The recent upsurge in Covid 19 deaths and cases in East Asian economies that had previously had remarkably good records of dealing with the pandemic (Tables 1a and 1b), has been driven by the rapid spread of the Delta variant, facilitated by cross border movements, relaxation of domestic restrictions and seasonal population movements. A situation that brings into question the continued viability of the East Asian approach. This had previously exerted significant control over the virus through combinations of restrictions on activities, track, trace and isolate, and domestic and cross-border movement controls. With generally very high levels of public compliance, backed by an acceptance that, particularly under such a threat as Covid 19, the interests of the community should be paramount take president over those of the individual. These measures, despite in some cases being supported by very limited resources, kept death rates low by global and even more, Western standards (Tables 1a and 2).
Though it is also important to note that even before the present outbreaks there were considerable variations in the level and patterns of Covid 19 deaths in East Asia. With, for example, very much less effective control been exercised in Indonesia, the Philippines and, to a lesser extent Japan (Table 1a). All of which experienced comparatively steady long-term increases in the number of deaths. A reflection of slow, confused and very partial imposition of domestic controls in Indonesia, the spreading of the virus amongst the improvised populations of Metropolitan Manila and related urban complexes during a very protracted lock-down, and a major spread in Japan ‘below the radar’ after the government was a convince that it had eliminated the virus at a very early stage in 2020.
It should also be stressed that the East Asian countries that have held their Covid 19 death rates at very low levels for much, if not the entire span of the pandemic, have had long periods of strict control, recurrent small-scale outbreaks and, in some cases comparatively large ones. Singapore during April-July 2020 had an outbreak concentrated in the migrant labour force which briefly took the city state to near the top of the global cases and testing per million rankings. Though the city state still managed to say at the lower end of the East Asian Covid death rates (Table 1a).
This Opinion considers the implications of the present surge for East Asia and the wider questions of Covid 19 control.
The current out-breaks
Sharp rises in deaths and cases have been recorded almost everywhere in the region – the current exception is Hong Kong which has continued to have only a trickle of cases (Table 1b). The increases have been particularly sharp in Cambodia, Indonesia, Malaysia, Myanmar, Taiwan, Thailand and – most recently -Vietnam (Table 1a and 1b). Elsewhere, while some of the outbreaks remain small, as in Singapore, they are proving remarkably difficult to supress.
Generally, governments have responded, as they have to previous surges, with the reimposition / tightening of domestic and border controls, and increased testing. Perhaps, most spectacularly in China, where although the number of cases is low (Table 1b) they are spread across some 20 cities and over 20 provinces. This has seen lockdowns of major urban areas and comprehensive testing, notably of Nanjing with 9.2 million inhabitants.
Indonesia and the Philippines (see below) had until the present outbreak by far the worst levels of Covid 19 deaths in the region (Table 1a). With Indonesia also having one of East Asia’s worst health systems, a low level of testing and perhaps the least effective overall response to the pandemic. Given this, the surge in deaths and cases from mid-June to mid-July (Tables 1a and 1b) was particularly disturbing. The government responded with significant restrictions across Java – including ‘stay at home’ orders and roadblocks. This was widely depicted as too little too late, and government statements suggest that everything was now being pinned to vaccination. However, the Javanese restrictions are proving effective this time and mid-July seems to have been the peak of this wave of infections, with a subsequent very steady decline (Table 1b). This is a remarkable turnaround.
Much more disturbing is Malaysia, given the sharpness of the rise in the death rate, which has now overtaken both the Philippines and Indonesia to become the worst in the region (Table 1a). This has prompted mounting criticisms of the government’s slow roll-out of vaccination – though it has one of the region’s better records (Table 3), the overloaded health system, failure to reimpose a full lock-down[1] – reportedly because of fears of the economic consequences – and the lifting of the state of the emergence on 1 August 2021[2] (which has been in place since 12 January).
