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Covid-19: Three immediate public health priorities

My friends, I hope that you are all well and healthy.

This outbreak landscape is very noisy. We have so much information that we don’t know which is the most important area to focus on.

Should we focus on public health and the increasing number of cases? Or the economy and the stimulus package? Or the effects of a further extended movement control order (MCO)?

Please let me help you cut through the outbreak noise.

Today, we’ll only look at the top three short-term priorities for the next one week: procurement, mass testing and getting more public health expertise into the National Security Council (NSC). (Editor’s note: Mercy Malaysia co-founder Tan Sri Dr Jemilah Mahmood was appointed Special Advisor to the Prime Minister on Public Health on March 31, after this column was submitted.)

These three short-term priorities are interlinked as they must support the long-term outbreak strategy, meet our resource gap, reduce the total number of cases and help make more evidence-based decisions.

Buy from China now

Crisis procurement is different from “peacetime” procurement in two important ways.

One, any inefficiencies, corruption and wastage are magnified.

Two, global demand spikes far higher than any supply.

Malaysia needs three important pieces of healthcare equipment: test kits, personal protective equipment (PPE, like masks and gowns) and ventilators.

Almost none of these are manufactured locally, so we must go overseas to procure them.

China is the factory of the world. As they restart their manufacturing engine, the whole world is lining up to buy their medical equipment.

My friend Steven Wong Weng Leong, who is the chief operation officer of China Construction Bank Malaysia, tells me that the United States, Europe and Brazil are actively procuring in China now – Malaysia cannot be left behind.

This means that Malaysia must quickly do three things in parallel.

One, set up a coordination hub that can map the country’s needs so that we know what to procure.

Two, begin procurement channels into Chinese factories using our Chambers of Commerce and SME contacts.

Three, begin strategic stockpiles of the equipment procured over multiple rounds.

This also goes for the latest test kits from Singapore, South Korea and Taiwan; PPE from Vietnam; and ventilators from Australia.

The biggest question during any crisis procurement is “who needs what where and when”.

We can’t wait for a perfect answer to that question before placing orders in China. We must move now, and find the answer to that question as we go along.

Test everyone gradually

We can learn the best lessons from China, South Korea, Taiwan and Singapore, because they were among the earliest to be hit by Covid-19.

There are three main lessons to be learnt: social distancing, mass testing and IT-enabled contact tracing.

Mass testing is crucial because it helps identify infected patients, who can then be treated or isolated.

Temporarily isolating infected patients helps reduce their contact with healthy patients; this is called “breaking the chain of transmission”, something our Health director-general Datuk Dr Noor Hisham Abdullah has frequently said.

But if mass testing is so important, why didn’t Malaysia institute it early?

There are a few reasons. The main one is that our domestic production of test kits is low and concentrated primarily in the Institute of Medical Research.

Global production of test kits was also low in the initial stages of the disease. Any production in China, South Korea or Taiwan was understandably kept for their domestic use, not for export to Malaysia.

Until about a month or so ago, the number of cases in Malaysia was relatively low, which meant that testing wasn’t considered the first public health priority.

However, right now, it’s the correct public health priority.

Delivering mass testing means that Malaysia must quickly procure the latest test kits, which utilise throat swabs, from Singapore, Taiwan and South Korea, which now have spare manufacturing capacity and an adequate domestic stockpile.

Testing 16,500 people per day means that we must import approximately 500,000 test kits for April alone.

Mass testing must be accompanied by three things in parallel: revised guidelines for who can get tested, protocols to manage those who test positive, and adding more IT and digital solutions to contact tracing.

Mass testing means more public healthcare facilities must be designated for Covid-19 screening and treatment, and it must be decentralised to include all of Malaysia.

As the stock of test kits will come in batches, testing can be done for high-risk areas first, then moved out to lower-risk areas.

Public health expertise required

It’s true that outbreaks are not only public health problems, but it’s glaringly true that public health is under-represented in the NSC.

Over the last several days, the Defence Minister has issued further MCO rules, restricted NGO operations, reduced the operating hours of food and transport services and stated that he will put more security personnel on the roads.

I believe his intentions are good and I don’t envy his choices. However, his decisions have many unintended consequences.

As one example, reducing public transport operating hours may paradoxically cause more people to be packed more tightly into the fewer available buses due to the fewer operating hours.

Healthcare workers finishing the night shift and without personal transport will be stranded.

There are no perfect choices during crises, only mitigating trade-offs. To better mitigate these trade-offs, there must be a permanent public health expert in the NSC for the duration of this crisis.

This expertise can come from the Health director-general of or his team, or can be an external public health advisory group working closely with the Health Ministry. This group must be highly competent technocrats selected for their expertise, not political affiliations.

With this public health expertise inside the NSC, better decisions can be made.

For example, a risk-based “precision MCO” might be considered, where the levels of restrictions can be adjusted based on the risk levels in different neighbourhoods, towns or cities.

Cut through the noise

There’s a lot of noise in the landscape, and everything screams to be the first priority.

Over the coming weeks, I will try to simplify this landscape for us, so that we know where the healthcare system should go.

Although the situation may get harder before it gets better, we should not feel powerless. We’re getting more knowledge, strength and resources to fight this virus.

All Malaysians are frontliners. By staying home, washing your hands, being kind to your neighbours, watching out for each other and protecting your mental health, you’re helping us win.

Trust that your doctors, nurses, pharmacists, paramedics and other health professionals are standing right beside you.

Trust the science and trust us. We’ll win, together.

Dr Khor Swee Kheng has postgraduate degrees in internal medicine and public health. He has worked in five health sectors across three continents, including in Malaysia during the H1N1 epidemic and in Nepal for post-earthquake relief. He recently founded the Malaysian Health Coalition. The views expressed here are entirely his own.

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