SINGAPORE - Largely spared the brunt of the Covid-19 pandemic for most of last year, South-east Asia is now in the grip of a new wave of infections that is putting unprecedented pressure on healthcare systems and threatening to bring economies to their knees.
In Thailand, hospital beds are quickly filling up after infections, first seeded in some exclusive entertainment outlets in Bangkok, resulted in the country's highest-ever number of daily cases early last month. The number spiked again after Songkran, the Thai New Year.
Since then, the caseload has crept upwards and has more than quadrupled to nearly 135,000 as the authorities struggled to contain outbreaks in overcrowded prisons, markets and camps housing construction workers.
The youngest victim so far is a two-month old baby with a heart condition.
While the government reassured the public that it has enough beds to treat Covid-19 patients, more than half of those beds are in field or hotel hospitals, according to data from the Department of Medical Services.
Up until Jan 1, Thailand had only 7,379 cases.
In neighbouring Malaysia, daily cases have hovered at more than 6,000 for the past week. On Tuesday (May 25), 7,289 cases were reported, a day after a record 61 deaths were registered, along with 711 admissions to intensive care units.
While Malaysia's caseload of more than 525,000 infections is nowhere near India's 26 million, its per capita daily confirmed cases on a seven-day rolling average at 194 for every million people has already surpassed India's, which stands at 178 per million.
The Ro/Rt - the reproduction rate of the virus - has inched up to 1.21, which means 8,000 daily cases could be seen at the start of next month. The Health Ministry has revealed that more than a third of new Covid-19 patients last month required supplemental oxygen, pointing to more virulent coronavirus strains in Malaysia.
In the Philippines, a variants-fuelled surge that began in December has seen hospitals overwhelmed. Cases leapt to more than 15,000 a day, three times last year's peak number. As hospitals ran out of beds, harrowing tales of Covid-19 patients dying at home and in hospital parking lots and walkways dogged the headlines, forcing the government to fall back to what has proven to be its most potent weapon: a hard lockdown.
Sweeping quarantine restrictions in Metro Manila and four nearby provinces - home to a quarter of the nation's population and where cases were highest - from March 29 to April 10 brought infections down by half. Still, there are concerns that another surge is not far off. In one region just south of Metro Manila - with a population of some three million - 55 per cent of tests are coming back positive.
"We have variants of concern also circulating in this region which are two times more transmissible than the original strain. Also the severity caused by this strain is higher than the one caused by the original Sars-CoV-2," said Dr Abhishek Rimal, Asia-Pacific Emergency Health Coordinator of the International Federation of Red Cross and Red Crescent Societies (IFRC).
"In the Philippines, we are seeing the cases coming down, but not to the extent that we like because all four variants of concern are circulating there."
The four variants include the B117 which originated in Britain, the B1351 variant first detected in South Africa, and the P1 strain first found in Brazil.
The Philippines has also detected another highly transmissible variant, dubbed the "double mutant" B1617 that was first identified in India and which has also been detected in Malaysia, Cambodia, Indonesia, Thailand, Singapore and Vietnam.
While the explosion of cases in Thailand and Malaysia are worrying, experts are more concerned about other countries where the healthcare systems are not as well equipped and hence more vulnerable to rising cases, such as Cambodia, Laos and Myanmar.
Cambodia and Laos, which were largely spared last year - thanks to swift and stringent measures and protection from neighbouring countries which have done relatively well in keeping the virus at bay - are seeing an exponential rise in cases.
Both countries have blamed the outbreak on foreigners and returning migrant workers. In Cambodia, the B117 variant which spawned the new wave in the country in February was suspected to have spread to Thailand.
The hospitals are so overwhelmed in Cambodia that Prime Minister Hun Sen on April 7 ordered health officials to prepare to treat Covid-19 patients at home.
"We can't accept all patients in case that cases increase further," he told reporters. Three days later, he announced that the number of infections had reached a level beyond hospital capacity.
