10 Questions for Tan Sri Dr. Noor Hisham, Director General of Health
Two days ago, on the 16th of January, 2021, Malaysia reached a new high of 4,029 COVID-19 cases. We have just started the first week of the second Movement Control Order (MCO 2.0) and this will go on for two weeks from the 13th of January until the 26th of January. By contrast, we reached a high of 235 COVID-19 cases on the 26th of March, 2020, during the first MCO. Credit should be given to the leadership of Tan Sri Dr. Noor Hisham, the Director General (DG) of Health, and the public health front liners for their tireless efforts in combating the COVID-19 pandemic. But nine months after the first MCO, there are a number of questions that remain unanswered in our fight against the COVID pandemic. I hope that DG Noor Hisham can provide convincing answers to the following 10 questions in order to assure the public that the government has a comprehensive plan to control this pandemic.
Q1: What is the total number of daily COVID-19 tests done by the Ministry of Health (MoH) and what is the daily % of positive cases?
The daily focus has primarily been on the total number of new daily COVID-19 cases. While this number is important, we also need to know the total number of tests that are being done on a daily basis and the % of positive cases. This will give us an indication of (i) our testing capacity and (ii) the daily infection rate. According to a report in October 2020, Malaysia’s daily testing capacity then was approximately 54,000 but the average number of tests done was less than half this number. If the daily testing capacity cannot be reached because of human resource shortages, the private sector (which is already doing their own tests) can be roped in to address this gap. Daily testing by the state will also be able to show shortages in the number of test kits in places like Sabah, for example.
Knowing the daily infection rate is also a
useful indicator of infection trends moving forward. There have been many calls
for the DG to make known the daily testing figures but until now, for reasons
unknown, this figure has not been disclosed on a daily basis.
Q2: What is the number of contact tracers used by MoH? What measures have been put in place to address shortfalls in contact tracers?
As the number of daily cases spiked to more than 1000, it was not surprising that the contact tracers would be overwhelmed. Over the past few weeks, reports have surfaced on how some families who have tested positive for COVID-19 had to wait for days before someone from MoH contacted them. Earlier this month, my colleague and former Deputy Health Minister, Dr. Lee Boon Chye, asked for an additional 10,000 contact tracers to be hired on a temporary basis to deal with the spike in the number of COVID-19 cases. There has been little disclosure on the number of contact tracers used by the MoH and even less discussion on the need to hire more contact tracers by the government. Without a proper contact tracing infrastructure, our ability to contain this pandemic even after the end of MCO 2.0 will remain in question.
Q3: Can more accurate location information about COVID-19 cases be disclosed publicly?
To date, the MoH has been very reluctant to provide more accurate location information for new COVID-19 cases. According to official reasoning, the government doesn’t want to cause a public panic in places where positive COVID-19 cases have been identified. But at the same time, the DG has been asking the public to avoid crowded places. A more transparent and effective strategy would be for more accurate location information to be provided to the public so that they can stay informed. Without any official confirmation, unnecessary speculation about the exact location of new cases cannot be prevented. New sites such as Malaysiakini already provide a daily report of places with new COVID-19 cases but this list is not verified by MoH. More transparent sharing of data would enable the public to make more well-informed choices about where to visit and where not to visit, especially after the end of MCO 2.0.
Q4: What transmission trends can be analysed based on MySejahtera data?
As of the 19th of November, 2020, the Ministry of Health has recorded 1.7 billion check-ins by users via the MySejahtera app (with an average of 15m daily check-ins) including for those COViD 19 positive patients. But until now, we are not aware of whether this massive database has been analysed for transmission trends. For example, are the transmission rates higher in certain places such as gyms and restaurants compared to optometrists and hair salons? Once a factory cluster has been identified, what transmission mechanisms are most likely to cause community spread in the affected area?
We need to know this analysis in order to determine which businesses should be allowed to open during an MCO. We also need this information in order to improve and enhance our existing SOPs to reduce transmission rates. As of now, nobody is quite sure, if and how the data from the MySejahtera application is being analysed and processed. This is one of the reasons why, for example, there is still uncertainty as to whether hair salons and optometrists should be allowed to operate during MCO 2.0.
Q5: What is the capacity in terms of the number of beds available and the Intensive Care Unit (ICU) capacity by the state?
To date, there has not been daily data released to show the capacity of beds available for COVID-19 patients as well as the total ICU capacity. Ideally, this information should be given by the state so that there is public transparency over existing hospital capacity and what additional steps need to be done to address shortages in this capacity. This would include the need to rope in private healthcare facilities to take in COVID-19 patients (if necessary). The possibility of asking patients with no or mild symptoms to stay at home to quarantine should also be discussed in light of shortages in hospital beds. We only hear about the lack of capacity recently with the Prime Minister’s announcement that our healthcare system is at a ‘breaking point’ in terms of ICU and non-ICU bed utilisation rates. Why isn’t this information included as part and parcel of the DG’s COVID-19 briefing and press statement?
Q6: What were the COVID-19 transmission rates in schools when there was face to face classes in 2020?
One of the biggest challenges faced by parents in 2020 is the shutting down of schools due to COVID 19. The decision by the Ministry of Education to shut down all primary and secondary schools until the end of 2020 seems like a ‘one-size-fits-all’ approach that does not take into account variances in COVID cases across districts and states. As important, MOE has not disclosed any data or analysis with regards to transmission rates within schools.
