2021: The Year in Reflection
I vividly remember the period around December 2020. The usual festive feeling was subdued, likely because my family decided to skip our annual holiday (we skipped again this year), but more so was the lack of anticipation for the coming year. I am not usually fond of countdowns or resolutions, but the new year does give me a sense of renewal and that feeling invigorates me to an extent.
So, it was no surprise 2021 felt like a continuation of 2020. The pandemic rages on, showing no signs of letting up even as the world tries to move on. With the Covid-19 vaccines, there was hope that we could enter a ‘new normal’ or at least get back some semblance of a pre-pandemic life. This has played out quite differently than how we expected. The development of vaccines might be the most successful scientific endeavours in the century, but the key was distribution. As the world looked on at 91-year-old Margaret Keenan receiving the Covid-19 vaccine by Pfizer in December 2019, we held our breath and dared to hope that lockdowns are a thing of the past.
Mass vaccination begins
By January 2021, the world shifted into second gear and mass vaccinations programs started. Singapore, arguably the richest South Asian country, made a clever bet early and secured doses to start vaccinating health care workers in December 2019. I received my first dose in January 2021 and completed 2 doses by the following month. My countrymen and women back home in Malaysia started to receive theirs a month later in February, beginning with the healthcare and frontline workers.
Executing the biggest national vaccination exercise is no easy feat. Whether you have a country with a population of 33 million or a postage stamp sized country, the preparation and logistics are daunting. There were many layers of considerations, from the type of vaccines that require different cold chain requirements, a mechanism to ensure the vaccines are distributed equitably to making sure there were no wastages of the vaccines. Malaysia decided to embark on a tech-centric route, using an app called MySejahtera to allocate appointments and issue vaccination certs. The app started as a solution to contact tracing and health risk assessment tool for the public. As of now, the app has morphed into an all-in-one portal for Covid-19 related matters. On the surface, it would seem an app would be the perfect solution. Always on our fingertips (in our smartphones), easily accessible and standardised across the nation. But technology is fickle minded.
Reports of glitches began to surface. Appointment locations for the vaccine were too far from the registered addresses, some even completely in different states (there was still an interstate travel ban at this time). For some who successfully obtained the vaccine, the digital certificates weren’t reflected in the app. Nagging problems continue, even as recent as November, where there were reports of risk statuses being switched from low risk to Home Surveillance Order (HSO) or Person Under Surveillance (PUS), which meant people could not travel freely. Some even missed important appointments like flights or exams.
The other problem with relying on a smartphone app is it disregards the digital gap. Though there were other channels where the public can register for the vaccines, the emphasis was placed too much on the app. Technology is a powerful augment but if it is not inclusive, it will act as a barrier instead.
Similarly in Singapore, where the government has embraced technology in their administration, the approach in the battle against Covid-19 was two-pronged. A location-based system, called SafeEntry where the public must scan a QR code to gain access to almost everywhere from malls to coffeeshops. The second is TraceTogether, a Bluetooth proximity-based system that was used to determine close contacts of positive cases. I was part of the contact tracing team in a local hospital and both these systems were very helpful, cutting down our time taken to identify close contacts from days to hours. But such powerful data was too tempting for law enforcement agencies. It was revealed during a parliamentary session that the police were allowed to use the TraceTogether data for criminal investigations, sparking outrage from opposition politicians and the public. In the end, a bill was enacted to limit the use of this data only for serious crimes. But the damage was done.
The examples in Malaysia and Singapore highlighted important issues about relying on technology and data privacy. For an app to work, the user experience will have to be near perfect, especially when it dictates a large part of how we live our lives. Data governance and the assurance of data privacy is paramount for the public to be comfortable submitting their personal data. Both if poorly executed will only lead to trust deficit with the authorities. And trust deficit is not something that is easily recovered.
Misinformation is a pandemic
Covid-19 has dominated our conversations in 2021. With new information being fed to us almost daily, it was a struggle to keep up, even for those are who are familiar with the field. I spent a big chunk of this year reading, digesting and writing many issues around the pandemic but vaccine misinformation took most of my time. Getting the vaccine is still very much a personal decision and it is shaped by many factors. Over the year, two groups emerged, the pro and the anti-vaccines groups, each defending their choices and producing very heated discussions. The core issue in these discussions had been misinformation.
