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

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.

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.

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.

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.

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

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.

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.

Voices in Leadership webcast series enhances leadership, connecting high-profile leaders with the Harvard School of Public Health community. hsph.me/voices