COMMENT | The numbers straining intensive care units (ICU) and hospital beds in Sabah due to the current spike in Covid-19 cases are only the tip of the worst health crisis the state has ever faced. This comes after Sabah experienced a serious polio outbreak in January this year.
So far, the state has had 3,565 Covid-19 cases, of which over 2,000 of these are currently active. Yesterday, with 277 new cases, a new cluster was reported in Kota Belud, adding to the multiple clusters across the state.
Given the exposure of many Sabahans to the disease, it is likely numbers will increase in coming weeks. These figures are the highest in Malaysia – and for many in Sabah (and Malaysia), frightening.
Concerns beyond the numbers
There are reasons for concern. The current cases stretch over the entire 73,631km of Sabah but are concentrated on the East Coast. Disproportionately, many of the cases are in areas with a high concentration of poorer residents. Importantly, the disease has extended into rural areas, places where testing facilities are not available. An accurate assessment of the scope of those affected is not possible to determine without wider testing or even a sample study in localities with high infection – both of which have not yet happened.
Beyond case numbers and widespread infection, there are other indicators of the growing intensity of Covid-19 in Sabah. Foremost is the stark number of unlinked cases, cases that show no clear tie to another infected patient. An estimate by Dr Amar-Singh places the most recent unlinked cases as high as 91 percent. This indicates that the virus is in the community and being spread untraceably in the community.
Second, the strain of the virus reported in Sabah is among one of the most infectious, contributing to higher rates of transmission. Third, even more troubling is the fact that more people are dying – a toddler last week, more women (who disproportionately are less mobile within Sabah and should be less at risk) and those without underlying health conditions.
At 28, Sabah has the highest number of deaths. In the last ten days, 19 people have died. So far, the mortality of Covid remains below 7.0 percent globally and greater than 1.0 percent in Malaysia, but this rests on access to health care and fully functioning facilities.
Sabah has long had deficits in health care provision and is already facing a grave shortage in personnel given two nurses have been exposed to Covid-19 in Kota Kinabalu. To date, the Health Ministry (MOH) has deployed 500 additional personnel (some of which have not yet arrived), but the deficits and strains on health care – with emergency units overflowing into sports centres – are real. They cannot be ignored.
Multi-faceted problem, decentralised multifaceted response
Other analyses have identified the multiple drivers of this crisis – the double standards of politicians, the failure of SOPs carried out in campaigns and increased contacts as a result of campaigning, the large number of migrants – undocumented and documented, mismanagement of prison and detention centres and grossly inadequate health resources. These factors merit further review as part of a holistic plan moving forward.
The serious Covid-19 situation in Sabah is a product of multi-faceted policy failures, particularly at the federal level of government, exacerbated by political negligence in how the policies in place were not followed. Leaders did not properly lead by example. Rather, they provided an example of poor leadership. The responding anger is real – and justified.
This emotion, however, is not going to help get Sabah through this crisis, as there needs to be a major rethink of how to address the situation, particularly as there are signs that community spread is extending into neighbouring Sarawak – with rural areas such as Lubuk Antu reporting cases yesterday – and the virus spreading to Peninsular Malaysia – where a majority of states in Peninsular Malaysia have reported cases tied to Sabah.
Most are calling for the MOH and its director-general Dr Noor Hisham Abdullah to lead. The fact is that given the multi-faceted dimensions of the issue, the solution requires multiple actors and greater local knowledge of Sabah.
This week Malaysia’s Medical Association (MMA) called for greater decentralisation of Covid-19 management to states to address the rising cases. This is especially in the case in Borneo, where conditions and the problems they are facing are starkly different. The policy model of one-size-fits-all based on Peninsular Malaysia does not fit with Sabah’s local conditions. It is not working, and a rethink with new approaches with collaborative leadership are necessary.
Rethinking health measures
The first area to reconsider is in health care responses.
Contact-tracing centred model: Given the large number of cases already taxing limited personnel resources, and the reality that not all contacts are reachable in a state where there are inadequate internet coverage and broad geographic areas, contact tracing cannot be the primary basis for testing and the method to identify risk.
While contact tracing should be part of the repertoire of responses – with greater resources to potentially assist from Peninsular Malaysia and with local civil society volunteers – it is taking too long, and there are too many gaps. The number of unlinked cases is illustrative. Moving forward, the spread may reach the point that it is not the most useful tool for prevention.
