At the outbreak of the COVID-19 pandemic, Thailand won global praise for the quality of its response. It has since watched a rising caseload overwhelm world-class public health defences. Craig Keating argues that government complacency left the country unprepared for the influx of new, highly-transmissible, virus strains.
A country that in March had few COVID-19 patients and was being hailed as one of the ten best countries in its management of the pandemic. A government that placed its faith in domestic AstraZeneca production, and which had not, until recently, given great urgency to a rapid vaccine rollout, nor to procuring mRNA vaccines. A country whose vaccination rate lags behind the world average. An administration that only apologised last week for shortcomings in its vaccine rollout as casualties surged from COVID’s Delta variant. Thailand’s pandemic experience eerily mirrors that of Australia’s.
But there the stories diverge. Thailand has just reached the sad milestone of half a million COVID cases. Last week, Thais woke to news of people infected with COVID-19 dying in Bangkok streets, their bodies lying there for up to twelve hours. In another case, Bangkok police refused to help a man who had collapsed on the pavement, fearing he might have the virus. Hospitals are running out of morgue space. Crematoria are being overworked, in one case, to the point of failure. Meanwhile, the municipal government was decorating the streets with flowers and lights for the birthdays of King Vajiralongkorn and his mother, Sirikit.
How has Thailand descended to this? Its health system was regarded as one of the world’s best. In 2019, it was ranked sixth for its pandemic preparedness of 195 countries, and just four months ago, was rated the fourth best of 116 countries in its management of the pandemic.
There were signs unelected prime minister Prayuth Chan-ocha’s administration might fail to deliver an effective vaccination program. In 2016, when 2014-coup leader Prayuth headed a self-appointed government, the Food and Drug Administration destroyed stocks of substandard animal rabies vaccines. Their use coincided with an increase in animal rabies cases in 2016 and 2017 of 87 per cent and 156 per cent, respectively, above 2015 numbers. In 2018, the government refused to recognise the rabies outbreak as a “disaster”, and so did not dip into its national vaccine stockpile, likely contributing to the 17 human deaths that year.
In January-March 2021, Thailand’s reported COVID-19 infection rate was averaging 244 per day, and moving in a positive direction. On April 1, the government reported only 26 new COVID-19 infections, not bad for a country whose population is 2.7 times the size of Australia’s. The government imposed social distancing controls in the most affected provinces, and banned unapproved meetings and activities likely to draw crowds – individual provinces took additional, temporary, measures in response to localised outbreaks.
To monitor and help limit transmission, it required people in designated provinces use a contact tracing App. To discourage uncontrolled movement by its many illegal foreign workers, it introduced an amnesty. It encouraged mask use – though a sizeable minority in some Bangkok areas had become complacent by March 2021.
New COVID strains change everything
These measures worked until there was a surge in case numbers from April 4 onwards, centred on an outbreak of the Alpha variant in Bangkok’s Thong Lor entertainment district. At the same time, Cambodia reported that COVID’s highly transmissible Delta variant had been detected in some of its nationals returning from Thailand. Their effect immediately became apparent (see Graph 1). By July 19, the Alpha and Delta variants accounted for 34 and 63 percent, respectively, of COVID infections.
Graph 1: Daily reported COVID-19 cases in Thailand
Sources: Daily media reporting of Public Health Ministry figures.
Prime Minister Prayuth’s decision not to restrict travel over mid-April’s Thai New Year holidays to stimulate tourism and the economy didn’t help. Even as numbers surged, ministers refused to impose a nationwide lockdown, confident the situation would soon be under control. They didn’t heed a leading scientist’s warning against any travel, lest infections skyrocket. This was the point the government lost control.
On April 14, after daily infections topped the one thousand mark, Prayuth ordered tighter controls, including targeted lockdowns. But it was too late. With less than one percent of Thais having received a vaccination, and in the absence of stricter lockdowns, there was little to stop the highly infectious variants spreading. Government plans to start mass vaccinations in June weren’t about to change this. Only the rich could afford to travel overseas to beat the queue.
Underestimating the threat
The seriousness of Thailand’s COVID crisis likely lies in three early government decisions:
- Its decision to contract with Siam Bioscience — a company owned by King Vajiralongkorn with no experience in making vaccines — to make the AstraZeneca vaccine under licence probably delayed the supply of vaccines in the large numbers needed.
- It greatly underestimated the number of doses needed, and failed to learn from other countries’ experiences when faced with the Alpha and Delta variants.
- It chose as its sole alternative vaccine, Sinovac, produced by a Chinese company that is 15 percent-owned by one of Thailand’s richest men, but which proved to be less effective against the Delta variant than either European or US vaccines.
