Has Cambodia been given enough credit for its Covid-19 response?

While Cambodia is among the world's least impacted nations health-wise by the pandemic, common perception is that this is more by luck than design. But new data, along with epidemiologist Michael Kinzer, suggest there's more behind this success than meets the eye

January 27, 2021
Has Cambodia been given enough credit for its Covid-19 response?
A staff member wears a facemask at a shop in Phnom Penh, Cambodia, in December. Photo: EPA-EFE/Kith Serey

This article was written with information provided to the Globe by data specialist David Benaim. A full breakdown of his research studying Covid-19 in Cambodia over recent months can be found here.

Eyebrows were raised when back in May it was announced that the Khmer Writers Association would be chronicling Cambodian premier Hun Sen’s Covid-19 response in a new book enthusiastically titled Hun Sen: The Handsome Hero Who Went Against the Current to Fight COVID-19

While Cambodia has remained one of the world’s least impacted countries from a public health perspective, the narrative surrounding the Kingdom’s pandemic response has centred on notions of luck and deception, as opposed to skill and good judgement. 

But a year to the day since Cambodia recorded its first Covid-19 case, data compiled for the Globe by Phnom Penh-based data and Excel specialist David Benaim paints a picture of Cambodia that, at least in terms of facts and figures, has proved remarkably resilient to the worst health effects of the pandemic. The Kingdom has recorded the fourth lowest cases per capita globally, and of countries with more than 20 cases is the largest population-wise to report no fatalities. 

But just as data alone doesn’t tell the full story, simplistic narratives of officials relying on chance to ward off the virus don’t either – at least according to medical epidemiologist Dr Michael Kinzer.  

“Luck is always involved in emergency management, but you need to be in a position where you can take advantage of the luck otherwise it’s wasted,” he said. “I think there are very good reasons why Cambodia has been so successful in addition to luck. There’s technical reasons, political reasons, and probably environmental reasons as well.” 

Kinzer is an officer with the US public health service posted to the Centers for Disease Control’s Cambodia country office, where he serves as the global health security programme director. 

He told the Globe that an early response centred around the Institut Pasteur du Cambodge – a research institute that’s part of the International Network of Pasteur Institutes, but under the patronage of the Cambodian government – set the groundwork for an early and effective fight against the virus.  

“Back in January, the Ministry of Health designated the Pasteur Institute as the only laboratory allowed to test, and not only did that guarantee timely and reliable results, it also, because of Pasteur’s international position, made it much more likely that the results would be transparent,” he said. “And so, unlike almost any other country on earth, starting in January we had next day results on whether or not somebody had Covid.” 

People queue for Covid-19 tests at the Olympic Stadium in Phnom Penh, Cambodia in December. Photo: EPA-EFE/Mak Remissa

Everyone was sceptical of our numbers, just because no other country had had those kinds of numbers. And we were sceptical as well, we’re the ones who are going to get in trouble if they were wrong

On the political side of the response, Kinzer said the government was quick to enact what the World Health Organization calls non-pharmaceutical interventions. 

“Things like movement restrictions, cancelling mass gatherings, cancelling holiday events, targeting high-risk populations for quarantine, or testing, or follow ups in the case of migrant workers or garment workers. All of those had a predictably positive effect on controlling spread.” 

While Cambodia’s contact tracing procedures may not be as sophisticated as the likes of South Korea and Singapore, or even as tenacious as neighbouring Vietnam, Kinzer pointed to the rapid assessment and containment processes adopted by Pasteur and the Ministry of Health. 

He added that while a commonly held suspicion is that undetected cases are rampant across the Kingdom – with Cambodia holding some of the lowest testing rates globally – the outreach work his team had conducted suggested otherwise. 

“Everyone was sceptical of our numbers, just because no other country had had those kinds of numbers. And we were sceptical as well, we’re the ones who are going to get in trouble if they were wrong,” he said. “So we did hotspot surveillance, going into places where we think we would find cases, and we just weren’t finding them. At one point we tested five high-rise buildings in Phnom Penh that were linked to a cluster. We ended up testing about 900 people and none of them were positive.”