The information which has been released by the Ministry of Health tells us nothing about how children of a school going age may have gotten the virus. Indeed, the manner in which some data has been released by MOH and reported in the news seems misleading. For example, in a statement on the 23rd of June 2020, the DG of Health said that one of five COVID 19 or 20% of patients in Malaysia is 18 years and below. On the 22nd of October, the DG was reported to have said that more than 1,000 school-going children were infected with the virus since the start of the 3rd wave from the 20th of September to the 21st of October. During this time, it was reported that 587 cases involved pupils aged from 7 to 12, and 670 cases involved students aged 13 to 18.
These reports seem to give the indication that
the students contacted COVID while attending school. This will inevitably stoke
unnecessary fears among parents who may have 2nd thoughts about
sending their children to school.
What do international studies and benchmarks tell us?
In an update date 21st of October 2020, the World Health Organization (WHO) made the following conclusions among COVID transmissions in schools:
- There were few outbreaks reported in schools since early 2020 and in most COVID 19 cases reported in children, the transmission occurred at home
- More outbreaks were reported in secondary/high schools than in primary/elementary schools
- In school outbreaks, it was more likely that the virus was introduced by adults rather than by other children.
- School outbreaks were only high when the incidence of local / community transmission was high.
The same WHO study also recommended that schools be closed when there is no other alternative because of the negative effects of school closure especially on marginalized children who may drop out of school and who may be deprived of school-based services such as school meals and mental health support.
In a publication on the 14th of September, the WHO, UNICEF, and UNESCO wrote that “decisions on full or partial closure or reopening should be taken at a local administrative level, based on the local level of transmission of SARS-CoV-2 and the local risk assessment, as well as how much the reopening of education settings might increase transmission in the community”.
If schools are to re-open for face to face
classes in the RMCO and CMCO states on the 20th of January, 2021,
MoH and MOE have to disclose data publicly in order to convince parents that it
is safe to send their kids to schools.
Q7: Housing situation for foreign workers in the security, manufacturing and construction industries?
One of the main transmission channels for the COVID-19 virus has undoubtedly been dormitories which house foreign workers who work as security guards, construction workers and factory workers. Some of the glove manufacturers with a high number of COVID-19 cases were asked to shut down ‘in stages’ but were allowed to re-open after their workers were tested. But thus far, there has not been any concrete policy announced by the Ministry of Health or the Ministry of Human Resources to force employers to provide for less cramped accommodation for the sectors with the most number of COVID-19 cases. There has also not been a coherent testing policy announced for the construction and manufacturing sectors. There MUST be such policies put in place in order to keep the COVID 19 transmission rates low, especially after MCO 2.0 is lifted. Without proper testing and accommodation policies for these foreign workers, it is less likely that COVID-19 infection rates can be controlled after the lifting of MCO 2.0
Q8: What is the Rt Value by state and why isn’t this figure publicly available?
MoH publishes the daily Rt value for the entire country on its COVID-19 website. This figure currently stands at 1.17. Any value above 1 means that the number of cases is expected to grow and any number less than 1 means that the virus is under control and the number of cases can be expected to decrease over time. It would also be useful for MoH to publish daily Rt values for each state in Malaysia so that there is more clarity on which states are performing better and which states are doing worse from an infection control standpoint. The Rt value by the state can and should also be used as an indicator on when an MCO should be declared for a state and when it should be changed to a CMCO or an RMCO. For an even more targeted approach, the Rt value can be used for individual areas within a state. The Rt value by the state clearly exists since DG Noor Hisham has referred to it in one of his Facebook posts on the 20th of December, 2020. Why not disclose the state by state figures on a regular basis?
Q9: How has the federal government worked with the respective state governments to fight COVID-19?
Thus far, the fight against COVID-19 seems to be one that is controlled and dictated mostly by the Federal government with the Ministry of Health, specifically the DG, taking the lead. There has been little coordination between the federal government and the respective state governments to join forces in the spirit of cooperation and solidarity. The former Minister of Health, Dr. Dzulkefly Ahmad, who is also the chair of the Selangor Taskforce on COVID-19 (STFC) has publicly called for more data sharing and cooperation with the Ministry of Health but so far, his calls have gone unheeded. It is this kind of ‘silo’ mentality that has prevented Malaysia from using a ‘whole-of-government, whole-of-society’ approach to battle this pandemic. Will this kind of mentality change now that the number of COVID cases have spiked significantly, especially in the state of Selangor?
Q10: What are we doing differently now compared to March 2020?
My last and final question is simple. With nine months of experience in dealing with the COVID-19 pandemic, what lessons have we learned and what are we doing differently in MCO 2.0 compared to the first MCO? Do the plans which have been announced give the public confidence that the Ministry of Health and also the rest of the government are capable of bringing down the COVID-19 numbers without collapsing the economy?
There is little indication that this government has learned from the experiences of the past 9 months. Last minute SOPs issued AFTER the start of MCO 2.0, U-turns on which sectors can open e.g. the automotive manufacturing sector and optometrists and uncertainty over school re-opening are just some examples of the failure of this government to prepare for MCO 2.0. As the adage goes, “if we fail to plan, we plan to fail”.