Initially, the government had little sense of urgency. In a leaked letter to Health Minister Anutin Charnvirakul, AstraZeneca confirmed the government initially committed to buying 26 million doses at a rate of three million doses per month. The government planned for — but only contracted in May — for another 35 million doses. As it waited for Siam Bioscience to tool up for production and to commence delivery in June, the government bought the first 2 million of an eventual 14.5 million Sinovac shots. Minister Anutin said that, as Thailand’s situation was not as bad as that in other countries, the 63 million doses would be enough. Apparently, he did not see a need to increase the scope or speed of vaccinations in anticipation of the Alpha and Delta variants, even as they were spreading quickly overseas.
Locals receive vaccinations against COVID-19 at Phang Nga Hospital, Phang Nga Province, Thailand - July 21, 2021. Image credit: wandee007, Shutterstock.
As COVID cases began to soar in April, it dawned on some in government that its vaccination program was inadequate. Health Minister Anutin wasn’t one. He opposed buying more vaccines, saying other manufacturers’ minimum order requirements were an issue, as Thailand didn’t “need that many”. He added, “we won’t buy in large numbers — we will only buy as many as we can administer — to keep the inventory at a minimum.” As the government dithered, a university under the patronage of the king’s sister, Chulabhorn, stepped up, eventually importing three million of a total planned purchase of nine million doses of another Chinese vaccine, Sinopharm.
Government complacency was finally shaken in May, as daily case numbers topped 1,000. Prayuth announced a massive new vaccine goal: 150 million doses – enough to fully vaccinate everyone in Thailand, and then some. But it was too late. Relying on AstraZeneca and Sinovac, the government hadn’t sought approval for other vaccines as a precaution. In any case, the vaccine producers weren’t able to deliver doses quickly. Moderna, for example, could only supply vaccines by the first quarter of 2022. And with concerns emerging over the level of Sinovac’s effectiveness against the Delta variant, Thailand needed other vaccines urgently.
The government did little to help private hospitals buy vaccines from Western sources. These companies only sell to governments, to protect themselves from any civil damages claims, given their vaccines are new and for emergency use only. However, the Government Pharmaceutical Organisation would only act as a government intermediary if the hospitals paid it up front.
Health Minister Anutin did not appear to be in control. Belatedly acknowledging vaccine shortages, on June 10, he told Thais the government had signed a contract with Pfizer for 20 million doses. But Cabinet only authorised contract negotiations to commence on July 6; and the contract was signed on July 20, for delivery in the last three months of 2021. Anutin left it to a senior official to tell Thais on July 21 what was now blindingly obvious: that Thailand’s vaccine supplies were inadequate to cope with the deepening crisis caused by the Delta variant.
Desperate, Thailand is reaching out for help from other countries. Some have followed China in donating vaccines. In June, Japan gave 1.05 million doses of AstraZeneca. And in July, the United States offered 1.5 million Pfizer doses. The government has also asked Australia, South Korea, and Switzerland to provide vaccines through swap arrangements. It says it now will join the United Nations-backed COVAX program, through which it should get some vaccines next year. But the bottom line is Thailand is most unlikely to get enough additional vaccines it needs over the next few months to stop thousands more from dying.
Overworked and overloaded
To try to accommodate the growing number of COVID patients, authorities have converted some hotels into “hospitels” for those with mild symptoms; military and civilian authorities have set up field hospitals; and “community isolation facilities” for patients with less-severe symptoms waiting for hospital beds. On July 12, the government reversed its earlier policy requiring all COVID-19 patients be hospitalised, saying those with no or only mild symptoms who could not isolate at a community facility should do so at home.
But it’s not enough. Hospitals in Bangkok and in the provinces say they are at or near capacity. On July 27, the head of Bangkok’s medical services announced that all public ICU beds in the capital were occupied. One hospital told its doctors to withhold intubation from elderly COVID-19 patients with serious diseases. Others are treating patients in hospital car parks, or have closed temporarily, due to personnel contracting the virus. And a senior health ministry official reports a shortage of oxygen for COVID patients.
The media is reporting people waiting for an ICU bed dying at home. With more than 4,000 Thais in a serious or critical condition, hospitals at or near capacity, and infection rates rising, deaths (Graph 2) will remain high for some time.
Graph 2: Daily deaths attributed to COVID-19
Sources: Daily media reporting of Public Health Ministry figures.
Craig Keating is a former senior analyst with Australia’s Office of National Assessments (ONA). Prior to joining ONA, he held numerous positions with the Australian Agency for International Development (AusAID).
Banner image: Emergency workers transport the deceased into COVID-only crematorium, Bangkok, Thailand - July 17, 2021. Credit: Ekachai prasertkaew, Shutterstock.