3Cs petri dishes for Covid-19 to germinate and spread. The Benteng Cluster began with 2 cases of PATI (Pendatang Asing Tanpa Izin), illegal migrants, detained in IPD Lahad Datu before its onward transmission to a prisoner in Tawau Prison on 1 September 2020, a few days before the election campaigns of PRN 2020 Sabah. It has since increased exponentially and by 10 October 2020, the Benteng Cluster registered 967 cases.
On 29 September 2020, another cluster was brewing involving prisoners and prison officers in Alor Setar, Kedah. The index case, a prison officer who has since died, had spiraled the numbers to 1207 cases in the Tembok cluster.
Ingenious ideas and solutions from concerned academics and the former deputy minister of defence to decongest the detention centres and prisons were met with indifference and they were doing the same thing again and expecting a different outcome, which Einstein described as insanity.
Meanwhile, the political turbulence in Sabah was tempting the virus. Clandestine political designs to unseat a legitimate state government triggered the Sabah state elections (PRN 2020). The health ministry and the elections commission were adamant that the elections SOP was in place and was confident of an NZ-like and South Korean-like successful experience, which turned out to be their folly.
The Pilihan Raya Negeri (PRN 2020), was the harbinger of the 3Cs and was therefore a potentially explosive super-spreader event and the politicians with its entourage of die-hard party supporters, were super-spreader persons.
This super-spreader concept needs to be hammered into our psyche so as not to be pacified by the average notion of the Reproduction Number (Ro). A simple analogy would be me sitting in a room with 10 other private paediatricians. Our average wealth (Ro) would probably be (I am being overly optimistic here) about RM1 million. If we had the pleasure of the presence of a past PM (I’d leave that to your imagination) to join us for a drink, our average wealth would surge way past RM100 million! Surely, this average (Ro) is not a useful concept in this situation nor Covid-19 epidemiology.
If the doctors’ tea-room was small, poor ventilated, and the doctors were shouting at the top of their voices at close range, and one of us was Covid-19 positive, then you can bet your last dollar that all of us would be infected. This 1 to 10 spread (super-spreader) instead of an Ro of 1.0 (1 to 1 spread) has been observed repeatedly in this Covid-19 pandemic. It is not captured by Ro but now explained by a phenomenon “k” known as dispersion.
This is the new Covid-19 science which stipulates that Covid-19 infects in big bursts and the infected person may spread to several persons all at once which explains the phenomenon of clustering and 5-10 per cent super-spreading persons or events who are responsible for 80-90 per cent of cases (Pareto Principle). There have been multiple studies to validate this Pareto Principle, but the most massive research was undertaken in India, with a population of 1.3 billion, which has since reported 8 million cases and 121,641 deaths as at 31 October 2020. They studied 85,000 Covid-19 positive cases and traced 600,000 close contacts and concluded that only 5 per cent of the positive cases were responsible for 80 per cent of Covid-19 infections.
Our own experience early in the pandemic, reported that Covid Index Case Number (ICN) 26 infected 114 persons and ICN 8937 from the Sivagangga cluster infected 45 person in 3 different states.
The prison and PATI clusters in tandem with the Sabah election cluster was the precursor to the even more terrifying and worrying 3rd wave, a tsunami really in comparison to the first two waves. Three to four figure daily counts was the norm and the daily Covid-19 deaths were at an accelerated pace and quite a few of the cases were brought in dead in Sabah. The Sabah election fiasco was responsible for 30.8 per cent of the new Covid-19 cases on the mainland and since data sharing was opaque, we can only crunch the limited numbers in the public domain. We would suggest that gutter politics is the biggest culprit in our quest to tame the SARS-CoV-2. Our political guys behaving ala-Trump protégés and furthering their parochial agenda oblivious of the serious harm inflicted on the health, lives, wealth (or lack of it) of the rakyat. Not only was PRN 2020 a super-spreader event, it simultaneously unleashed to the Malaysian Covid-19 landscape, another set of super-spreader persons like ICN 26 and ICN 8937, this time round allegedly, a politician ICN 12553, sprouting the Bah Kasturi cluster which infected 18 persons. I wonder how many more similar super-spreader politicians if our Ministry of Health had been more transparent with their data.
And what makes it even more frustrating is the alleged collusion between civil governance, guys whom we entrusted with the science, and political big wigs. Even the lay-person, a singer of the baby boomers generation, pointed out to the top guys in the Ministry of Health that the decision “no need to quarantine if they tested negative” echoing the Putrajaya position “no quarantine for voters returning from Sabah” was against the SOP. If the MOH had stood their ground, and held firm to good pandemic science, the 30.8 per cent election cluster on the mainland could have been prevented if not mitigated. They totally ignored the calls of ID physicians and others to quarantine and retest the returnees from Sabah. To make matters worse they applied double standards in the treatment of politicians versus the ordinary rakyat vis a vis fines compounded, days of quarantine and if quarantined at all.