The country's caseload jumped 50 times since February to 25,205 as of May 23. As of Feb 1, it had only 466 cases, according to Johns Hopkins University's Covid-19 tracker.
Bogged down by its own political crisis after the Feb 1 coup, Myanmar has given up on updating its daily Covid-19 figures as rigorously as before.
"If we talk about the absolute number of cases, Thailand and Malaysia come on top. But, at the same time, we have to remember these two countries have a high number of people being tested and these two countries have good and robust health systems," said Dr Abhishek. "However, if we look at Cambodia, Laos and Myanmar, they don't have an equally developed health system. So, an increasing number of cases in these countries will be a matter of concern."
Hidden death toll
The virus has inflicted a human toll never before seen. All across South-east Asia, millions are suffering in silence with as many as 75,000 people dead so far. But the real death toll is more than likely to be higher for various reasons.
Research has shown that up to 70 per cent of cases are asymptomatic, which means many more would have escaped detection.
During the previous surge in the Philippines, for instance, most of those who died at home or while waiting for hospital beds were not included in the Health Ministry's daily tally because they were never tested or their results came out after they had already been buried.
Some of the poorer nations are ill-equipped to carry out rigorous testing and tracing of contacts, and isolation of confirmed patients. Many people have also avoided going to the hospital even if they suffered from Covid-19 symptoms because of social stigmas, said Dr Abhisek.
Universiti Malaya's public health professor Ng Chiu Wan found that Malaysia had 1,412 more deaths in the last quarter of 2019 among those 60 years and older, compared with the 2016-2018 historical mean for that period. This is despite other age groups reporting fewer deaths for that quarter against past averages.
The World Health Organisation said in a report released last Friday that up to three times more people may have died due to the pandemic than the officially reported figures.
The Economist predicted the global excess death toll to be up to four times higher at between seven and 13 million, most of them found in low- and middle-income countries. The magazine modelled the level of excess mortality using a method which takes the number of people who die from any cause in a given region and period, and then compares it with a historical baseline from recent years. The central estimate of the real death toll is very likely to be 10.2 million, according to the Economist.
"It is natural that in times like this you also struggle in reporting and that's not intentional. Several countries including China in February 2020 announced catch-up reporting. We know excess deaths in many countries is greater than that explained by reported Covid-19 deaths," Dr Dale Fisher, senior consultant at the Division of Infectious Diseases, National University Hospital of Singapore told The Straits Times.
The scenarios that are playing out in South-east Asia are bleakly similar to what we have been seeing in India and Nepal. There is a sense of pandemic fatigue in the increasing numbers of people flouting the rules that are meant to keep them safe.
In Malaysia, thousands tried to cross state borders during Hari Raya Aidilfitri this month despite rules banning such travel.
Indonesia, where daily cases have stabilised at under 6,000, is bracing for a sharp jump to up to 8,000 in daily new cases in the middle of next month, which could possibly turn out to be the possible peak as 2.6 million people return to major cities after the Hari Raya holidays, Vice-Health Minister Dante Saksono told an online media briefing with foreign journalists on Tuesday.
"We are boosting our tracing efforts… evaluating people with no symptoms but have had close contacts with confirmed cases," Dr Dante said, adding that micro-lockdowns - a type of localised lockdown in neighbourhoods where positive cases are detected in five or more households - have been in effect since early February and would continue.
But those who lead a hand-to-mouth existence have hardly any choice. They need to leave their homes for their livelihoods.
In the Philippines, with each reverse transcriptase-polymerase chain reaction test costing more than 4,000 pesos (S$110), or eight times the daily minimum wage, many are reluctant to be tested. A positive test result will also lead to a two-week quarantine which, for those earning on a daily basis, will be financially ruinous.
This may account for the uneven, skewed test data in cities like Paranaque, just an hour south of Manila, where more well-off districts are reporting more infections than in poorer, but more densely populated, neighbourhoods.
