SitRep: Laos and Cambodia

Both Cambodia and Laos report unusually low numbers of positive cases and deaths. With Cambodia reporting 122 cases and zero deaths, and Laos reporting only 19 cases and zero deaths, these two states raise a variety of questions about the spread and detection of COVID-19 in developing countries with limited medical capacity, young populations, and authoritarian governments. Both are high-tourism countries facing a pandemic with significant timelags in noticing cases and an estimated three-quarters of imported cases typically go undetected. 

As in most places, the outbreak is likely significantly larger in both countries than the reported numbers. Here, however, it’s difficult to disentangle whether the low numbers reflect the limits of their existing public health surveillance capacity versus authoritarian information controls producing a deliberate undercount. We are generally more concerned with Cambodia right now than Laos right now. So are their neighbors, which closed their borders once China detected a Cambodian import on March 19th. We have found at least six cases imported from Cambodia(five in China [four in March, one yesterday], one in Macau). The first sign of widespread community outbreak in the Philippines was Taiwan and then Singapore finding new cases with travel history there.

Cambodia Timeline: Green represents exported cases, blue represents local cases, orange represents border closures, and red represents government actions.

The uncertainty of the situation in these countries is compounded by uncertainty over the extent (and timing) of the Thai COVID19 outbreak. In addition to Western tourists traveling between the countries, tens of thousands of Lao migrant workers returned to Laos from Thailand in March. Bangkok reported that its bus station saw 84,000 passengers traveling to Laos, Cambodia, and Myanmar the weekend of March 21-22 when Thailand had 781 cases – the highest in the region. The extent of the outbreak depends on currently unknown variables like how many imports they had and when.

Cases

As of April 14, 2020, Cambodia had reported 122 confirmed cases, 77 recoveries, and zero deaths. Laos reports 19 confirmed cases as of April 12, 2020. Cambodia’s first case, a 60-year-old male Chinese national who arrived from Wuhan, was reported on January 27, 2020. The next case was not reported until March 7, 2020, a 38-year-old male Cambodian national who reportedly received the virus via his Japanese employer. It was not until March 25, 2020, that Cambodia reported its first case of a community infection (i.e., no travel history or contact with a known imported case). The authorities are currently on a “manhunt” to trace and test contacts of positive cases, but are met with resistance from individuals who are not forthcoming about their contacts and activities. Combined with a general population who may not be taking the virus threat and public health concerns seriously, the situation is described as “nightmarish.” 

Laos reported its first two cases on March 24, 2020, and 11 out of the remaining 17 cases can be traced to these first two, over five generations of spread. Case 1 is a 26-year-old male hotel worker in Vientiane, and Case 2 is a 36-year-old female tour guide in Vientiane, both of whom had travel history and contact with foreigner travelers. Another case cluster stems from a flight from Bangkok to Vientiane and the Lao authorities attempted to contact and test all 70 passengers. Case 11 is a foreign national from Papua New Guinea who works for a Lao mining company, and the authorities tested many of the employees of the mining company.

Both countries were heavily traveled before their borders closed. Xinhua reports that Laos is expected to report 1 million Chinese tourists out of 4.1 million total in 2019, and Cambodia 2 million Chinese tourists out of 6.2 million total tourists in 2019. More troubling is that it’s unclear if the new infections are from the First Wave that originated in Wuhan finally being detected or a Second Wave of American, European, and British tourists starting roughly in early March. Bordering both countries is Vietnam, where European tourists sharing a hotel with USS Roosevelt crew were likely the source of the aircraft carrier’s outbreak last month.

Healthcare Systems

The Cambodian Ministry of Health designated three hospitals in Phnom Penh for COVID-19 response and 25 provincial referral hospitals for ordering tests and treating suspected cases. After consultation with the WHO and the U.S. CDC, Cambodia assigned the Institute Pasteur of Cambodia (IPC) as the only lab for COVID-19 testing. The IPC is conducting 300-500 tests per day and as of April 6, 2020, has tested over 5,700 people using rapid test kits. With a population of 15.58 million people, this is a testing rate of 366 tests per million. 

