Jakarta, Indonesia – Timor-Leste, formerly known as East Timor, has a creaky health system and is one of the poorest countries in Asia, but even as neighboring Indonesia struggles with one of the worst outbreaks in the region, it has managed to keep the virus going .

The country had reported only 44 COVID-19 infections with zero deaths on Monday, making it the second-smallest outbreak in Southeast Asia after Laos, according to Johns Hopkins University.

Experts recognize the government’s swift action, the introduction of strict border controls and the expansion of testing and health facilities within weeks, and their willingness to work with experts to ensure the relative success of their response.

Michael Ryan, executive director of the World Health Organization’s (WHO) health emergencies program, said on December 5 that Timor-Leste has “relied heavily on the support of the United Nations and non-governmental organizations.

“It is very encouraging that countries with very fragile infrastructures that are still emerging as nations and still need a lot of outside support can show that they can gain reasonable control over a devastating disease like COVID,” he said.

In reality, Timor-Leste, with a population of more than 1.2 million, had no choice but to act decisively.

Women wear protective masks when walking down a street in Dili, the capital of Timor-Leste, in April [File: Lirio da Fonseca/Reuters]Experts say its weak health infrastructure and economy is grappling with a sudden surge in infections.

According to the World Bank, Timor-Leste had a per capita income of $ 1,560.51 in 2019, and although it has kept the virus in check, its economy is expected to still shrink 6.8 percent in 2020 – the worst of the decline since its independence. In addition to COVID-19, the country is also facing a political crisis earlier this year.

Feeling of emergency

Timor-Leste was a Portuguese colony for centuries before Indonesia invaded the area in 1975. Hundreds of thousands of people died during more than two decades of brutal rule.

The country finally gained formal independence in 2002 after more than three-quarters of voters voted to leave Indonesia in a United Nations-administered referendum.

Mariano Ferreira has been working as a researcher for the Dili-based NGO La’o Hamutuk for around 12 years, overseeing the activities of government agencies in the country.

He says the government’s immediate action in imposing a state of emergency a week after the Catholic-majority nation reported its first case on March 21 was crucial to fighting the pandemic.

Timor-Leste celebrated independence in May 2002 [File: Dita Alangkara/AP Photo]“All public and private activities and government services have been closed, even masses are not allowed. We felt that it was really an emergency and everyone was returning to their hometowns [from Dili] and stayed there, ”he said to Al Jazeera, adding that schools were also closed.

The state of emergency has been extended to January 2 and the borders remain closed to most foreigners except residents. International flights are suspended except for government and humanitarian purposes. Those entering the country will be quarantined for 14 days in state-administered facilities.

Strict border control

The community of Cova Lima borders Indonesia, which has reported the highest number of infections in Southeast Asia with more than 719,000 cases.

Traditionally, the border is fairly fluid and many Timorese have close ties with Indonesia. They cross the border informally to see relatives and enjoy family gatherings.

The pandemic has forced change as borders have been closed and quarantines have been imposed.

“In Cova Lima, the groceries sometimes come once a week. But [only] the goods that come in, not the people, ”said Domingos Gavrila Amaral, head of the Cova Lima office of the Timor-Leste Red Cross (CVTL).

Communities also played a role.

People have made their homes available to the government to quarantine thousands of people and keep an eye out for those entering the country by land from Indonesia. The border opens once a week to citizens who want to return home, but those who go straight to their homes without being tested and quarantined will be reported.

The students arrived at Nicolau Lobato International Airport in Dili last month. They were brought home on a repatriation flight because they were concerned about the coronavirus outbreak [Antonio Dasiparu/EPA]”The government has also tightened controls in border areas to anticipate the transmission of COVID-19 from Indonesia,” said Anacleto Bento Ferreira, general secretary of CVTL.

The WHO office in Dili says the country’s strict border controls and quarantines have given the nation “valuable time to strengthen its health system.”

The months since the pandemic began has changed some health services.

Initially, it had no testing capacity – samples were sent to neighboring Australia and the results were only received about two to four business days later. There were no isolation or quarantine facilities and limited monitoring options.

Now it is able to conduct tests in the country, has developed a testing strategy and implemented active monitoring.

‘Limited test capacity’

According to the Ministry of Health, Timor-Leste ran more than 16,400 coronavirus tests on Monday – far fewer than neighboring countries like Singapore, despite the fact that the city-state has a larger population and is more affluent.

And while there is likely to be insufficient coverage, the situation on the ground suggests that not a large amount of infection goes undetected.

Augustine Asante, a lecturer at the University of New South Wales (UNSW) School of Population Health, says it is “very difficult to rule out underreporting” in a country with “limited testing capacity” like Timor-. Leste.

“I’m not concerned about this at this point because the health system has not seen any increase in patient numbers by any means, nor have we seen any abnormal increases in deaths,” said Asante, who has been researching the country since 2009.

“There is nothing to suggest that COVID is wreaking havoc in Timor-Leste or covering it up.”

Experts who work closely with the Ministry of Health agree.

Jeremy Beckett, director of the Dili-based NGO Maluk Timor, which works to improve the quality of private health services in the country, is “absolutely confident” that the number of positive cases will be reported accurately and transparently.

“So the tests went on uninterrupted and didn’t slow down at all. The national health laboratory is still processing a large number of tests, ”he added.

Other health challenges

Despite the improvements in health care in Timor-Leste, the country has had minimal capacity to handle intensive care.

“There are a limited number of intensive care units across the country. More importantly, clinical expertise in treating critically ill patients with ventilators is limited, ”said the WHO office in Dili.

Asante, who is also UNSW’s health economist and health systems expert, says the country is already under 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 smoking rates and poor health care, all of which are making government efforts to control tuberculosis under control and overall health outcomes difficult,” he told Al Jazeera.

“But perhaps the biggest challenge is widespread poverty. In 2014, nearly 42 percent of the population lived below the national poverty line. If the COVID situation worsens, poverty would most likely worsen,” he added.

Timor Leste’s health system is fragile and the country faces a wide variety of challenges from dengue to TB [File: Romeo Gacad/AFP]Beckett from Maluk Timor states that 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 huge impact of this nature,” he told Al Jazeera. “I think it reveals the areas that are not fully developed.”

A legacy of the pandemic could still be a better health system for Timor-Leste, but even as COVID-19 vaccines finally roll out elsewhere in the world, WHO says the approach of smaller states is drawing lessons for others.

“Really early robust measures” helped such countries deal with the virus, said Maria Van Kerkhove, WHO technical director for COVID-19, noting that these measures “have successfully prevented these first cases from really occurring and taking off “.