According to Benaim’s data, who over recent months has scrubbed government and local news sources to collate otherwise scattered Covid information, while Cambodia has had only 23 tests per thousand (36th lowest globally), only 1.2 tests per every thousand have returned a positive result – the fourth lowest of countries with more than 20 cases. 

Cambodia’s first mini-spike came in March and April as 22 local infections were detected, prompting the government to change its tack, closing schools and other venues for a period of almost six months. Although there has not been a full lockdown to date – as shops, markets, cafes and restaurants have remained open – members of the public have mostly been diligent about wearing masks and maintaining social distancing, especially in the early stages of the pandemic.

The Cambodian government also shut national borders early on, placing strict entry requirements on those entering the country. Tourist visas and visas on arrival were halted in March, while from June incoming passengers were made to have monitored quarantine for two days, self quarantine for a further 12 days and have three Covid-19 tests before, during and after quarantine. 

“Credit needs to be given to the government and their partners for moving quickly and appropriately,” Kinzer said. 

Viruses don’t like heat, they don’t like UV light, they don’t like ventilation, and Cambodia has plenty of all that

But beyond the control of epidemiologists and government officials are the environmental factors that have worked in Cambodia’s favour in keeping the virus at bay. 

“Viruses don’t like heat, they don’t like UV light, they don’t like ventilation, and Cambodia has plenty of all that,” Kinzer said. He added, however, that a tropical climate hasn’t protected the likes of Indonesia and Myanmar from handling spiralling caseloads. 

Speculating at a more comprehensive explanation, he turned to cultural factors, with Kinzer adding that the World Health Organization’s ‘Three Cs’ – crowded places, close-contact settings, and confined and enclosed spaces – were all in short supply in the Kingdom. 

“Cambodia doesn’t really have public transport, doesn’t have situations where people are jammed together for a long time. People travel around in open, ventilated transport, they frequently live in houses that are on stilts and open to the air, there isn’t a culture of spending long periods of time in air-conditioned malls.” 

Passenger wave as they leave the MS Westerdam cruise ship at a seaport in Preah Sihanouk province, Cambodia on 14 February. Photo: EPA-EFE/Mak Remissa

Cambodia detected its first case one year ago in the Chinese-backed boom-city Sihanoukville, when a 60-year-old man arrived on a direct flight from the pandemic’s then-epicentre in Wuhan. 

No further cases were detected for six weeks, and Prime Minister Hun Sen initially displayed an arguably reckless skepticism about the seriousness of the virus, even becoming the first world leader to visit China at the emergence of the pandemic in February. He gambled again in February, welcoming the Westerdam cruise ship to Sihanoukville after the vessel had been turned away from five ports over fears there were infected passengers onboard. 

Most recently, in November, the visit of the Hungarian foreign minister – who was not subject to quarantining or testing, and later tested positive – as well as what became known as the ‘November 28 incident’ – in which the wife of a senior prison official visited Aeon Mall while infected – became allegories for the double standards applied to the rich and powerful in Cambodia.

But notwithstanding these missteps, a year on, the Ministry of Health, in partnership with the Institut Pasteur, has detected a total of only 460 reported cases as of writing. Of these, only 67 (or 14%) came from in-country transmission, according to Benaim’s data. 

Cambodia also remains the fourth lowest country globally in cases per capita, with only 27 cases per million inhabitants. Also among the most resilient countries globally when it comes to deaths, Cambodia is by far the largest state, population-wise, to report no fatalities from the virus to date, reports Benaim. Second and third are Laos and Timor Leste. 

It’s on this second point, the lack of fatalities, or even publicly-reported life-threatening cases, that Kinzer can only speculate as to potential reasons, saying he doesn’t “think anything should be ruled out”.

“It’s true that we did have a large dengue outbreak last year, and a lot of the population was exposed, if not infected. It’s also true that we have coronaviruses circulating in Cambodia that are not found in many other countries,” he said.

“But I haven’t seen any evidence yet of how exposure or infection by either of those, or any other pathogen, would protect against Covid-19. We’re not ruling it out, we just don’t have evidence.”

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