ON APRIL 25TH Bloomberg ranked Singapore as the world’s best country in which to weather the pandemic, in part because it had almost no local transmission. Two days later a 46-year-old nurse at Tan Tock Seng Hospital tested positive for the virus, revealing a cluster of dozens of infections. Within a week the government identified other new clusters, including at the airport and port. “We are now on the knife’s edge,” Lawrence Wong, a minister on Singapore’s covid-19 task force, warned on May 11th. “Our community cases can go either way in the next few weeks.”
Much of South-East Asia is similarly poised. Across the region, clusters have been found in places where defences are weakest: hospitals, quarantine facilities and border crossings. Lapses in those places allowed infections to spread more widely. Moreover, the virus has mutated over the past year, and the variants spreading now are more transmissible. That includes B.1.617, first identified in India, which has appeared in Cambodia, Indonesia, Malaysia, Singapore and Thailand.
New cases in Malaysia have more than tripled in the past month, hitting 4,765 on May 12th. Thailand’s daily tally has jumped from 50 in early April to more than 2,000 a month later. Of Cambodia’s 20,000-odd recorded infections, nearly 90% have occurred since the start of April. At least eight hospitals in Vietnam have locked down because of the virus since May 5th. Indonesia, where detected cases have levelled off at around 5,000 a day (though actual numbers may be higher), is preparing for a sharp rise after hundreds of thousands of city-dwellers defied a travel ban to return to their home villages for Eid al-Fitr, a Muslim holiday, in the first half of May. And as India has shown, the pandemic can shift from an apparent retreat to an unstoppable onslaught in a matter of weeks.
The reasons each country lost control of its outbreak vary, but in most, festivals, foreigners or fornication played a part. In Vietnam, Malaysia and Thailand, experts blame travel and mass intermingling during festive periods, in addition to complacency. Malaysia’s Muslim majority has for the past month been celebrating Ramadan, when people pray and socialise in the evenings. A cluster of cases in Bangkok’s nightclub district accelerated after the Songkran holiday in mid-April. In Laos, too, the festival resulted in a rash of cases. On April 29th, on the eve of “Reunification Day”, a national holiday, more passengers passed through the airport in Ho Chi Minh city, Vietnam’s largest, than on any other day since it opened decades ago.
Laos, Vietnam and Cambodia, none of which has previously faced an outbreak on the scale they are currently experiencing, also point the finger at outsiders. Laos blames infected visitors from Thailand. Vietnam ascribes its cases to lax observation of quarantine by people arriving from China, India and Japan. In Cambodia two prostitutes infected with the more infectious British variant of covid-19, known as B.1.1.7, arrived on a private jet from Dubai in early February and promptly broke quarantine to visit clients, nightclubs and other places. By mid-May the outbreak they seeded had infected thousands of people and killed more than 100. The Institut Pasteur, a medical-research institution, is sequencing 1% of all positive samples in the country. With the exception of newly imported cases, “It’s all B.1.1.7” from the same source, says Laurence Baril, its director in Phnom Penh.
The strain is beginning to show. Bangkok’s hospitals are filling up. “Our health care, with the increase in numbers, is becoming a bit overwhelmed,” says Subramaniam Muniandy, president of the Malaysian Medical Association. “Frontliners are tired, exhausted.” The Laotian health-care system could very quickly be overrun if the number of severe cases shoots up, says an expert in Vientiane, the capital. Dr Baril says it took her institute weeks to charter a plane, despite the Cambodian government’s support, to import 2.7 tonnes of the chemicals needed to conduct the most reliable test for the virus.
The rise is particularly worrying for countries that had avoided big outbreaks, and so have a wholly vulnerable population. Exactly how they escaped is a mystery. One commonly cited explanation is that they acted early to close borders, impose quarantine measures and trace the contacts of infected people, having learnt from the SARS epidemic of 2003-04. It helped that citizens complied when authorities instructed them to wear masks.
Other factors beyond the control of policymakers probably contributed, too. Most Cambodians, Laotians and Vietnamese live in rural areas, many in homes they cool by keeping windows open. This naturally dispersed, well-ventilated way of life may have slowed the spread of the virus. South-East Asians may also have had an immunity acquired through previous exposure to coronaviruses circulating in the region, but that hypothesis is unproven.
Countries are scrambling to contain the virus by reimposing restrictions. Vietnam and Singapore have extended quarantine for incoming travellers from two to three weeks, and closed some recreational facilities. On May 10th Malaysia imposed a four-week national lockdown. Laos shut down the capital in April and sealed its borders. Vaccination rates are rising but, with the exception of Singapore and Cambodia, less than 10% of the adult population in each country has received a single dose (see chart).
A huge question mark lingers over the two countries where infections are stable or falling, Indonesia and the Philippines, between them home to more than half the region’s population and seemingly out of step with the trend in the region. Indonesia, which has not yet seen a second wave, has worrying parallels with India, says Dicky Budiman, an epidemiologist at Griffith University in Australia: the virus has been circulating for well over a year, the health-care system is already stretched, the messaging from the government is muddled and a religious holiday has drawn millions of people into celebrations in groups. Officials are expecting the worst.
The Philippines suffered a surge in March, when new cases reached 10,000 a day. A strict lockdown brought that down by half. Yet the proportion of tests coming back positive, while falling, is still 15%, suggesting that many cases are escaping detection. “We don’t want to end up with a surge like India,” says Drew Camposano, a pediatric infectious-disease specialist in Iloilo City, in central Philippines. “It is a cautionary tale.” ■
Correction (May 14th 2021): This article has been updated to more accurately describe the Institut Pasteur.
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