Dr. Subramaniam Sathasivam, Malaysian Minister of Health (2013–2018) and Minister of Human Resources of Malaysia (2008–2013)

Balancing Act: Lessons in Best Pandemic Mitigation Practices from Malaysia’s Former Minister of Health, Dr. Subramaniam Sathasivam

By Kristina Lyons

Not too long ago, protests in the wake of the murder of more Black Americans by the U.S. police dominated news headlines, while the COVID-19 pandemic carried on, reaching record highs of global daily tallies of cases. Many communities around the world, already challenged with finding a balance between public health and economic interests as stay-at-home restrictions eased, have faced attempts to curtail the spread of COVID-19 while holding governments and their actors accountable via the right to protest. After months of policy directives limiting the size of gatherings, large crowds assembled in cities — from Los Angeles to London, Pretoria to Pristina, Tokyo to Tunis, and Sydney to Seoul — in solidarity with those advocating for racial justice and structural reform.

While many demonstrators have taken precautions by wearing masks, efforts to mitigate exposure have been compromised by the difficulty of maintaining social distancing measures during protests, and further challenged in the U.S. by aggressive application of crowd control measures by law enforcement. These include the use of chemical weapons, such as tear gas and pepper spray, which caused those affected to cough and remove masks in efforts to breathe. These also required close-quarter assistance of victims, increasing the risk of COVID-19 transmission, though there is currently little evidence that protests have increased incidence rates. Regardless, skilled and sensitive leadership and holistic approaches have never been more important as social, economic, and health considerations collide during this historic time.

Physician and former minister of health of Malaysia (2013–2018), Dr. Subramaniam Sathasivam shared the secrets of his country’s success in managing the current COVID-19 crisis and balancing science with internal politics as part of the Voices in Leadership series. The conversation, guided by Dr. Rifat Atun, Professor of Global Health Systems at the Harvard T.H. Chan School of Public Health, took place over Zoom on Thursday, May 14, 2020.

Act Early and Let Science Lead

Dr. Subramaniam, who is known as Dr. Subra, cited the example of the sovereign nation of Taiwan, which many assumed would be the next hot spot of the pandemic because of its relative proximity to the city of Wuhan where cases were first identified. But Taiwan was able to leverage its previous experience with the SARS epidemic and took vital preemptive steps, according to Dr. Subra. Before the virus even landed on their shores, Taiwanese experts visited Wuhan in mid-January to analyze the situation and swiftly implemented public health measures based on their firsthand understanding and data gathered from what was the epicenter of the COVID-19 outbreak at the time. Symptom screening onboard direct flights from Wuhan were initiated, followed by surveillance at international ports of entry, home quarantines, diagnostic capacity building, and banning exports on surgical masks and N-95 respirators. Taiwan also employed innovative digital technology solutions, as did many of their Asian neighbors, to trace cases and flag hotspots.

The first COVID-19 case in Malaysia was identified on January 25, 2020. Dr. Subra recalled that there were 20–30 more cases reported in February that were believed to have originated in China. But a very large religious gathering in the capital, Kuala Lumpur, at the end of the month involving 15–20,000 people from all over the world, created a super-spreader event. According to Dr. Subra, 35–40% of all diagnosed cases in Malaysia could be traced to that one cluster, not dissimilar in timing and impact to the Biogen Conference in Boston, which led to the transmission of cases locally, as well as across the U.S. and abroad, when attendees returned home after the gathering.

Manage the Tension between Competing Interests

“Let me put it very clearly that leaders ignore the realities of science during the management of pandemics of this sort at their own peril”, he asserted, adding that science can also act as useful political cover — a neutral “true north” — to shield leaders from the storm of internal political pressures, serving as a body of information behind which all stakeholders can align themselves, regardless of other interests. “If the fallback for leaders to make…tough decisions is based on the bedrock of science, then that is going to be their protection”, he remarked.

What began as a smaller health issue in Malaysia quickly became a crisis involving the entire national leadership, explained Dr. Subra. The “whole government” response, which he believes is essential in effectively combating COVID-19, can best be understood in terms of three dimensions: health, economic, and social, which governments have the unenviable task of attempting to balance. Dr. Subra additionally stressed the importance of a very complete cohesive government position — well-coordinated, avoiding duplication, and maximizing the utilization of all resources within the government… all moving towards a common goal with a single voice”. He highlighted the necessity for compromise and the futility of absolutist positions, which are simply unrealistic: “for example, the custodians of health cannot insist that we want the cases to become zero”.

Build Trust with Strong Clear Communication

He explained Malaysia’s tiered communication strategy. First, the prime minister was tasked with explaining and justifying all vital policy decisions, such as when new controls on movement were imposed or relaxed, or when the government released economic stimulus packages, in language accessible to ordinary people. Second, the representative from the Ministry of Health (MOH), tasked with containing the pandemic, went on the air daily at a regular time to provide updates on the latest data: the number of cases, number of deaths, healthcare capacity at all levels, and the evolution of the evidence-base of symptoms of COVID-19. Questions from the media were also fielded in these sessions. Third, the Minister of Defense held daily press conferences, leaving little room for misinformation, which can be especially counterproductive when trying to fend off a highly contagious disease with very specific and intrusive compliance demands required of the population. Dr. Subra affirmed this, stating: “when communication is accurate, transparent, and reliable over a period of time, that, of course, leads to the development of trust”. The Malaysian government successfully built credibility and trust through consistent systematic messaging, which unified the country at all levels in efforts to flatten, and in fact reverse, the epidemiologic curve by suppressing the reproduction rate, and provided reassurance to the public at a time of great uncertainty.