In Laos, Mittaphab Hospital (Hospital 150) in the capital of Vientiane is the designated center for virus testing and treatment. That facility is currently treating and isolating 16 of the 19 reported cases, only one of which (Case 16) is in “serious condition.” The remaining three cases are being treated in the provincial hospital in Luang Prabang. According to reports on hospital upgrades in 2019, Mittaphab Hospital contains approximately 600 hospital beds, with 30 wards, over 500 medical personnel, and 100 doctors. As of April 10, 2020, Lao authorities had tested 1,140 individuals, at a rate of 153 tests per million. 

Cambodia is ranked 89 out of 195 countries for infectious disease preparedness in the 2019 Global Health Index report and lacks adequate health facilities and capacity to deal with the outbreak, regardless of extent. Laos ranked 73/195 on the 2019 Global Health Index. While Lao public health capacity is minimal, but the authorities have participated in ASEAN collaborations, and on February 14, 2020, the U.S. CDC sent six specialists who provided training, exercises, and simulations on virus detection and control. Laos has accepted medical equipment and supplies from China, Vietnam, and the U.S.

Mitigation Policies

On Thursday, April 9, 2020, restrictions on travel into and out of Phnom Penh went into effect for a one-week duration. Through this lockdown policy, PM Hun Sen also canceled the annual week-long Khmer New Year, a holiday which traditionally involves nationwide travel. In addition to these measures, school, museums, and entertainment venues—cinemas, karaoke establishments, and bars—are closed, and religious gatherings are prohibited.

Laos entered into what the media has called a “full lockdown” on March 30th. It expected to last until April 19, 2020, “or until further notice.” Prime Minister Thongloun Sisoulith’s nine-point plan generally forbids: leaving home except for essential matters; traveling among provinces within Laos; hoarding goods or selling at a mark-up; spreading false or misleading news; gatherings of more than 10 people; international travel except for foreigners returning home; entertainment businesses from operating; non-essential businesses from operating. 

Cambodia suspended U.S., Italy, Germany, Spain, and France travelers on March 14, followed by a suspension of all visa-free entry, e-visas, and visas-on-arrival, effective March 31, 2020 and lasting for one month. For other urgent travel, foreigners may apply for a visa in advance and present a medical certificate and proof of medical insurance with minimum U.S. $50,000 coverage. 

In Laos, entry-exit controls went into effect on April 3 when they closed their international border gates. These gates had remained opened while smaller “traditional” checkpoints were ordered closed on March 13 due to lack of temperature scanners. On March 19, Laos suspended visas on arrivals, tourist visa issuance at overseas diplomatic missions, e-visas, and visa exemption programs. Non-tourist visa issuance was restricted.

Beginning March 17, Laos implemented detailed policies on required 14-day self-quarantine for certain arrivals: those entering Laos without symptoms from a country with more than 100 confirmed COVID-19 cases; those entering Laos from a bordering country and bordering province with more than three positive cases; and those entering Laos from a bordering country but not a bordering province with more than ten positive cases. For those entering Laos with symptoms, they are required to go to Vientiane for testing and treatment.

Local reporting in Laos suggests that citizens and business owners are not taking the decree seriously. A headline in the Vientiane Times states that karaoke and massage parlors are still open and that they “don’t care about preventing COVID-19.” Prior to the March 30 decree, the government had issued a non-binding public notice for citizens and businesses on March 12. The notice urged the public to suspend “unnecessary social events” including weddings and the celebration of the Lao New Year on April 13-15. Businesses were advised to respect this by not hosting such large events and limiting the duration of events on their premises. In Luang Prabang, specifically, the local authorities cancelled public festivals and events on March 9, to the dismay of local businesses. On March 9, preschools and kindergartens were ordered closed, and parents called for all schools to close. 

Economic Stimulus

Prior to the European and U.S. economic slowdowns due to the virus spread in those regions, economic forecasts for Cambodia estimated losses of $300-700 million, indicating that the current outlook is much worse.

On March 10, 2020, the Cambodian authorities set aside between $800 million – $2 billion for economic stimulus, which accounts for 25% of the planned 2020 budget. However, these funds lack a clear plan for their use, and primarily comprise tax breaks, and delayed and suspended tax payments in anticipation of Cambodia’s partial removal from the EU preferential trade scheme in early 2020. Union leaders have called for the government to urge banks and microfinance institutions to delay loan repayments, and the National Bank of Cambodia already eased restrictions on borrowing.