The problem with misinformation around Covid-19 vaccines is not only just ‘fake news’ but misinterpretation of the data and evidence. The pandemic has generated a treasure trove of data, and everyone has pivoted to studying it. Journals published new material faster than we could read them. Pre-prints, which are scientific papers before peer review suddenly became a main source of information for many. My medical school lecturer once told me, “Not all evidence is of the same quality”. But the world didn’t care, it had hungrily lapped up every bit of news from vaccine side effects to conspiracy theories.
Fighting misinformation suddenly became very real. When the Malaysian health authorities decided to release Astra Zeneca’s Covid-19 vaccine, I took time to explain a risk specific to the vaccine, which was something called vaccine-induced immune thrombotic thrombocytopenia (VITT) and immediately my Twitter inbox was filled with questions to clarify doubts on the safety of the vaccine. This showed misinformation can be corrected. Some of the misinformation was more light-hearted in nature, such as claims that the vaccines made the body magnetic, which I also took the time to explain on Vice News.
But more blatant attempts at misinformation were dangerous to the public and could undermine vaccination programs. Both Malaysia and Singapore decided to clamp down on such attempts using the law. A housewife in Malaysia was fined RM12,000 for sharing fake news on vaccines. In Singapore, multiple individuals and websites were issued a correction direction under the Protection from Online Falsehoods and Manipulation Act (POFMA).
Social media became a battleground of sorts between the pro and anti-vaccine groups. It was clear after a while for some, there was no way to convince them that the vaccines are safe, even with convincing evidence. Many began to deplatform them, denying the anti-vaccine groups the attention they needed to spread misinformation. But the anti-vaccination groups have a wide range of narratives, such as conspiracy theories, safety concerns and religious issues. Pro-vaccine groups are mostly single tracked, focusing on efficacy and safety. So as much as we want to ignore or deplatform anti-vaccine groups, eventually we will cross paths with them. The question is, how do we engage with them, is it even worthwhile to try and convince their minds? I shared some thoughts on this on a BFM interview previously.
Before we engage with anti-vaccine groups, we need to understand their position. We tend to generalise them with a singular characteristic but there is actually a spectrum in this group. It ranges from people having valid concerns, such as bad experiences with other vaccines or conditions like pregnancy to vaccine-hesitant groups where people lack the proper information to make an informed decision. Only at the end of this spectrum are the hardcore vaccine deniers. I talked about this in a podcast hosted by He Says, She Says, They Say, breaking down the different groups in that spectrum and the underlying causes.
Deciding whether to get the vaccine might seem like a simple choice but because of the complexity of the situation, it might not seem so. An early survey in Malaysia found that 33% of respondents were unsure of getting the vaccine. We have been focusing on this 33% and trying to change their minds but we forget that the other 67% can change their minds as easily too. I wrote about how having a wide range of vaccines affect the decision of getting vaccinated in December 2020. The decision of getting a vaccine is not set in stone, and we must remember this when new information is available to us.
The year is nearly at its end, but still, Covid-19 remains the topic to talk about. I suspect this will persist in 2022 as well. The fight against misinformation never really ends.
Healthcare workers are not an infinite resource
It is undeniable that healthcare workers were the ones who carried the burden of the pandemic. All over the world, the story is the same. Doctors, nurses, paramedics and other allied health workers continued to serve, taking up responsibilities and putting in the hours no other jobs will require. Even with the long hours and an increased risk of exposure to the virus, healthcare workers have put duty above self to care for their patients.
But two years is a long time to carry this burden. It was in hope that governments learned from the lessons over the past two years and prioritise healthcare, building up capacity, hiring more manpower and creating a better working environment for healthcare workers to be able to continue doing their jobs effectively. Unfortunately, it has fallen on deaf ears. Wave after wave of outbreaks continued and the mental stress took its toll.
In Singapore, it was reported that around 1,500 healthcare workers resigned in the first half of 2021, compared to 2000 resignations pre-pandemic annually. Travel restrictions for much of the past two years meant many foreign workers in Singapore couldn’t visit their families. When borders were finally opened, many opted to migrate back to their home countries. This left a big gap in the healthcare system and the remaining workforce had to shoulder more work, even as Singapore is relatively shielded from a large outbreak.
