How Thailand contained COVID-19: Why a public health system with popular support matters
BANGKOK, Thailand – When the novel coronavirus began its swift spread from China in mid-January, people here feared the worst.
The country being the favorite destination of tourists from China, thousands of Chinese visitors had come into Thailand in January, including some 7,000 people from Wuhan, then the epicenter of the viral outbreak.
The shoe that didn't drop
In the following weeks, the country waited for the other shoe to drop. It didn't.
With the country decompressing and people returning to work under "new normal" conditions, a question many are asking is why the other shoe didn't drop. Why has Thailand performed so much better than other countries in containing the virus?
True, Taiwan and Vietnam have a better record than Thailand, with the first recording 441 infections and 7 deaths, and the second 327 cases and no fatalities. But Thailand's record is nothing to sneeze at: 3,083 infections and 57 deaths, with a 96% recovery rate. This becomes starkly evident when one compares the explosive rates of infections in the US, Europe, and Brazil. Germany is one of Europe's best performers, with its 83 million population size not too far from Thailand's 70 million; yet its infection rate of 181,288 and death rate of 8,498 are of another order altogether. And in Asia, if we go by the numbers, Thailand has done much better than Japan and South Korea, which are often written about as success stories.
An exhaustive study of why Thailand has managed to do better than most other big countries will probably not be available for some time to come. While waiting for that, let me take the risk of proposing an explanation stemming from my observations while stranded in Bangkok at the height of the pandemic and from my knowing something about a country I have followed over the years.
At the height of the pandemic in March and April, Thailand was on a partial or "soft" lockdown. Public and private establishments were closed throughout the country except for hospitals, drug stores, supermarkets, markets, takeout, and other essential services. Wet markets were open and Bangkok's ubiquitous street food vendors continued to do brisk business. While interprovincial bus trips and air travel were stopped, there were no restrictions on local mobility, except a curfew from 10 pm to 4 am. In Bangkok, buses and the light rail and subway systems continued to function.
A measure of disorganization attended this process, especially in the beginning. The sudden closure of businesses and factories in Bangkok, without attention to how people would survive, led to many leaving the capital in a hurry, resulting in the spread of COVID-19 cases beyond Bangkok. Also, there was a lack of national coordination, so travel became difficult across provinces since some of them imposed local lockdowns so that travelers could not enter them without permission from local authorities.
In spite of these fumbles on the part of the political leadership, the public health authorities soon stabilized the situation. As in most other countries, public health authorities very early on discarded mass testing, saying they did not have the resources to conduct this. In its place, they put into effect an aggressive strategy of contact tracing, quarantining those testing positive and hospitalizing those with serious symptoms, and requiring international travelers arriving from "dangerous communicable disease areas" to self-isolate or, in some cases, be confined to government quarantine centers.
A critical role was played by village health volunteers (VHVs) in flattening the spread of COVID-19 at the community level. They monitored people's movement in and out of their villages, conducted home visits to check temperature, shared health information about COVID-19 and how to prevent it, recorded household health information, and reported their data to the provincial health office and then the central government afterward. There were over a million VHVs across the country, in addition to more than 15,000 public health volunteers in Bangkok.
Thailand is not China
A popular explanation going around about why Asian countries have done better in dealing with COVID-19 than the United States and Europe is that they have authoritarian governments that could quickly muster a centralized, unified response from above. The Thai case, with its military-dominated conservative government, appears to fit this stereotype, which is drawn mainly from China's response to the pandemic.
This view is superficial, indeed extremely so. For while the government did adopt an Emergency Decree, the battle against the pandemic was led by public health authorities deploying a strategy of persuading people to use face masks and hand sanitizers, observe social distancing, and stay at home. As noted above, much of this work was carried out at the grassroots level by hundreds of thousands of village health volunteers.
Polite visual and audio reminders were ubiquitous in both public places and supermarkets. On television, COVID-19-related advice was pervasive, and one of the most watched spots was the daily 11 am update of the Center for COVID-19 Situation Administration led by a medical doctor who laid out the numbers, offered assessments of the national and international situation, and used the opportunity to boost popular morale.
The current regime is a polarizing one, so whatever were their intentions, it proved a smart decision for its military leaders to yield center stage to public health authorities with a thoroughly professional image. This was in contrast to the United States, where President Donald Trump consistently contradicted his medical experts, or the Philippines, where President Rodrigo Duterte has used police coercion and threats of shooting people instead of persuasion to achieve citizens' compliance. Indeed, in the view of some observers, the public health authorities' response did not need the Emergency Decree, the main objective of which was, in their view, twofold: to unify a fractious ruling coalition and to contain the public criticism of the disorganization that marked the political leadership's confused response to the crisis in the beginning.
