The need to forge a sustainable and adaptive New Normal

As of 24 June 2020, there have been 8,590 confirmed cases in Malaysia. Approximately 99.9% of our population is still susceptible to this infection. Even if we eradicate this infection from Malaysia, an imported cased may restart the disease transmission and cause another major outbreak. The Ministry of Health and the other Ministries have done an excellent job in controlling this 1st major outbreak. However, we have to accept that the next significant COVID-19 outbreak may happen anytime in the future.

The ongoing COVID-19 pandemic is akin to the Atlantic Hurricane Season where devastating Atlantic hurricanes start as much milder tropical rainstorms of the west coast of Africa. These rainstorms move slowly from Africa across the Atlantic Ocean to the Gulf of Mexico, waxing and waning in size and intensity, and few develop into massive destructive hurricanes. New storms continue to develop as long as the environment is conducive for its propagation. Malaysians are currently experiencing the calm associated with being in the eye of a storm.

This pandemic is also a timely reminder to our vulnerability as humans to mother nature. The evolution of Public Health (Medicine) over the past century has allowed us to prevent and control many diseases successfully. As our life expectancy and quality of life increased, so did our confidence in our ability to ward off suffering and death. However, the evolution and trajectories of this pandemic remind us that we are only human and that future outbreaks are inevitable, even possibly by other viruses. Acknowledging our vulnerability demands humility but will allow us to mitigate this pandemic better.

To make better-informed decisions, we need to let go of our fear. With the implementation of prevention programs by the healthcare system, COVID-19 is no different from many other deadly infections in the world, for example, Ebola, Dengue, TB, Nipah virus, SARS, etc. The only difference today is that we have accepted the baseline risk associated with the previous diseases but may not have had the time to acknowledge the baseline risk of COVID-19. There are many stages one goes through before accepting change. Exaggerated responses to the prevention of COVID-19, especially in times of low community transmission may be a sign that we are still in the process of accepting a new normal with COVID-19.

We have the luxury of time and hindsight as we now forge the Policies (SOPS) for the prevention and control of COVID-19 in a new normal. A lot has been learnt over these last few months. Our COVID-19 SOPS should be adaptive and account for the intensity of community transmission. One possible gradation of community transmission is nil (imported cases only), low, medium, and high. The threshold for these gradations should be scientifically calibrated and be based on community transmission independent of imported and artefactual contained clusters. The intensity of preventive measure should then correlate to the intensity of community transmission. Policies (SOPs) for the new normal should selectively apply the pillars of prevention (hand hygiene, social distancing, restriction of movement, and use of face mask) based on intensity of community transmission. The implementation of intense preventive measures during periods of zero or low community transmission is not beneficial as it leads to loss of trust in the community and higher non-compliance. Acknowledging that there will always be a baseline risk of COVID-19, even when the healthcare system is fully primed to prevent COVID, will help prevent exaggerated preventive measures from being implemented during zero or low community transmission.

There is also a need to emphasize evidence, feasibility, and sustainability in our new policies. For example, the advice and enforcement of wearing a face mask by “everyone everywhere”. The WHO has promoted a risk-based approach to the use of a face mask by the general public. Scenarios that mandate general use of a face mask include when the community transmission is high or when public health measures such as quarantine, testing, isolation and contact tracing have been overwhelmed. There is a lack of high-quality scientific evidence to support the use of a face mask by the public when the community transmission is zero or low. We should further review many other recently introduced practices for its evidence, feasibility, and sustainability.

Our policies should also accommodate vulnerable populations. We must balance between benefit, harm, and feasibility of the different preventive interventions. The effect of an intervention depends on the population characteristics, environment, and disease transmission dynamics. A policy may have a disparate impact on different strata of the populations based on their prevailing socio-economic resilience. Thus, interventions should take the different benefit-harm ratios across various sub-groups of the population into account before implementation.

Malaysia and many other countries are now recovering from the first global wave of this pandemic. We are in this for the long term, as our populations remain highly susceptible in the absence of herd immunity, and we must learn to co-exist with this new virus. We need adaptive and sustainable policies, which are rationalized by existing evidence, levels of community transmission, and feasibility, over the coming years to help us get through this pandemic.

Dr Sanjay Rampal is a Public Health Physician and a Professor of Epidemiology and Public Health at the Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Malaysia. He also Chairs the Public Health Society of MMA.

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