Jakarta, Indonesia – Timor-Leste, formerly known as East Timor, has a creaky healthcare system and is one of the poorest countries in Asia, but even as neighbouring Indonesia grapples with one of the worst outbreaks in the region, it has managed to keep the virus at bay.
The country had reported only 44 COVID-19 infections with zero fatalities as of Monday, leaving it with the second-smallest outbreak in Southeast Asia after Laos, according to Johns Hopkins University.
Experts credit the government’s swift action, imposing strict border controls and ramping up testing and healthcare facilities within weeks, as well as its willingness to work with experts for the relative success of its response.
Michael Ryan, executive director of the World Health Organization (WHO) Health Emergencies Programme, said on December 5 that Timor-Leste had “relied very heavily on UN and NGO-based support.
“It is very heartening that countries with very fragile infrastructure that are still continuing to emerge as nations, still require a lot of external support can demonstrate that they can get reasonable control upon a devastating disease like COVID,” he said.
In reality, Timor-Leste, with a population of more than 1.2 million, had little choice but to act decisively.
Experts say its weak health infrastructure and economy would have struggled with a sudden spike of infections.
Timor-Leste had a per capita income of $1,560.51 in 2019, according to the World Bank and even though it has kept the virus in check its economy is still expected to contract by 6.8 percent in 2020 – the worst decline since its independence. The country is not only dealing with COVID-19 but also a political crisis earlier this year.
Sense of emergency
Timor-Leste was a Portuguese colony for centuries before Indonesia invaded the territory in 1975. During more than two decades of brutal rule hundreds of thousands of people died.
The country finally secured formal independence in 2002 after more than three-quarters of the electorate voted to leave Indonesia in a UN-administered referendum.
Mariano Ferreira has been working as a researcher at the capital Dili-based NGO, La’o Hamutuk, for some 12 years and monitors the operations of government agencies in the country.
He says the government’s prompt action in imposing a state of emergency a week after the Catholic-majority nation reported its first case on March 21 was crucial in the fight against the pandemic.
“All public and private activities, as well as government services were closed, even masses were not allowed, so we felt it was really an emergency and everyone returned to their hometowns [from Dili] and stayed there,” he told Al Jazeera, adding schools were also shut.
The state of emergency has been extended until January 2 and borders will remain closed to most foreigners except residents, with international flights suspended unless for government and humanitarian purposes. Those entering the country are quarantined for 14 days at government-managed facilities.
Strict border control
The municipality of Cova Lima borders Indonesia, which has reported Southeast Asia’s largest number of infections with more than 719,000 cases.
Traditionally, the border is quite fluid and many Timorese have close links with Indonesia, crossing the border informally to see relatives and enjoy family gatherings.
The pandemic has forced a change as borders have been closed and quarantines imposed.
“In Cova Lima, sometimes the groceries come in once a week. But [only] the goods that come in, not the people,” said Domingos Gavrila Amaral, the head of Timor-Leste Red Cross (CVTL)’s Cova Lima office.
Communities have also played a part.
People have made their homes available to the government to quarantine thousands of people and keep a close eye out for those entering the country by land from Indonesia. The border is opened once a week for citizens wanting to return home but those who go straight to their homes without first being tested and going through the quarantine, are reported.
“The government has also tightened controls in border areas to anticipate the transmission of COVID-19 from Indonesia,” said Anacleto Bento Ferreira, secretary- general of CVTL.
The WHO office in Dili says the country’s strict border controls and quarantines have allowed the nation “precious time to strengthen its health system”.
The months since the start of the pandemic have transformed some health services.
At the beginning it had no testing capacity – samples were sent to neighbouring Australia and the results received only about two to four working days later. It had no isolation or quarantine facilities and limited surveillance capability.
Now it is able to do tests in-country, has devised a testing strategy and implemented active surveillance.
‘Limited testing capacity’
The health ministry says Timor-Leste has carried out more than 16,400 coronavirus tests as of Monday – far fewer than neighbouring countries such as Singapore although the city-state has a larger population and is wealthier.
And while it is likely there is under-reporting, the situation on the ground suggests there is not a huge amount of infection going undetected.
Augustine Asante, a senior lecturer at the University of New South Wales (UNSW)’s School of Population Health, says it would be “very hard to rule out under-reporting” in the country with a “limited testing capacity” like Timor-Leste.
“I am not concerned about that at this stage because from all indications the health system has not witnessed a spike in patient numbers, neither have we seen an abnormal increase in deaths,” said Asante, who has been researching the country since 2009.
“Nothing suggests that COVID is wreaking havoc in Timor-Leste and it’s being covered up.”
Experts who work closely with the health ministry agree.
Jeremy Beckett, director of the Dili-based NGO Maluk Timor, which works to strengthen the quality of private healthcare services in the country, says he is “absolutely confident” that the number of positive cases is being accurately and transparently reported.
“So the testing has continued uninterrupted and hasn’t slowed down at all. The national health laboratory’s still processing high numbers of tests,” he added.
Other health challenges
Despite Timor-Leste’s healthcare improvements, the country still has minimal ability to handle critical care.
“There is a limited number of Intensive Care Units in the entire country. More importantly, there is limited clinical expertise to manage critically ill patients on ventilators,” said the WHO office in Dili.
Asante, who is also a UNSW health economist and health systems expert, says the country already faces significant pressure from one of the highest rates of tuberculosis in the world – about 500 cases per 100,000 people.
“In addition, there is chronic malnutrition, high rate of smoking and poor quality healthcare, all of which complicate the government’s efforts to bring tuberculosis under control and improve health outcomes generally,” he told Al Jazeera.
“But perhaps the biggest challenge is the widespread poverty, nearly 42 percent of the population lived below the national poverty line in 2014. If the COVID situation deteriorates, poverty would most likely worsen,” he added.
Beckett of Maluk Timor notes Timor-Leste’s “health system is still comparatively young”.
“And it takes many, many years to develop a sophisticated and effective health system that can handle a major impact of this kind,” he told Al Jazeera. “I think it exposes the areas that are yet to be fully developed.”
A legacy of the pandemic could yet be a better health system for Timor-Leste but even as COVID-19 vaccines finally begin to be rolled out elsewhere in the world, the WHO says the approach of smaller states holds lessons for others.
“Really early robust action” helped such countries deal with the virus, said Maria Van Kerkhove, the WHO’s COVID-19 technical lead, noting those measures “had success in preventing those initial cases from really seeding and taking off”.