The government appears to have responded to the current Covid wave rather more slowly and less firmly that it did in previous outbreaks. This is almost certainly a reflection of the government’s declining popular and, more importantly, parliamentary support which came to a head on 16 August when the Prime Minister Muhyiddin Yassin and the entire cabinet resigned following the collapse of its thin majority. Given that the Covid situation would appear to rule out any immediate election,[3] Muhyiddin has been reappointed as an interim prime minister. This further weakening of the government does not bode well for dealing with the current Covid surge – though it may have passed its peak (Table 1b).
In Thailand while the rise in cases and deaths is far less sharp (Tables 1a and 1b), the tightening of restrictions in the Bangkok Metropolitan Region and ‘high risk’ provinces, and heavy restrictions on domestic airflights have resulted in very significant public criticism – not least because of the limited financial support – and fuelled anti-government demonstrations. These, while focused on the low level of vaccination, (Table 3) government mishandling of the pandemic and the state of the economy, also reflect a low and declining level of support for the government that pre-dates Covid 19. In earlier stages of the pandemic the unpopularity of the government did not adversely impact on cooperation with Covid policies – there are now concerns that this can no longer be relied on.
The Philippine surge since mid-July has, like Indonesia, has been a focus of concern because of its already poor record. Though the increase in cases and deaths has been very much less sharp than Indonesia, which it had previously generally closely matched (Tables 1a and 1b). More disturbing is that while the cases have continued to be concentrated in Metropolitan Manila and related urban complexes – where strict lockdowns has been imposed – the current outbreak is much more widely diffused, affecting 13 of the countries 17 regions.
As in Indonesia, the government has shifted very strongly to a vaccine-led approach, but not only from a similarly low base (Table 3), but also with a very high level of vaccine ‘hesitancy’ – a reflection of some past debacles, notable the 2016 vaccination of children against dengue fever, which was suspended after 12 months when the manufacturer Sanofi revealed that for children who had never had dengue, vaccination increased the risk of serious infection and hospitalisation.
As was noted above Japan, also has a poor record of Covid 19 management and mounting public criticism, not least with respect to the holding of the 2020 Olympic and Paralympic games at a time when cases and deaths were surging, and major urban centres were still under a Covid state of emergency. With the surge showing only limited signs of abating, this saw the resignation on 3 September of Prime Minister Yoshishide Suga. There are concerns that this may usher in a period of instability and short-term premierships, like that which proceeded the appointment of Shinzi Abe in 2006. Scarcely conducive to a move to a more effect set of Covid policies.
However, perhaps the most worrying case is Myanmar where both reporting of deaths,[4] restrictive measures and testing appear to have broken down following the 1 February military coup, subsequent disorder, if not outright civil war, dislocation[5] of an already poor and over stretched health system, and effective termination of a vaccination programme that was just getting started.
The sharp rise in deaths during July and August reflects resumption of some measure of reporting, though there is almost certainly very substantial under recording. While there has been a steep decline from the mid-July peak – this may, at least in part, reflect further disruption of reporting (Table 1b). Given such doubts, it is difficult to be optimistic, though the military restarted vaccination at the end of August and are reportedly attempting to restart the vaccination programme and are seeking to obtain vaccine supplies from Russia and China.
Only in Taiwan does the outbreak appear to have been significantly supressed (Table 1b).[6] Though, as noted above, the sharp fall in new cases in Indonesia is encouraging and, while it is too early to be certain, it may be that in many countries the outbreak has peaked (Table 1b). But, even if this proves to be the case, the outbreak is far from over.
Overall, in East Asia the there are concerns that measures that had previously resulted in comparatively rapid reductions in infection rates are proving less effective this time and, for some, the strains of repeated waves of restrictions are beginning to tell. That is not to say that the established methods of control will not be able to supress the Delta wave if keep in place long enough and strictly enforced. But at what cost and for how long will the suppression last? Perhaps not surprisingly all governments have moved to prioritise vaccination, though not at the expense of their established forms of control. This shift to vaccination raises questions of vaccine supply and the capacity to vaccinate, with many countries still at a very early stage, particularly compared to the West (Tables 3 and 4). It also brings the countries concerned firmly into the whole international mess of vaccine nationalism, vaccine diplomacy, corporate interests and related geopolitical rivalry.