The textile and garment industry make up about 11% of Cambodia’s GDP, and it is this industry’s situation that the government more immediately responded to. In the first plan, announced on March 31, 2020, PM Hun Sen cited 50 factories that suspended production because of lack of raw materials, and 7 factories that suspended due to lack of orders. He offered these suspended workers a guarantee of 60% of their minimum wage; 40% would come from the factory and 20% from the government. Cambodia’s minimum wage for textile workers was increased to $190 per month in 2020, meaning workers would receive $114/month: $76 from the factory and $38 from the government. 

After employers objected on the grounds that they could not pay 40% of the minimum wage, the government introduced a new plan guaranteeing workers only $70 per month, of which the factory would pay $30 and the government $40. The government’s contribution barely changed under the second plan, meaning that the workers are the only ones who lose out, receiving less than 37% of the minimum wage. The President of the National Trade Unions Coalition, Far Saly, urged workers to accept this amount without complaint.

On April 10, this $40 monthly guarantee was extended to workers in Cambodia’s tourism industry for a two-month period. This low amount, and the fact that workers send much of their pay to their families across Cambodia, may have a widespread, negative effect on citizens’ ability to purchase necessities.

On April 5, 2020, PM Hun Sen announced that rice exports would be halted as a food protection measure. Rice exports are a substantial percentage of Cambodia’s GDP, causing concern that in addition to economic loss, Cambodia will lose credibility with trade partners and other countries in the region may follow this example, leading to global supply chain disruption. Vietnam has already limited its rice exports.

Prior to any cases reported in Laos, it was projected that the economy would grow by 6.1% in 2020. This was based on perceived benefit to Laos as its neighbors are hit harder by the virus, and accounted for “negative spillovers” in tourism, construction, and manufacturing.

The national decree specifies that factories must close unless they produce consumable items, medicine, and medical equipment. This means that garment factories are closed, but some have converted to producing medical equipment. The decree stipulates that factory owners must administer terms of self-isolation of their workers and must provide “social welfare.” 

Politics and Overreach 

Both countries are both rated “not free” on Freedom House’s 2019 Freedom in the World Index, with Laos rated 14/100 and Cambodia 26/100. Information controls in both countries apply to spread of information about COVID-19, so it is difficult to assess the situation not captured by official reports. The information environment in both countries is heavily controlled, and any sign of political dissent is not tolerated. Although the Laos government has been forthcoming regarding the reported cases, alternative viewpoints are not available.

Cambodia and Laos exhibit noticeable differences in their responses to the virus outbreak. While both countries share a historically close relationship with China, Cambodia’s response to the pandemic was outwardly far more politicized than Laos. The Cambodian government has been brash in its display of political support to China and was late to respond with policies that are both sweeping and vague in its policies. In contrast, Laos was quick to respond to the virus outbreak, cooperative and receptive to international aid. It was also clear and specific in its control measures, and has implemented strict contact tracing and testing of all potential carriers regardless of symptoms slow to respond with control measures and lockdown. 

Journalist Sovann Rithy was arrested on April 7, 2020, for posting to Facebook a direct quote from Prime Minister Hun Sun about the country’s virus response, and was charged with “incitement to commit a felony.” Rithy’s media outlet then had its license revoked for broadcasting information “which was to generate an adverse effect on the security, public order and safety of society.” This comes after the Ministry of Information warned against citizens using Facebook to spread misinformation causing fear and damaging the authorities’ reputation, and the Minister of the Interior, Sar Kheng, warning on March 20, 2020, that anyone who spreads misinformation would face legal action.

On Friday, April 10, 2020, the National Assembly passed a state of emergency law, with the bill moving on to the Senate the following week. A state of emergency may be declared for a pandemic, as well as war or disruption of public order. Cambodia’s leadership, however, has failed to specify why the specific provisions of the bill are necessary to combat the pandemic itself, leading speculation that this is an overreach. The draft bill carries a 10-year sentence for violations and is criticized as sweeping and vague, regulating speech and assembly, allowing for increased surveillance and control of media, and the ability to seize property. Other details are unclear, such as how this law will be used to prevent the virus from spreading (full lockdowns, mandatory quarantines, etc.).

Human Rights Watch reports discriminatory conduct against Muslims and foreigners, fueling private citizens using hate speech online, and discriminatory business practices. This state-sponsored narrative violates WHO guidelines on governments’ COVID-19 response, which forbids discriminatory practices and suggests that public information campaigns regarding virus spread can combat this type of discrimination.

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