Since March 2020, the Government of Timor-Leste has implemented a series of extraordinary measures aimed at containing the transmission of SARS-CoV-2 within the national territory, including declaring a State of Emergency, suspending commercial flights, mandatory quarantine for international arrivals and internal restrictions on gatherings and movement. Until March 2021, these measures had been credited with preventing Covid-19 from spreading in Timor-Leste, and been praised by both Timorese and foreign observers, including positive articles in international media.
Fundasaun Mahein appreciates that the Government’s actions were taken based on limited information and genuine fears that Covid-19 posed a major threat to the wellbeing of the population and the public health system. Although the international situation and debate have evolved considerably since March 2020, until now there has been no serious public debate regarding the sustainability or overall impacts of Timor-Leste’s Covid-19 response. In light of the growing panic and escalating restrictions due to community transmission, Fundasaun Mahein feels that it is especially important to assess the current Covid-19 response, with reference to new evidence from around the world on Covid-19 itself, as well as the impacts of restrictions on people’s lives, especially in developing countries. While we agree that ongoing measures are needed, this article raises some critical questions about the long-term strategy of the Government, and offers some suggestions for improving the state’s management of the crisis.
On Wednesday 10 March, a video circulated on social media showing a heavily-armed policeman forcing two sanitation workers to slap each other in the face due to supposedly breaking the new ‘sanitary fence’ rules in Dili. In addition to being a clear violation of existing laws regulating police conduct, this incident reveals the limitations of PTNL’s capacity to implement emergency orders without violating people’s rights, disrupting essential activities and provoking social conflict. PNTL commanders have already released a statement condemning the action and announcing an investigation of the officer in question. Fundasaun Mahein welcomes the quick response of the PNTL command.
Rather than viewing this policing incident as a one-off act committed by a ‘bad apple’, Fundasaun Mahein sees it as an inevitable consequence of the authoritarian approach taken towards Covid-19 in this country, as has indeed happened in most other countries. While Covid-19 threatens public health, a heavy-handed approach which creates public panic and provokes human rights violations is itself a threat to public security and democratic rights. Indeed, as a result of the widespread violations which have occurred during the Covid-19 crisis, UN Secretary-General António Guterres recently wrote that Covid-19 has also unleashed “a pandemic of human rights abuses”. Calls for harsh enforcement and increased penalties for violations of Covid-19 restrictions, including from some sections of civil society, are therefore extremely concerning, as they are inviting further violations of people’s rights and social conflict, the impacts of which will fall disproportionately on vulnerable people. Fundasaun Mahein reminds the public and policy makers that Covid-19 is a health crisis, and not primarily a criminal or policing issue.
We were also extremely worried to hear that police were preventing the transportation of essential goods, including agricultural products and imported food, into and out of Dili. While we are glad that the Government quickly released an advisory to ensure that police allowed the movement of food products, as well as other essential goods and services, it is nonetheless deeply concerning that the sanitary fence was implemented without explicitly informing the police that food products must be allowed to move between the capital city and rural areas. This reveals a dangerous lack of forethought on the part of the authorities about the consequences of implementing such drastic measures as a “lockdown” of the capital city.
To improve police understanding of Covid-19 rules and restrictions, Fundasaun Mahein suggests that the Government should create a formal mechanism attached to the Integrated Crisis Management Centre to ensure proper communication and coordination with police and other state authorities, including the Human Rights Ombudsman (Provedor), Ministry of Interior, Ministry of Commerce and Industry and Ministry of Agriculture. Not only will this prevent violations of people’s rights, it will also ensure that police understand that movement for transportation of agricultural products and other essential goods and services are allowed to continue as normal, as disruptions to these activities can be devastating for people’s livelihoods, the national food supply and the overall functioning of society.
More fundamentally, Fundasaun Mahein observes that the current approach involving daily emergency announcements, sudden “lockdown” orders, and insufficient assistance for vulnerable groups struggling with the economic impacts of the restrictions, is causing significant anxiety, hardship and social conflict within the general public. Such an approach also creates widespread psychological stress which negatively impacts public health. As has happened in many countries, the National Hospital currently lies mostly empty, as people are currently scared to attend hospital due to fears of Covid-19, which will have major health impacts as other diseases are left untreated. In addition, while most view the recent Dili lockdown as inevitable and necessary, it may have been counter-productive for control of Covid-19 itself, as many people rushed from Dili to the rural areas on Monday night due to concerns that lockdown would make livelihoods impossible or invite unwanted state intrusion.