Increased testing: There needs to be a better mapping of the virus. There are too many unknowns. This involves increased testing, use of the affordable Rapid Antigen (RT-Ag) tests in hot spots is a good beginning, complemented by a random study to look at how serious the spread of the virus is within the community and other even more reliable testing methods.
Experts suggest the need to increase testing to 30,000-50,000 daily, with a better turnaround time on the test results. The RT-Ag test results can be completed within an hour and importantly, do not require sending these to Peninsular Malaysia or other test facilities within Sabah.
Increased testing is possible with additional resources and better logistics. The announced increase of 15,000 RT-Ag tests flown in is not adequate. The mortality rate in the past few days suggests that the virus infection is much higher than the numbers found to date.
It is necessary to understand the locations and concentrations of infection better. This comes with a needed reframing that finding cases is not a negative, but a positive, as it helps save lives.
Better access to testing: To date, the model of response has assumed that people can go get tested. This is not the case in Sabah. Testing has to go to them due to the limited and inaccessible health facilities. Also, calling people to come in for testing needs to be more sensitive to the realities that many cannot afford the costs of transport to go to a testing centre. Supporting measures for costs associated with coming in for testing are needed for the poor, easily a fifth of the population.
Pro-active protection of vulnerable communities: There needs to be a recognition that communities living in high-density areas, especially poor settlements on islands, and those in closed air-conditioned facilities such as nursing homes, are especially vulnerable when there is community spread. Forging cooperation with local leaders and civil society can help to make sure those at most risk are protected.
Rethinking hospitalisation: With the pressing demands being placed on the limited number of hospitals in Sabah (only 20) and ICU units, there needs to also be a rethink on how to handle those who have Covid-19, but only have mild symptoms or are asymptomatic. Not all of those infected require the same level of hospitalisation and can receive care in quarantine centres.
Addressing state political vacuum
The reality is that these measures cannot be implemented without better leadership at the state level. Sabah’s Gabungan Rakyat Sabah (GRS) state leadership, whose Chief Minister Hajiji Noor (photo) is currently in hospital with Covid-19, has not responded as it should.
The state government has downplayed the importance of health, taking away the health minister portfolio, failed to provide a clear state point-person to lead within Sabah, not appointed a task force as has occurred successfully in other states such as Selangor and Sarawak, and alienated itself from the alliances it needs to harness the societal resources it needs to address this crisis – particularly glaring and self-defeating is the exclusion of women in appointments.
Even more of concern, they have apparently abdicated responsibility to federal authorities, who have repeatedly shown in Sabah that they lack local sensitivities/understanding and fall short in terms of resource commitments. Federal policy failures are part of the problems being faced in Sabah. It is unreasonable to expect that federal leaders will be able to get out of their closed framing of Sabah’s challenges without better local inputs.
State task force: GRS’s political state leadership vacuum needs to be urgently addressed. There needs to be a state task force, with health professionals and respected local leaders. The GRS government to date has not met the mandate Sabahans have given them, focused on internal squabbles about its composition rather than attention to the crisis at hand.
Changing governance practices
Denial: Part of the problem is persistent poor governance practices. There has been a repeated pattern of denial of the seriousness of the issues. There is an impression of complacency, as the leadership statements of “normality” do not instil confidence. Assurances to the public are needed, but these come best by showing interventions and competence.
Inadequate transparency: At the same time, there are concerns about a lack of transparency in who has been infected and how. More information is needed on how individuals are being tested, the rates of infection, and hospital admissions. This information can reduce fears and speculation.
Distrust of government runs deep in a polarised political environment, reinforced by failings on the part of politicians to contribute to the seriousness of the situation. Sabahans - all Malaysians - deserve better information as they are at risk. How communication is being handled and shared needs to be improved. Sabah needs improvements in sharing information locally.
The time for a “normal” response has passed. The normal response has repeatedly disadvantaged Sabahans as federal authorities lack adequate appreciation of the realities on the ground. It is important to understand those federal failures surrounding Covid-19 add to the deep resentments and divisions that already exist.
A normal response could cost lives. It has already cost lives unnecessarily. The time to change approaches and responses has come.
BRIDGET WELSH is a Senior Research Associate at the Hu Fu Centre for East Asia Democratic Studies and a Senior Associate Fellow of The Habibie Centre. She currently is an Honorary Research Associate of the University of Nottingham, Malaysia's Asia Research Institute (Unari) based in Kuala Lumpur. She tweets at @dririshsea.
The views expressed here are those of the author/contributor and do not necessarily represent the views of Malaysiakini.