Across the straits, the Malaysian healthcare manpower has been a constant source of debate over the decade. Poor policy planning resulted in short term measures like a contract-based system for new graduates which ignores the long-term issues like career advancement and maldistribution. This finally bit back in 2021. After nearly two years into the pandemic, a group of junior contract doctors staged a peaceful protest in July. Hundreds of doctors nationwide walked out of their hospitals, carrying signs of Hartal Doktor Kontrak (Contract Doctor Strike). No patient care was compromised as the protest was well organised, with other doctors covering their colleagues. And it worked. The government took notice and promised changes, including equal terms in employment for the contract doctors. But the terms are yet to be seen fully implemented on the ground till today and reports of unequal treatment still surface from time to time.
The mental stress of healthcare workers has been one of the biggest talking points in 2021. The pandemic has caused healthcare workers to make very hard decisions over the past two years, leading to a condition called ‘moral injury’. This made an already tough working condition tougher and eventually worsened mental health. I proposed a framework to provide continuous mental health support to healthcare workers in an earlier article. We are beginning to see some changes in how we deal with mental health but there is much more to be done.
We must realise healthcare workers are not an infinite resource. The pandemic has shown that the preparation we had for a global outbreak has failed because the spine of a healthcare system is its people. Being a part of the healthcare fraternity, there is a sense of duty, a calling that we identify with but that calling is also a double-edged sword. We often fall headfirst into the work, ignoring all the red flags of burnout or anxiety until it is too late. We pretend that we can carry the burden without any harm to ourselves and this had led to oversight by health authorities to ensure the welfare of healthcare workers. Going into 2022, there must be a commitment to build healthcare capacity as well as protecting healthcare workers so that we can do the job we are trained for.
Changes in how we live and work
2021 marked the second year into the pandemic and much of how we work, play and grow as a society has changed. And it is still changing. Many of us went from working in an office to working from home. My family bubble consists of six adults with two young children. While my wife was able to shift her workplace to our home, the rest of us working adults in the family continued to commute to work. I am probably considered lucky that my parents could help with some babysitting duties. Singapore moved away from a hard lockdown in 2021 but the constant change in regulations such as home visiting numbers, dining out groups and even carpooling has disrupted our well-oiled routine, giving us some unwanted stress as we try to juggle between work and surviving the pandemic.
Meanwhile, lockdowns continued in many parts of the world. I mentioned that we went from working in an office to working from home. But it is really working from home in a pandemic. We cannot brush off the fact that for many, home is not a conducive environment to be work productive. The situation can be twice as challenging with children at home.
Mothers bear the brunt of this new way of working and living. It is shown that mothers are the main caregivers of a family, taking on more housework and childcaring than fathers. The blurring of lines between work and home meant the time for these responsibilities often overlap, leading to more working mothers either being laid off from work or forced to resign. These burdens are on top of other structural barriers for women in the workforce. The pandemic has begun to worsen gender equality and reverse progress made in household income gains, particularly in the middle class.
For this to stop, employers must take a more active role to help working mothers. For example, a more flexible work arrangement could be established by understanding the needs of working mothers. More childcare support programs can be implemented, such as subsidised childcare programs. Policies that recognise working mothers and their struggles during this pandemic will not only ensure a better working environment but also allow them to thrive.
Global inequity, new variants and the pandemic response
The biggest issue of the global pandemic response today is the continuous global inequity it creates. Earlier in 2020, I wrote about how the pandemic is a potential equaliser, but we have failed to respond correctly. We are now at the end of 2021 and yet the world is repeating the same mistakes. The Covid-19 vaccine development is only one part of the equation. The other part is the distribution.
Today, 67% of people in high-income countries are vaccinated with at least one dose while only 10% of people in low-income countries received a dose. Lower to middle-income countries are more affected by the pandemic and yet received the least vaccines, mostly due to politicking among the countries in the Global North. Vaccines have become a geopolitical currency for some, and this has greatly affected the distribution to lower and middle-income countries.
Halfway through the year, as vaccination rates grew, many countries started to talk about ‘exiting the pandemic’ or ‘living with the virus’ in an endemic state. It was clear that a Covid zero strategy will not work, and the virus truly will remain in our communities. But trying to live with a constantly evolving virus is tricky. Personally, I reject the phrase ‘living with the virus’. We are still trying to survive the pandemic. A SARS-CoV-2 endemicity is not unachievable, but it takes a thorough understanding of the situation and even more preparation, which I explained here.