The lack of capacity of the police and military to safely implement these emergency rules, and the increasing public panic about community transmission of Covid-19, suggest that a change of approach is needed. While measures so far may have been effective, the Government has relied too long on the hope that closed borders and quarantine would prevent any local transmission. It was predictable that new cases would eventually be found, especially when mass community testing was done. It was equally predictable that human rights violations would occur when an under-trained police force is given orders to strictly limit people’s movements and daily activities, as has already happened in dozens of countries around the world. Thus, rather than continuing to operate based on decisions made in March 2020, Fundasaun Mahein believes that several assumptions underpinning the Government’s pandemic response require further scrutiny and debate.
First of all, it is now known that the SARS-CoV-2 virus was circulating internationally since at least December 2019, with evidence suggesting that it had already arrived in Europe as early as September 2019. Furthermore, while most experts assumed at the start of the pandemic that SARS-CoV-2 would cause dramatic levels of hospitalisations and deaths everywhere it spread, including in Timor-Leste, major serology (antibody) studies in places such as New Delhi and Tokyo have shown that it is possible to widespread transmission without substantial illness or fatalities. As Timor-Leste’s borders only closed in March 2020, it is possible that SARS-CoV-2 had already been circulating undetected during the months prior. As there are currently no data available to confirm this, it would be useful for the Government to perform antibody testing among the population. However, it is also important to note that serology studies do not capture the full extent of exposure and thus underestimate population immunity levels, as antibodies can quickly drop off to undetectable levels following exposure, or are sometimes not produced at all despite the body mounting an immune response through. In other words, if people were exposed to SARS-CoV-2 in March 2020, they may no longer have detectable antibodies in their system, despite having already mounted an immune response.
Another major assumption among experts was that there was no pre-existing immunity to SARS-CoV-2 in any population. However, many studies have found that prior exposure to other coronaviruses – including those which cause the common cold – provides significant cross-immunity to SARS-CoV-2. In particular, substantial cross-immunity is thought to be a key factor in limiting the epidemics in Africa and East Asia, while relatively young populations and climatic factors and also thought to play a major role, especially in developing countries. Various comparative studies have found that the key factors in determining the severity of Covid-19 epidemics within countries have been structural factors such as population age structure, GDP per capita (wealthier countries suffered worse outcomes), climate and underlying population health, especially obesity.
Another unquestioned assumption is that mass screening using PCR should guide the Government’s response and restrictions on individuals and society. In Timor-Leste’s case, small numbers of positive test results have led to whole areas being put under “mandatory confinement” orders, including the capital city. However, many scientists have pointed out that the high sensitivity of PCR tests means that a positive result does not necessarily indicate an active infection, especially at high cycle thresholds (defined as greater than 30 cycles). A recent Lancet paper warned that PCR tests run at 30-40 cycles are so sensitive that “50–75% of the time an individual is PCR positive, they are likely to be post-infectious.” Dr Rui de Araújo recognised this issue and confirmed that the Government is testing at a high cycle threshold when he noted that the person who tested positive in Baucau was likely already in recovery due to the patient’s low viral load, which was detected by PCR at forty-two (42) cycles.
Responding to the many scientific articles raising the issue of false positives and the implications for PCR as a mass screening tool, the WHO recently advised that positive PCR results should be interpreted carefully. This is because the greater number of cycles used, and the lower the prevalence of SARS-CoV-2 in the community, the more likely it will be that many – perhaps even the majority – of positive test results will be false positives, rather than active infections. While some may argue that finding false positives and unnecessarily quarantining healthy people is a sacrifice worth making in order to contain transmission, it is important to point out that incorrect diagnosis can bring negative overall consequences for individuals and society, as it can lead to people being denied essential healthcare, suffering stress, trauma and stigmatisation, as well as causing financial and productivity losses.
Mass screening asymptomatic people and daily announcements about new positive test results may seem like the safest approach to the Government and its advisors. However, it is also undeniably contributing to a growing sense of crisis and fear, especially when new cases are announced daily with limited information on whether these people are severely ill or even symptomatic. Although each Government announcement is accompanied by a message of “don’t panic”, it is impossible to reduce panic while restrictions and case numbers continue to escalate. The lack of trust in authorities and social panic produced by the crisis are also boiling over into tensions between communities and healthcare workers, as evidenced by the recent threats of violence against a Ministry of Health team.
As continued Covid-19 monitoring is still necessary, we suggest that the Government should consider alternative strategies other than mass PCR screening and localised lockdowns whenever positive results are found. One example is requesting donors to assist the Government to develop the capacity to carry out rapid antigen testing, which gives results in minutes, rather than hours or days, and is also less costly and technically sophisticated than PCR testing. This testing regime has been recommended by the WHO for developing countries for exactly these reasons, and is already being implemented in Indonesia.
To reduce panic and improve public knowledge and confidence, Fundasaun Mahein feels that the Government should make greater efforts to provide the public with realistic information about the risks of Covid-19. Treating every positive PCR test as a national emergency may even undermine the Government’s own response by contributing to public distrust, as many people already believe that the severity of the disease has been exaggerated in both media and governmental announcements. The Government could share more detailed information on the condition of patients (ie. whether they are symptomatic or not, suffering severe illness etc.), while providing more realistic information on the relative risks of the disease as well as advice for improving overall health.
