Explaining Successful (And Unsuccessful) COVID-19 Responses in Southeast Asia
The response to COVID-19 across Southeast Asia, indeed around the world, has varied. We have seen huge disparities in the number of confirmed cases, even when we account for cases per capita. There are enormous differences in case fatality rates, from well under 1 percent in Singapore and Brunei, to over 9 percent in Indonesia. Clearly, testing in the region is inadequate and the scale of the crisis is much larger than the more than 30,000 confirmed cases as of April 21.
A handful of governments were extremely proactive, quickly put in place robust testing regimens, did contact tracing, and imposed strict quarantines at the short-term expense of their economies. Other governments were in complete denial, downplaying the crisis for fear of negative economic repercussions.
A successful response has nothing to do with regime type. Some democracies (Taiwan, South Korea, and New Zealand) have had fantastic responses, while others, the Philippines and Indonesia, have floundered. Likewise, some autocracies have done a good job, while others have been at the forefront of virus denial. A government’s success in flattening the curve is the result of leadership and competent government administration, regardless of regime type.
No government should be blamed for a pandemic, but they should be scrutinized for how they respond. There are four interrelated criteria to understand why some states have succeeded, while other states look like they are in for a very rough ride — with devastating economic impacts — until a COVID-19 vaccine is developed and mass produced.
While economically painful in the short run, governments that were decisive, implemented public health screening and contact tracing measures, were willing to bite the bullet and shut down both international and domestic travel, and shutter non-essential businesses fared well. We saw this most clearly in Vietnam and Singapore during its first wave of the pandemic.
Leaders who made decisions based on medical and scientific evidence — deferring to their public health and medical officials — have come out on top. Leaders who have made their public health decisions based on short-term economic and political calculations have not been able to get ahead of the situation. Indeed, they lost very valuable time, and in a pandemic, with exponential growth, every day matters.
Governments that used COVID-19 to accumulate power, attack the media, and silence critics, have fared poorly. Using emergency powers in such ways only serves to build mistrust. If authoritarian leaders such as Hun Sen or Rodrigo Duterte are looking at a pandemic as a political opportunity instead of a public health crisis, their priorities are terribly misplaced and people will die as a result. The Cambodian parliament passed a law granting Hun Sen, already an autocrat, sweeping new powers, including the ability to conduct electronic eavesdropping and curtail freedom of assembly and speech. The crux of Duterte’s new powers involve the ability to take over utilities and private firms.
It’s not just decisive leadership that’s important, but effective orchestration of state powers, whether at the national level through the inter-ministerial process or coordinating between the central government and the provinces.
Effectively responding to a pandemic requires a whole-of-government approach. Governments that had a holistic strategy to deal with food supply and public health, create a broad-based stimulus package, and mitigate the economic slowdown were able to win public trust and compliance. This requires effective inter-ministerial coordination.
2. Government Transparency
Governments that communicated with their publics in a transparent manner tended to quickly win the confidence of their publics. The governments that admitted the problem, communicated the risks, outlined effective mitigation efforts, and spoke with one voice, have fared much better than governments that have multiple speakers or leaders who downplayed the threat, have publicly reversed their policies, spewed scientific nonsense, looked for scapegoats, and repeated conspiracy theories. Greater trust led to much greater social compliance when it came to wearing face masks, social distancing, and sheltering in place.
Singapore’s Prime Minister Lee Hsien Loong and Vietnam’s Deputy Prime Minister Vu Duc Dam have been models of effective communication and transparency. Vietnam is a fully authoritarian state and Singapore is quasi-authoritarian — regime types that are not always prone to transparency. But both know that in public health matters transparency and communication are essential.
Vietnam, in particular deserves plaudits, and not just for their TikTok dances and catchy handwashing song. They have come a long way: When SARS hit in 2003, the Vietnamese government acted a lot like China, at first denying the problem, covering it up, denying access to international health officials, and failing to communicate openly and honestly with the public. After a disastrous initial response, the government reversed course, and since then, they have become a model of transparency and effective communication. In thee present crisis, Vietnam started on the right foot.
Indonesia might be a democracy with a fairly free press, but its president downplayed the threat, then publicly admitted that he downplayed the threat while peddling nonsense about herbal remedies. The minister of health attributed the early lack of cases to prayer. There are multiple messages coming out of the government, and policies have been repeatedly reversed.
Thai public health leaders have looked to foreign scapegoats and made outrageous assertions, while the prime minister seemingly contradicts himself at every turn. In the Philippines, the people want facts not the tiresome bluster of Duterte, who has threatened to shoot people who violate quarantine.
Public trust is tied to another issue: government legitimacy. Governments that had low levels of legitimacy, which leads to corresponding low levels of public trust, fared more poorly. Legitimacy leads to greater public trust, and thereby to greater social compliance when it came to coping with economic losses, social distancing, and sheltering in place.
I am not stating that a democracy is necessary to confirm legitimacy. The Vietnamese and Singaporean governments garner their legitimacy via performance, not polls.
The Malaysian government came to power in February following a political coup d’état that established a pan-Malay government, overturning the popular election results of 2018. This government was widely seen as illegitimate, referred to as a “backdoor government.” The new prime minister’s first action was to delay parliament by two months so as to forestall a vote of no confidence. And yet the government has largely allowed its competent civil service and medical professionals to do their jobs. The government has heeded their advice and imposed a very strict stay-in-place order. It is the first government in the region to flatten the curve.