The global vaccine inequity is arguably the reason why new variants emerged, the most recent in November 2021 called the Omicron variant. The world went into a frenzy upon the announcement by the South African scientists and again, the first reaction was to ban entry of travellers from African nations. Such knee jerk reactions are unhelpful and only serve to discourage data reporting when what we need now is solidarity and transparency to combat the pandemic.
As we continue to learn more about the new variant, we must also accept the uncertainty the answers will bring us. The two biggest questions were transmissibility and severity, and I unpacked them in an earlier article. It is still early days to make any hard conclusions but already Omicron has spread and is the dominant variant in several countries. What the South African scientists gave us is not conclusive data about Omicron but a very early warning of the potential harm it might cause. The world must take heed and apply the appropriate steps to prepare for the eventual wave of infections Omicron will induce. Punishing the African nations is not one of them.
Climate change, floods and the Malaysian spirit
I am not well versed in the topic of climate change apart from what I read from headlines but the events of the last two weeks in my home country made me pay attention. On a rainy Friday night, I came to know the news of flash floods in major cities in Malaysia. Flash floods are not uncommon in our cities, but this was one of the worst in recent years, displacing tens of thousands and the death toll now stands at 48 with some victims still missing. I scrolled social media in horror as I read and watched how the floodwater was rising and people struggling to save themselves.
Climate change has played a part, but it was due to poor urban planning and indiscriminate logging activities in certain states. Over the next two weeks, I struggled to process what has happened, but one silver lining was the spirit of Malaysians. Within hours, help poured in from volunteers. Selfless men and women braved the floodwaters to reach those who were stranded in the cold, ferrying them in canoes and rafts. Appeals for donations, whether monetary or in provisions were not left unanswered and the ever-generous Malaysians chipped in. MUDA, a new political party, raised RM2 million within days. Many other NGOs and civil societies also raised money, all channelling to the flood victims. Volunteers offered services such as cleaning flood-affected homes, car cleaning services and even repair of prosthetic limbs. I felt somewhat guilty not pulling my weight but also felt really proud of my fellow Malaysians.
However, aid in the form of volunteers or donations is unsustainable. The biggest criticism of the government response to the floods was the speed and bureaucracy. Many complained that government agencies were too slow to react and worse, there was little to no planning to deal with flash floods. When aid to the victims was announced, the bureaucracy to apply for it was too cumbersome. The government must learn from this and start to have a national disaster plan specifically for flash floods. An early warning system needs to be placed to warn residents of potential danger. There is also a need for a framework or protocol to activate once there are flash floods, sending government agencies for rescue operations, setting up flood shelters and distributing aid. A post-disaster plan is also helpful to coordinate clean up and rebuilding efforts in the affected communities.
Malaysia might be shielded from many natural disasters, but the danger is not only from nature. Urban planning must consider the danger from flash floods and other environmental dangers. Logging activities need to be reviewed to ensure deforestation do not cause soil erosion.
Climate change is something no government can ignore, in any part of the world. Rising sea levels, prolonged droughts, heavy rains and other global climate changes are all part of an interconnected climate system. If we do not take any action to slow down or stop the effects of climate change, we will only suffer more of these man made disasters.
Being hopeful for 2022
2021 was probably not the year that we hoped for. It was fraught with challenges for many of us. The pandemic continues to evolve with new variants and efforts to vaccinate the global population is hard, due to global politics and misinformation. Our greatest resource against the pandemic, the healthcare workers are tired and frustrated. Changes in our lives continue, with many struggling to balance work, family, personal lives and mental health. The world is focused on the pandemic but events outside the pandemic continue, such as the effects of climate change.
But if we looked at 2020, just before the pandemic began and how far we’ve come, there was certainly progress. Against the pandemic, we now have quite a reliable toolkit of vaccines, therapeutics and non-pharmaceutical interventions. The question remains whether we have learned enough in the past two years to stop making the same mistakes.
One common theme running through the past two years is the tendency to fall back to nationalistic actions. But the virus does not care for borders or nationalities. Without global cooperation and solidarity, the battle against the pandemic will be slow and likely unsuccessful. Victor Hugo once said, “In joined hands there is still some token of hope, in the clinched fist none.” The message we must take going into 2022 is that we can only do better if we work together.
I will not pretend to deny that 2022 will likely be equally challenging but I remain hopeful. Lastly, I hope everyone is safe during this end of the year and thank you for doing your best in the past year. Come 2022, I wish everyone to have a fruitful year ahead. Reach out if you need help and be kind to each other.