Failing to communicate the relative risks for different age groups and health conditions is likely to further erode the public’s trust as more people learn more about the realities of the disease, or, worse, access misinformation which denies the existence of the disease entirely. On the other hand, positive messaging which clearly communicates relative risks and sensible ways to mitigate them would help to reduce social panic and improve people’s faith in authorities. It is now well-known that obesity and Vitamin D deficiency are major contributing factors in severe Covid-19, as indeed they are in many diseases. Rather than forcing people to stay indoors (where most transmission occurs) or well-intentioned – but arguably unrealistic – calls for social distancing, the Government could advise the public that they need at least thirty minutes exposure to sunlight, fresh air and exercise each day to boost their immune systems. It can also use the crisis as an opportunity to educate the public about the importance of nutrition for overall health.
The Government could also use resources more wisely and further reduce panic by ending mass PCR testing of healthy people – which is likely to find positive results in many non-infectious people – and daily announcements of case numbers, and instead focus its efforts on finding symptomatic people among the population and test them and their direct contacts. The Government also urgently needs to increase the capacity of the health system to deal with all kinds of diseases and epidemics. Indeed, this has received far less attention in most countries compared to mass testing, quarantining and lockdown of populations. This may be because it is easier for governments to issue emergency orders than invest in public health over the long-term. However, it is essential for combating this and any future epidemics, as well as managing public health in general.
While the vaccine may bring an end to the pandemic, given Timor-Leste’s limited healthcare capacities, it will take a long time to achieve high rates of vaccination. Timor-Leste urgently needs to exit the crisis which is causing so much distress, additional health problems, economic damage and eroded trust in authorities. Therefore, rather than simply relying on mass vaccination as the only way of exiting the crisis, the Government should consider alternative strategies. As mentioned above, it is vital to address the structural problems of healthcare capacity and population health. In the meantime, the Government can prepare to reduce the health impacts of Covid-19 by purchasing supplies of cheap, safe therapeutics such as corticosteroids and anti-malarial drugs, which have already been studied and used widely, and incorporated into national treatment guidelines in numerous countries. Death rates have plummeted worldwide as doctors have improved their understanding and treatment of Covid-19 – there is no reason why Timor-Leste should repeat the same mistakes as were made in many parts of the world in March-April 2020.
Finally, it is also important to recognise that many academics and international organisations have warned that population “lockdowns” in developing countries with little government welfare and high rates of informal employment rapidly lead to substantial loss of income and reduced food intake. Indeed, Dr David Nabarro of the WHO appealed to Governments to stop using lockdowns as their primary control method due to their severe and disproportionate impacts on the poor. The United Nations and numerous academic studies have pointed out that poverty and malnutrition have dramatically increased as a direct result of government restrictions on economic activity, which will have major health impacts affecting many millions of people now and into the future. International organisations have warned that the suspension of vaccination, TB and malaria programs and school closures across the developing world are all set to have massive and deadly consequences, especially for children, which will likely outweigh the direct impact of Covid-19 itself in many countries. While Timor-Leste has fortunately escaped many of these harms, the long-term impacts of the Government’s measures have yet to fully emerge. Fundasaun Mahein believes that these serious negative impacts of Covid-19 measures must be weighed carefully against the risk posed by Covid-19 itself, rather than simply being dismissed as a necessary sacrifice to contain this disease. At a minimum, greater recognition of the harms caused by current measures, and efforts to tackle them, is needed.
In conclusion, Fundasaun Mahein recognises the achievements of the Government in limiting the impacts of Covid-19 in Timor-Leste. While we do not deny the risk posed by Covid-19 to overall health in Timor-Leste, we believe that more public discussion is needed in order to weigh the costs and benefits of the current measures, which has been lacking so far. While the measures have been overwhelmingly viewed as successful, it must be acknowledged that they are also creating widespread hardship, eroding trust in the authorities and contributing to social panic, while there appears to no clear exit strategy other than mass vaccination, which could mean continued border closures and repeated lockdowns for years to come. We remind policy makers that public health is not simply the control of a single disease – it involves managing competing priorities and difficult trade-offs, and impacts to livelihoods and other diseases caused by Covid-19 measures can be just as deadly as the disease itself. Indeed, travel restrictions have already killed numerous people in Timor-Leste due to the inability of people to travel abroad for essential medical treatment. We therefore ask the Government to consider the totality of evidence and alternative strategies, which can reduce the social panic, conflict, and other second order impacts of the pandemic response, while enabling Timor-Leste to gradually exist from this crisis while limiting the impacts of Covid-19 itself.