Another disturbing development in our partnership to tame the coronavirus is the recent reluctance of the MOH to continue to share data with the states, specifically with the Selangor Task Force on Covid-19 (STFC). The STFC chairman alleged “you asked us to box in the ring but you blindfold us” since they no longer received granular data from MOH from the first week of October 2020, thus hampering their state efforts to contain the outbreak.
I am pretty clear in my mind that the MCO in Sabah was a Clinical MCO founded on good science, namely data confirming unlinked, sporadic cases in 90 per cent of positive cases. The massive upsurge of cases meant that the infection has spread far and wide into the Sabahan community, which poses a monumental challenge to testing, tracing and isolating of positive cases.
In my opinion, there were many shortfalls in the federal and state response in terms of a “whole of government and whole of society” framework of action to end the outbreak. I will stick to the science of pandemic crisis management and suggest that the response was lacklustre and old school. Instead of targeted testing it should have been mass testing. Instead of slow, laborious, needing mercy flights, and back-logged PCRs, the MOH should have gone big with RTK-Ag, which are rapid testing kits churning results on site within 1-2 hours, thus allowing prompt isolation of cases, immediately tracking the contacts, rapidly busting the clusters and a faster end to the outbreak.
Without the benefit of our national Covid-19 big data, which suspiciously was stopped in the early days of the third wave, I can only suggest that the second MCO mandated in the Klang Valley, inclusive of Selangor, Putrajaya and Kuala Lumpur, was not a Conditional Movement Control Order (CMCO) but more nuanced as a PMCO aka Political MCO.
Analysis of the available data in the Klang Valley showed that there was actually down-trending of the unlinked cases from a high of 63 per cent to a low of 7 per cent on 12 October 2020. This informs us that the outbreak in the Klang Valley was clustered, which is “relatively less morbid in comparison to Sabah” since clusters are much easier to detect, trace and contain. The infection rate of active cases in Sabah was 1.9 which is 6 times the national average (0.3), 9.5 times that of Putrajaya and Selangor (0.2) and 19 times that of KL.
The end-game of any degree of physical distancing, ranging from the extremes of a complete lockdown ala-Wuhan to herd-immunity ala-Sweden, to the varieties of Taiwan, South Korea and the various alphabet-MCOs of Malaysia, is to quickly suppress the total positive cases, reduce the case fatality rates (CFR), provide immediate relief to the healthcare system and to allow the infected, isolated and quarantined healthcare workers (HCW) to stay alive, get better and get back to work. It buys precious time, such that the healthcare capacity is protected and not overwhelmed.
At no point in time, was the healthcare capacity in the Klang Valley challenged nor compromised unlike the criticality of the healthcare facilities in Sabah. These scientific rationale among others, debunks the need for any form of MCO if the built in testing-tracing-isolation rapid response was functional and robust.
The attempt at declaration of Emergency Ordinances submitted to the Council of Rulers, which suspends the parliament and confers extra powers to the Prime Minister further reinforces the notion of a PMCO, to freeze the democratic process, neutralize the opposition and prevent the remote possibility of a no-confidence vote in parliament.
The Covid-19 landscape and experience in Malaysia has truly been a roller coaster ride. The good science and public health that kept the virus at bay in the early days of the pandemic, had somewhat lost its pristine maqasid, the higher objectives of pandemic management in the aftermath of the third wave.
The fiqh waba’ the jurisprudence and principles of outbreak management, in the latter days of the epidemic was somewhat old school, not contemporary and bereft of new ideas to meet the challenges of a raging Covid-19 tidal wave.
Extremely worrying was the intrusion of politics into the scientific game-plan to end the pandemic. Politics was riding on the epidemic to stifle the democratic process, suspend the parliament and confer draconian powers to the PM which would slide our nation on the slippery slope towards an autocracy.
That the science was submissive, maybe even colluding with the politics was most unfortunate, absolutely detrimental and dashed all our hopes of a healthy and vibrant civil and political governance in the midst of an unforgiving virus. Our elder statesman has often exclaimed that “Melayu mudah lupa”. In the context of today’s outbreak “Kita semua mudah lupa” would be a more appropriate desperate wake-up call. The Covid-19 pandemic is the sixth in the 21st century nor will it be the last that an invisible and miniscule enemy has brought post-modern civilisation down to its knees.
The coronavirus has ruthlessly exposed the inequalities in our society and worst still, has amplified it even further. It reminds me of our literature class in secondary school, dissecting George Orwell’s Animal Farm. My favorite quote from the book sums up the dire situation we are all in today, compounded by the dangerous pandemic mix of FDI outflows, bearish stock markets, mass unemployment, food insecurities, a compliant civil service and political insecurity:
“All animals are equal but some animals are more equal than others”
*This is the personal opinion of the writer and does not necessarily represent the views of Malay Mail.