Balancing Act: Lessons in Best Pandemic Mitigation Practices from Malaysia’s Former Minister of Health, Dr. Subramaniam Sathasivam
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
As of mid-June, in Malaysia there were approximately 8,556 COVID-19 cases and 121 resulting deaths out of a total population of 32 million people. In comparison, the United States had over 2 million cases and 121,900 deceased during the same period. Adjusting for the fact that the U.S. population is ten times larger than that of Malaysia, the caseload in the U.S. is nearly 27 times greater, and the death toll is nearly 100 times higher than in Malaysia. Furthermore, the curve of new infections is declining in Malaysia, and the economy is on its way to returning to previous levels, while incidence rates continue to rise in many U.S. states. This is a staggering contrast, not intended to suggest that the U.S. should be doing better than Malaysia, but to highlight the critical importance of decisive leadership, strategy grounded in science, and a strong health system in the face of a health crisis, as has been presented by COVID-19. Clearly there is much to be learned from Malaysia’s approach, which stands out as an exemplar, along with similar success stories in other countries, many in Asia, including South Korea, Japan, Cambodia, Thailand, and Vietnam, where levels of infection and death remain low.
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
To successfully manage such a crisis as the COVID-19 pandemic, Dr. Subra recognized leaders must ask citizens to make compromises and navigate between competing drivers, such as the desire to follow directives to limit disease exposure vs. the need to work or congregate for family or cultural activities. He suggested science should guide leaders to make data-informed decisions about how to best balance public health and economic interests, where to direct resources and how commerce and travel might be restricted for maximum benefit.
“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
Once leadership across domains work together to juggle the often competing imperatives within a country in the face of the pandemic, communication should become a central pillar of containment. Trust is critical and can only be established among the citizenry “when the public knows what the government is doing and believes that the government is doing the right thing”, particularly in this age when there is such an insatiable desire for information, Dr. Subra noted. He added that a failure to quench this thirst can manifest in misinformation and even “fake news”. In his opinion, it is vital that governments be transparent and also show empathy and support for the population in their messaging.
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.
Buy-in developed through the process of building trust, which was especially critical for navigating through sensitive periods when public health interests were likely to conflict with other priorities, such as during observance of Ramadan, which this year took place between April 23 and May 23. More than 60% of Malaysians practice Islam, and for Muslim people around the world, Ramadan is the holiest part of the Islamic calendar. It is commonly expressed by a month of religious austerity, fasting, prayer at mosques by day and festive dinners and bonding between families and friends after sundown. It is a tall order for governments to curtail the religious expression of their devout populations and the buying and selling of festival-related treats at bazaars, a particular sacrifice, Dr. Subra noted, during the ideal victory festival, known as the Eid in much of the world. “This is extremely difficult to ask of people, and represents a significant sacrifice, and therefore it is essential that people recognize that their sacrifice is for the common good and truly has a meaningful impact.” Public health officials had sociocultural norms of a stronger collective spirit, as noted by Dr. Atun, more typical in Asia, working in their favor, but it was also essential for the government to collaborate with key influencers, which they did by partnering with religious leaders who made statements supporting the measures and indicating that these were indeed sanctioned by Islam.
Protect At-Risk Groups
In his prior role at the Ministry of Human Resources, Dr. Subra was instrumental in the introduction of a minimum wage in Malaysia and brought forth various reforms to protect workers, many of whom are of Indian descent. It is estimated that over 10% of Malaysia’s population are non-citizens, and the MOH has always taken the stance that a person’s documentation status would not be a factor “as far as managing public health issues are concerned”. He highlighted the example of Singapore, which had initially controlled the pandemic but then discovered a cluster among migrant workers, and acknowledged the importance of protecting at-risk groups, particularly those residing in crowded congregate housing. In contrast to U.S. policy, the Malaysian MOH made testing available regardless of migration status and treated all patients equitably if they happened to be diagnosed with the virus.
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 also underscored one of the most fundamental ingredients of success in managing a pandemic: investment in strong health systems and public health functions, which allow for rapid response and resilience, as exemplified in many of the previously referenced Asian success stories. Preventive medicine on both the personal and societal levels was the signature of his tenure as Minister of Health, where he emphasized nutrition to combat obesity and non-communicable diseases (NCDs), and early detection of disease. The public health system in Malaysia, the origins of which predate the country’s emergence as an independent nation in 1963, focused on two primary objectives, Dr. Subra elaborated: 1) ensuring optimal maternity and child health care and 2) ensuring a capacity to control infectious and contagious diseases. Originally established under British colonialism, the system was structured to manage these two priorities at the federal, state, and district levels in an integrated manner, enabling services to expand to the most rural villages. Malaysia’s preparedness also benefited from a commitment to universal health coverage and a long history of dealing with malaria, tuberculosis, filariasis, Nipah virus, and Dengue fever. In efforts to control these diseases, Malaysia’s government created a surveillance and containment approach grounded in basic public health measures. In addition, Malaysia developed sophisticated systems of environmental and vector control.
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.