From most indications, the strategy of persuasion has been successful. Personal observation showed fairly widespread compliance with the one-to-two-meter social distancing rule, though, in the typical Thai fashion, people tried to make compliance as unobtrusive as possible to avoid hurting people's feelings. Buses and metro rail and light rail coaches traveled at only 15% to 20% of capacity, which meant people were staying at home. In light rail and subway coaches, I never saw anyone seating on the designated empty seat separating passengers. Face mask use was universal.
The face mask question
On the question of face masks, Thais did not wait for the public health authorities to tell them to wear them. They were smart to have ignored the early, foolish World Health Organization (WHO) advisory discouraging people from wearing masks. Indeed, even before the pandemic, they had already been using face masks in great numbers, owing to Bangkok's high levels of air pollution, which had breached the critical limit several times in 2019. When fears of infection escalated in early January, mask wear rose to some 90%. Despite the WHO's ill-advised advisory, mask wear was about 99% by mid-March, according to my informal monitoring from riding the subway and light rail system.
These observations have been confirmed by a recently released survey of global face mask use by a United Kingdom-based research firm, YouGov. Ninety-five (95) percent of Thais currently wear face masks in public, the highest of 6 ASEAN countries surveyed. This is in contrast to a 15% positive response in the UK, 44% in France, and 48% in the US.
In February and March, dirty looks met large numbers of unmasked Western tourists who were probably still following the ill-advised WHO directive to their governments. This had unfortunate consequences, with the controversial minister of health in early March blaming "dirty" Caucasian tourists for the pandemic, saying, "Ninety percent of Thais are wearing masks. However, none of the Caucasians are wearing masks." (Fortunately, this gentleman was not the public face of the public health system during the crisis.) However, since the WHO reversed its decision not to recommend face mask use in early April, rare is the Westerner or farang who is seen without a face mask in public.
But the face mask controversy did underline one thing: that compliance with government advisories was either voluntary secured mainly by communal pressure.
Hygiene and COVID-19
So what accounted for the extremely high degree of compliance to public health advisories?
My sense is that the campaign of persuasion was successful because it was built on a number of solid elements, one of them being personal hygiene. Thais are very hygienically conscious. Non-Thais quickly realize that one of the things that one never ever does is to enter a house without taking off one's shoes. Most Thais make sure to have a change of clothes daily and to take at a minimum two showers a day – something I learned from personal experience, my late wife being Thai. Moreover, from my informal observation, these hygienic practices are not simply upper class or middle class practices, but extend to all social groups, including people in rural areas.
Culturally transmitted hygienic practices and communally enforced government advisories are not the whole story, however. What has been said so far may give the impression of a conformist society marked by a high degree of consensus. In fact, Thailand is a turbulent society rent by social conflict. Massive street protests marked the period from around 2004 to 2014, as populists and conservatives struggled for political control of the country. Today, a military-dominated pro-royalist government rules, but conflict is not far from the surface. This history of social conflict makes the high degree of consensus in the area of public health even more remarkable. Indeed, public health is one of the few non-politicized areas of social life, and public health authorities enjoy a degree of trust and confidence that other state authorities – and certainly high profile political leaders – do not have.
The consensus on public health was not always there. It arose from a number of public health campaigns, which were successful because they were not seen as being imposed from above but involved the energetic participation of civil society. The country's COVID-19 success was built on this record of cooperation between public health authorities and civil society that goes back 50 years. When COVID-19 appeared on the scene, this relationship of trust kicked in, reconciling people to the personal, social, and economic sacrifices that would be required of them. Without this trust between civil society and public health authorities, the country would not have seen the deployment of more than a million committed village health volunteers that played a key role in containing the spread of the virus.
Citizen-supported public health landmarks
There have been 4 landmarks in the country's history of cooperation between public health authorities and civil society.
The first was a successful family planning campaign, perhaps the most successful in the world. While this was a government-led campaign, its success was due to widespread civil society cooperation based on the public health system's providing contraceptives to meet a widely felt need for smaller families to ward off poverty. From 1970 to 2010, Thailand's population growth rate fell to an astonishing 0.6%, compared to 2.04% registered by the Philippines, another Southeast Asian country to which Thailand is often compared. Thailand actually had a bigger population in 1970 than the Philippines, 36.9 million to 35.9 million, but owing to successful family planning in Thailand and obstructive opposition to it in the Philippines from the hopelessly benighted male Catholic Church hierarchy, Thailand's population is currently at 69.6 million as of 2020, while the Philippines' has ballooned to 109.5 million.