Thailand had elections in March 2019, but one could hardly call the government legitimate, following a coup, a constitution that weakened large parties, an appointed senate, gerrymandered districts, the dissolution of opposition parties, and legal cases against opposition leaders. The government’s wildly inconsistent pandemic response has done little to enhance their legitimacy. Deputy Prime Minister and Public Health Minister Anutin Charnvirakulhas hobbled the government with his outbursts, including attacks on public health professionals. And yet he controls a key coalition partner, the Bhumjaithai party, in a government with a razor thin majority, and thus, cannot be fired.
The Philippines and Indonesian governments may have come to power via elections, but their incompetent handling of the pandemic has weakened their legitimacy. Indonesia has been a spectacular failure despite the fact the president won re-election in mid 2019 with over 55 percent of the vote. In his second term, President Joko Widodo did not have to learn the ropes of government; he should have been better prepared. The president admitted to covering up the early spread of the virus for fear that it would have a negative impact on the economy. He encouraged tourism as other countries were locking down. He did not put in place social distancing measures until the virus was running rampant. His ministry of health peddled herbal cures and other junk science. He allowed post-Ramadan travel, which further spread the disease across the archipelago. Indonesian authorities are using criminal defamation laws to crack down on public criticism of the government.
The Philippines now has third highest number of COVID-19 cases in Southeast Asia, with the second highest case fatality rate. Duterte’s response has been inconsistent and ham-fisted. After doing nothing for weeks, Duterte did what he normally does; he lashed out at critics and expected the Chinese leadership to quickly come to his rescue. He tried to be decisive and shut down Manila only to quickly abandon that policy. Like the Thai government, Duterte has tried to use the crisis to silence critics and accumulate more power. We are seeing the limits to his willful ignorance, populist broadsides, and bluster. The higher rates of poverty in the Philippines will exacerbate the pandemic’s spread. With such a large percentage of the population living at the poverty line, the ability of large swaths of the population to shelter in place and not work is minimal.
In the Philippines, Cambodia, and Thailand, the governments have adopted emergency powers, while Widodo toyed with the idea in Indonesia.
The Vietnamese government has far less money at its disposal to enact a broad-based stimulus, or even immediate cash payouts to businesses and affected citizens. But people have accepted that and are willing to incur short-term pain because the government is deemed legitimate and competent. You see less of that in Indonesia, the Philippines, and Thailand.
4. Planning and Preparedness
The COVID-19 pandemic was not a “black swan” event (low probability, but high impact). It was a “pink flamingo” event, glaringly obvious, but something that political leaders turned away from and ignored. Every few years since SARS in 2003, epidemiologists and virologists have been warning about a major pandemic that is fairly lethal, quickly transmissible, and that can leap from animals to humans. This was both knowable and known.
Governments that were prepared, including having a pandemic response plan incorporating lessons learned from other pandemics such as SARS, H1N1, the Swine Flu, MERS, etc., have fared better. Those that stockpiled PPE and maintained the physical infrastructure to do rapid and mass testing and contact tracing, as well as having made sufficient investments in medical professions, hospitals, and local-level clinics, have fared better. Governments, such as Singapore, which have adopted technology to enforce quarantines and conduct contact tracing, have fared better.
Governments who starved their public health system of resources have fared poorly. It is worth taking a look at the Global Health Security Index as a baseline reference point.
And here I want to make a clear distinction between public health and the medical sector. Vietnam’s medical sector is really quite rudimentary. Yet they have extremely good public health because it is cost effective. Prevention is pennies on the dollars of the cure. Testing, contact tracing, thermometers are really cheap compared to ICUs with ventilators. Vietnam has conducted well over 200,000 tests, or 2.1 tests per 1,000 people. In contrast, as of April 19, Indonesia had conducted under 50,000 tests, only 0.15 per 1,000.
But investments in hospitals are absolutely key to saving lives: Malaysia and Thailand have case fatality rates well under 2 percent. In the Philippines it’s over 6 percent and in Indonesia it’s over 9 percent. Singapore has 2.41 physicians per 1,000 people, Brunei has 1.77, and Malaysia has 1.51. The average across the region is 1.04. Indonesia, by contrast, has 0.38 physicians per 1,000 people. And over 32 health workers have died in Indonesia already from COVID-19.
Thailand has fared well so far, in spite of its political leaders, because it has such a good public health system, world class hospitals, and nationwide network of provincial and district hospitals. The Global Health Security Index makes clear that Thailand had the best medical infrastructure to cope with the crisis in the region.
The Philippines has starved its domestic public health system. Despite having very good nursing schools and medical schools, many of its medical professionals work overseas.
Singapore’s initial first-world response to COVID-19 was quickly undermined by a second wave, the result of the compact and poor living conditions of some 300,000 migrant workers, which allows Singapore to have its first world infrastructure and lifestyle.
It is a reminder that viruses are not bound by class, wealth, ethnicity, or status. More importantly, it is a reminder that public health is determined by the least common denominator. If the poorest and most marginalized within a society are not protected then no one is. That is a lesson that all governments need to take to heart.
Zachary Abuza is a professor at the National War College in Washington, D.C.