Stringent lockdowns in Cambodia have sparked an outcry from the economically vulnerable population, which was going hungry locked inside their homes, and with government-promised food and aid slow to come.
The Cambodian government has dismissed these concerns as fabricated news and banned journalists from broadcasting live in the capital, Phnom Penh, altogether.
These difficulties highlighted the dilemma of governments everywhere, who are stuck between a rock and a hard place. In countries such as the Philippines and Malaysia, governments are avoiding a full lockdown to prevent their economies from free-falling.
"Government always have to swallow this bitter pill when they make a decision between full lockdown and semi-lockdown as they try to make sure people also don't die of hunger," said Dr Abhishek.
Among the biggest economies in South-east Asia, only Singapore and Vietnam have expanded. Gross domestic product growth in Malaysia contracted by 0.5 per cent in the first quarter and the Philippines by 4.2 per cent. Indonesia and Thailand have also reported negative growth.
Herd immunity aim
Many experts say one way to bring down Covid-19 deaths is through herd immunity. Governments have therefore ramped up vaccination campaigns after a slow start but they are still falling short.
Thailand, which inoculated about three million people or slightly more than 4 per cent of its population, was heavily criticised for its original vaccination strategy, which relied largely on locally produced AstraZeneca vaccines which were not due to come on stream until next month.
In the interim, it relied on smaller batches of Sinovac and imported AstraZeneca shots. On May 13, the Thai Food and Drug Administration granted emergency authorisation for use of the Moderna vaccine, which would pave the way for private hospitals to offer the shots and speed up the pace of inoculation. It is also spacing out the second dose of the AstraZeneca vaccine to give more people the first dose. In an effort to speed up vaccinations, Thailand is allowing on-site registrations from next month.
Malaysia has tripled the number of doses administered on a seven-day average, compared with just a fortnight ago. Prime Minister Muhyiddin Yassin said on Sunday that 80 per cent of the population could be vaccinated before the end of the year.
Indonesia and the Philippines, which make up more than half of South-east Asia's 655 million-strong population, have inoculated only about 5 per cent and 2 per cent of their populations respectively, according to website ourworldindata.org and SDG-Tracker, a joint effort between the University of Oxford and non-profit organisation Global Change Data Lab.
The best bet, for now, is still for wealthy nations to delay vaccinating their young and healthy and donate their unused doses to developing countries.
The European Union has pledged to donate 100 million doses, either bilaterally or through the Covax facility - a United Nations-backed programme for distributing Covid-19 vaccines to low- and middle-income countries.
President Joe Biden said last week the United States would donate 20 million Pfizer/BioNTech, Moderna and Johnson & Johnson vaccine doses on top of the 60 million AstraZeneca doses it had already planned to give away.
As inoculation proceeds in earnest, some companies and universities in Vietnam and Thailand have started conducting clinical trials on home-grown vaccines. But they have largely hit a brickwall trying to get a manufacturer who can take their orders against the backdrop of tight production schedules currently.
It will take some time before South-east Asia can achieve herd immunity. An Economist Intelligence Unit forecast released last month showed that countries in the region will not do so until at least the end of next year.
If anything has been learnt from past pandemics, it is that a virus evolves and the second wave tends to be deadlier than the first. South Asia is unfortunately bearing the brunt of the second wave at the moment. Given its porous borders and the high movement of people, South-east Asia may have to brace itself for the same scenario if countries do not get their acts together.
"The first wave was controlled very well across Asia... But what we see now is a huge surge of patients in South Asia - many more patients need hospitalisation and the hospitals are getting full. That should be a stark reminder to South-east Asian countries that we must double our efforts in containing the pandemic right now," says Dr Abhishek of the IFRC, which has been involved in the distribution of aid and Covid-19 testing across South-east Asia, as well as engagement works in communities to battle the pandemic.
"If we wait too long, we might see a situation like in Nepal or India."