The second landmark was Meechai Viravaidya's successful campaign to get Thai sex workers to wear condoms to prevent HIV-AIDS in the 1990s, the famous "100% condom campaign." Like the family planning campaign, this was not imposed from above. It depended on the voluntary participation of sex workers who were educated by grassroots activists and a high-profile media campaign on the consequences of not requiring their clients to wear condoms. And like the family planning campaign, it was a huge success, with new HIV cases dropping from 150,000 in 1991 to less than 14,000 cases in 2008. HIV prevalence among sex workers working out of brothels in Bangkok dropped to 2.5% during that period. As Meechai jokingly told me in a 2011 interview: "Our sex workers know they are in the frontline of the war against AIDS and when they do battle, they put on their helmets. Our sex workers are very, very safe, though I am not recommending that you go out right now to find out."
The third public health-civil society campaign that had a lasting effect was the anti-littering drive in Bangkok led by Khunying Chodchoy Sophonpanich, a socialite-turned-activist. Known as the "Tawiset" or Magic Eyes campaign, it turned Bangkok into one of Asia's cleanest cities, and its ethos of taking responsibility not just for private space but for public space spread through the whole of Thailand. It also gained the reputation of being one of the few successful anti-littering campaigns internationally. Again, this was not imposed from above, but involved activists mobilizing citizens, school children, business, and the media. Indeed, government took a back seat in this campaign. Though it took place more than 30 years ago, people still remember the jingle, "Tawiset, tawiset." When, years ago, I asked her the reason for the success of the campaign, Chodchoy answered, "Unlike other anti-littering campaigns, Magic Eyes didn't tell people what to do but appealed to their sense of self-respect and respect for their neighbors."
The fourth public health landmark was the country's universal healthcare coverage established by the government of Thaksin Shinawatra in the early 2000s, which provides quality and extremely affordable health care to 98% of the population, with funds drawn from the general income tax. The Thai system is widely regarded as one of the most successful in the world, being credited with reducing infant mortality, decreasing sick days, and placing quality medical care within reach of the poor. True, there are long queues every day in public hospitals like Chulalongkorn University Hospital, but poor people are willing to wait since the service delivered is qualitatively better than that provided in most private hospitals, say many analysts.
According to one person I interviewed, the universal health system "is probably the reason why Thaksin remains so popular among urban and rural poor, so that if truly free elections were allowed, his party would have a permanent majority." Whether this observation is true or not, the fact of the matter is that the 18-year-old universal healthcare program has become the cornerstone of that relationship of trust between the public health system and the people that came into play when COVID-19 came on the scene. "People were no longer turned off by the cost of medical assistance," one businesswoman told me. "They did not hesitate to seek the help of the doctors if they felt they were coming down with COVID-19."
To be sure, coercive measures have not been absent during the lockdown period, with some people arrested, indicted, or threatened with arrest under laws and directives that included the government's Emergency Decree to deal with COVID-19. According to a recent Amnesty International report, 3 activists have been indicted for their staging peaceful protests, while several organizations marking the sixth anniversary of the May 2014 coup against Yingluck Shinawatra were reportedly harassed. The report also mentioned the arrest and indictment of an artist who posted on Facebook that there were no health checks at Bangkok's Suvarnabhumi Airport upon his arrival in March. It is unlikely that these events made a contribution to the successful campaign against the pandemic. Indeed, with the widespread publicity they elicited, it is more likely that they detracted from the public health authorities' effort to build national unity against COVID-19.
The Thai 'recipe'
So what was the recipe for Thailand's success in containing COVID-19? It was not one of authoritarian politicians dictating from above and whipping people in line with coercive measures. To a large extent the political leadership was superfluous.
Culturally transmitted norms of personal hygiene were one ingredient. But what really made the difference was voluntary compliance of citizens and the voluntary service of hundreds of thousands of grassroots public health activists that built on a history of successful public health campaigns and institutions that were founded on cooperation between public health authorities and civil society. The lesson of Thailand for the world is that a good public health system with popular legitimacy really makes a difference in times of crisis. – Rappler.com
Walden Bello is the principal author of A Siamese Tragedy: Development and Disintegration in Modern Thailand (London: Zed, 1998), a book on political economy the Thai edition of which was used as a text in some of the country's leading universities.