Implications
While some East Asia, countries, most notably Taiwan, have managed to keep their economies largely open, and others led by China have been able to rapidly restore them to operation, there has been significant disruption and uncertainty everywhere. This has tested the resolve of governments, the robustness of political systems, and the resilience and compliance of people and business. The current further wave of disruption, when the opening of many of the Western economies was raising business expectations, not least in major tourist destinations, such as Thailand, may be one step too far. But even where this is not immediately the case, there are real concerns over ‘pandemic fatigue’ and loss of any economic advantage that might have been expected from the generally effective pandemic policies compared to Western countries that generally failed to control the virus until they were able to shift to mass vaccination (Table 4). That is, from a position of global leaders in Covid 19 control, East Asia faces a major challenge of vaccination ‘catch up’ under conditions of limited supplies. Which suggests that the position of those East Asian regimes that saw the level of control that they had imposed over Covid 19 as enabling them to allow the West to take the lead in mass vaccination (and take the risks with rapidly developed and approved vaccines), has been undermined by the spread of new and more infectious variants of the virus That is, with the benefit of hindsight the East Asian countries should have moved as early as possible to vaccine procurement and mass vaccination.
It may also be that there needs to be some shifts in policy away from the aim of ‘zero Covid’ – most strongly articulated by the Chinese authorities and reflected in the very rapid and stringent responses to even small outbreaks. For it can now be argued, that the spread of new variants, particularly Delta, has been made zero Covid an unrealistic goal (or perhaps more correctly, made clear that it was never realistic). A view reinforced by the economic, social and political consequences of repeated imposition and lifting of restrictions. Rather, it now needs to be recognised that while the virus may well fade, it cannot be eliminated. That is, Covid 19 should now be seen as endemic and as such will have to be lived with. This position has already been stated by the Singapore government with indications that Indonesia, Malaysia and Thailand are beginning to shift in this direction,[7] while comments are emerging in China over ‘long-term coexistence with the virus’.[8] A process that will of necessity include vaccination, a continuation of some degree of control, vigilant monitoring and maintaining the capacity to reimpose restrictions in the event of a further major surge of a Covid 19 variant or, indeed, an entirely different contagion. For East Asia as a whole, this would mean both an enhancement of the already embedded national pandemic preparedness (not just in those such as Indonesia where this were found wanting), further development of the regional institutional capacity, centring on ASEAN and ASEAN Plus Three, and a major push to develop sufficient local vaccine development and production capability, to ensure there is no repeat of the current shortages.[9]
There is here a blending of the Western and Eastern approaches, that should also be taken on board by such countries as the UK, where the apparent success of the vaccination programme runs the risk of abandoning all controls. For in the short-run these need to be significantly refined and kept in reserve and in the longer-term utilised in developing pandemic preparedness and management capacity in the interests of the countries long-term health and economic security. Something that cannot rest on the capacity to developed and administer vaccines alone.
Notes
[1] Though tight restrictions have been imposing on the number of people permitted on public transport and in shopping malls, interstate movements, curtailed, schools closed closing. dining in restaurants banned and people have been told to work from home where possible.
[2] Except in Sarawak.
[3] Not least because the 2020 election in Sabah are widely blamed for spreading Covid
[4] Note ‘plateauing’ of deaths January-June 2021 in Table 1.
[5] With reports of the military both wrecking facilities and hunting down and killing medical staff.
[6] Though the very low level of vaccination is a concern.
[7] SCMP ‘Coronavirus: Southeast Asian countries choose to reopen, balancing virus with economy’, 13 September 2021, https://www.scmp.com/news/asia/southeast-asia/article/3148514/coronavirus-southeast-asian-countries-choose-reopen
[8] Vincent Ni ‘Daddy Zhang: Plain-speaking doctor who persuaded Chinese public to take Covid seriously’, Guardian, 14 September 2021.
[9] China, with its WHO approved Sinovac and Sinopharm, remains the only significant regional source. Though Thailand has started to produce AstraZeneca and Vietnam Sputnik 5, while in late-July regulators in Taiwan gave emergency approval to the locally developed Medigen Vaccine Biologues vaccine, but rejected that developed by UBI Pharm because it did not trigger enough antibodies.
Tables