Dr. Subramaniam Sathasivam, Malaysian Minister of Health (2013–2018) and Minister of Human Resources of Malaysia (2008–2013) (Left), was virtually interviewed by Dr. Rifat Atun, Professor of Global Health Systems at Harvard University and the Faculty Chair for the Harvard Ministerial Leadership Program (Right) for the Voices in Leadership web series for the Harvard T.H. Chan School of Public Health.

Cultivate Solidarity

Protect At-Risk Groups

There can be tension between the priorities of the Ministry of Health and the Ministry of Home Affairs, tasked with protecting the country’s borders, a role that takes on an added dimension of importance during a global pandemic. Dr. Subra stressed that open channels of communication between countries that share significant flows of populations across borders, commonly Nepal, Indonesia, Bangladesh, Burma, and the Philippines, is critical to ensure fundamental human rights are protected while officials try to stem the spread of the disease. Again, trust and social capital are essential for an appropriate response within Malaysia but also across borders to develop effective inter-country collaboration.

As a result of his advocacy and experience, Dr. Subra is highly attuned to the particular challenges faced by those who are living paycheck-to-paycheck and who may be expected to distance physically, yet do not have the luxury of working or staying at home. Equity has emerged as a central theme in the discussion around COVID-19, as the pandemic has exposed stark racial disparities in health in the U.S., as evidenced by dramatically higher rates of infection and death among Black and Latinx populations. Differential outcomes within countries and between them will likely highlight the critical importance of the social determinants of health in settings across the globe.

Invest in Health Systems

Dr. Subra pointed out that Malaysia had a head start because the measures required to address COVID-19 are the same as measures they have used to mitigate previous disease outbreaks; they already had the physical infrastructure and human resources in place and simply had to amplify their efforts in proportion to the present COVID-19 challenge. “Nations probably should learn from this pandemic to invest in public health systems [ahead of time]. You cannot wait for a pandemic”, he stressed. Dr. Subra believes this crisis has been eye-opening for those outside the MOH who previously may not have appreciated the importance of public health and are now more likely to recognize the value of prioritizing meaningful investments to support adequate infrastructure and people power.

He also acknowledged that some countries may simply not have the resources to invest, but he offered a fitting solution from a former World Health Organization (WHO) official: “I think global collaboration and assistance from agencies like the WHO and from other more developed nations which have the strength and capacity to ensure that every country in the world has got a (responsive and effective) public health system” is critical. These are wise words that will no doubt resonate and prove prescient, as the current U.S. administration has now chosen to defund the WHO, in the wake of the dismantling of the Office of Global Pandemics of the National Security Council in 2018 and constant assaults on efforts to move the country in the direction of universal health care, all steps in direct contradiction to Dr. Subra’s emphasis on preparedness.

Dr. Subra’s prescription for success in Malaysia is truly universal and may be of particular value to diffuse the highly charged politicization of the virus in the U.S., which has weakened the country’s response, resulting in the highest caseload in the world and continuing surges in many states. He recommends a whole government approach, clear communication, openness, transparency, and trust to build social capital and solidarity, protecting those at risk, and investing in health systems. This remedy could be the closest thing we have to a miracle cure for leaders faced with public health challenges, whether it be a novel coronavirus or pernicious systemic racism.

Story written by Kristina Hare Lyons, a humanitarian, filmmaker, consultant, entrepreneur, and mother. She started her own business in 2007, Portobello Road, a retail concept that emphasizes fair trade and eco-friendly products. Previously, she worked at Physicians for Human Rights on a landmark study on war-related sexual violence in Sierra Leone, at Elle Magazine as West Coast Editor, as an Associate Producer at Frontline, and with filmmaker Oliver Stone on numerous projects. More recently, she consulted with the Ministry of Health in Liberia through the Harvard Ministerial Leadership program on efforts to address maternal mortality and is developing content at her film company, Lyonshare Pictures. Kristina currently sits on the boards of The Population Media Center, Urban Improv, and The Population Institute. She holds a Master’s degree in Global Public Health and Population from Harvard, a Master’s degree in Law and Diplomacy from the Fletcher School, and a Bachelor of Arts degree from Tufts University. She resides in Boston and Chilmark, Massachusetts.

Story edited by Sherine Andreine Powerful, MPH, a Doctor of Public Health student at the Harvard T.H. Chan School of Public Health. A Diasporic Jamaican, she received her Bachelor’s degree in Latin American and International Studies from Yale University and holds a Master of Public Health degree in Population and Family Health, with a concentration in Global Health, from the Columbia University Mailman School of Public Health. Her interests, centered around the English-speaking Caribbean, include feminist global health and development leadership; gender and sexual health, equity, and justice; and pleasure, healing, and liberation.