AsianScientist (Apr. 3, 2020) – By Dr. Jeremy Lim – In 2003, the Severe Acute Respiratory Syndrome (SARS) hit Singapore badly with 228 cases and 33 deaths. While Singapore bounced back, the experience was viscerally seared into the individual and collective consciousness.
The National Centre for Infectious Diseases, designed to handle future outbreaks, was built to add more than 300 beds to the national surge capacity. In addition, doctors were sent to the World Health Organization (WHO) and the US Centers for Disease Control and Prevention’s Epidemic Intelligence Service to build up human expertise.
National exercises such as Exercise Sparrowhawk, which involved over a thousand healthcare professionals, were also conducted to heighten awareness and test preparedness.
So we were not caught off-guard when the next epidemic came around. In fact, Singapore was one of the first countries outside China to be affected by the SARS-CoV-2 novel coronavirus, with our first case of the coronavirus-19 disease (COVID-19) reported on January 23, 2020.
Singapore is experiencing a ‘second wave’ of imported cases as thousands of Singaporeans based overseas for work or studies have hurriedly returned home, with many found to carry the coronavirus. Of the 52 new cases diagnosed on March 26, 28 were imported (29 of them were citizens and long-term residents). Of the remaining 24 local cases, ten were linked to existing clusters and 14 were unlinked, which gives concern of some degree of unchecked community transmission.
This is after the ‘first wave,’ largely due to cases imported from Wuhan city in China’s Hubei province, was successfully mitigated. What helped Singapore? There are many interlocking reasons, which I will attempt to distill into three key factors.
Early and effective government-led, multi-agency response
Singapore established a multi-agency task force chaired by two ministers (health and national development) with representation across the entire public service including ministers in charge of trade, manpower, education and communication, even before the first case was reported in Singapore.
The mechanics of Singapore’s meticulous approach to contact tracing are well documented by media outlets including the New York Times and BBC News. The impressive statistic of 40 percent of COVID-19 infections detected through contact tracing while still asymptomatic is testament to the speed and thoroughness of those at the helm.
But effective containment measures go much beyond identifying contacts and tracking them down. With its previous experience of SARS, Singapore had contingency plans to use government-owned holiday chalets which were quickly activated, and when these proved insufficient, university hostels were quickly emptied to free up capacity.
People also need to be motivated, or at least not disincentivized, to come forth if testing is warranted. The Singapore government did well to announce early on that all medical expenses related to testing and treatment would be covered, and that S$100 per day would be provided to compensate for any loss of income while quarantined.
Balancing carrots and sticks, Singapore announced heavy penalties for defying quarantine and isolation orders. In a widely publicized case, it took away permanent residency status from a resident who had breached a ‘stay-home notice’ and permanently barred him from re-entry.
Finally, Singapore’s national Biomedical Sciences Initiative, which started over two decades ago with the ambition to make Singapore a hub for scientific research and discovery, has paid off handsomely so far in the COVID-19 outbreak. Expertise was quickly brought together and organized early on, leading to early development of diagnostic kits, serological tests and the ability to trial novel drugs for therapy.
Science is difficult and involves a high degree of uncertainty, with even experts openly disagreeing on the appropriate measures to be taken to address the pandemic. Lay persons cannot possibly understand fully the complexities and trade-offs involved, and consequently have to trust that their leaders are placing their interests above all.
Likewise, politicians need to trust that medical and public health experts are providing unbiased advice with no hidden agendas, and everyone needs to trust each other to be socially responsible in making travel declarations, reporting their symptom and distancing themselves when unwell.
Thankfully, Singapore has managed to maintain reasonable levels of trust in political leaders and the bureaucracy over the years and has not openly disdained experts. An interesting Harvard survey showed as of March 21, 2020 most Singapore residents (a caveat that only 16 people were sampled) had confidence in the ‘authorities,’ while over 80 percent of US residents (n=3,286) reported little or no confidence when asked “How do you rank the ability of the authorities in your country to control the epidemic?”
Clear and consistent over-communication
It was decided very early on that clear and consistent information was essential and that Singapore had to prevail over what the WHO describes as the ‘infodemic.’ Fake news, wild speculation and reporting errors are the realities of modern communication.
Singapore Minister Lawrence Wong, co-chair of the Multi-Ministry Task Force, now runs daily press conferences, explaining patiently and in simple (but not simplistic) terms the situation and why certain government actions were decided upon.
The Gov.sg WhatsApp account, which hundreds of thousands of Singapore residents have subscribed to, puts out at least two to three daily reminders about public health measures as well as case counts. It is also used to debunk misinformation and allay concerns. The Ministry of Health also works with physicians in closed Telegram chat groups to obtain feedback and explain in more technical and candid terms the rationale behind certain policies.
In surgery, there is a saying, “The operation was a success, but the patient died.”
Singapore needs to adroitly manage the pandemic, but it also needs to keep its economy alive. People are harmed not just by the virus but also from job losses, an inability to afford healthcare and the effects of social isolation.
It is still early days in the COVID-19 pandemic and for Singapore, only the end of the beginning. There will be many more cases, hopefully not too many local, unlinked transmissions, and certainly as low a fatality number as possible.
The real test of national resolve and readiness is coming, and I am worried but cautiously optimistic. An infectious diseases physician at the forefront of caring for the COVID-19 patients shared with me, “It is like seeing the tsunami rising before one’s eyes, and hoping the surfboard will hold.”
God bless Singapore, and the world.
Jeremy Lim, MD, MPH is co-director of the global health programme at the National University of Singapore’s Saw Swee Hock School of Public Health. He also is co-founder of AMILI, a gut microbiome startup.
Copyright: Asian Scientist Magazine; Illustration: Shelly Liew/Asian Scientist Magazine.
Disclaimer: This article does not necessarily reflect the views of AsianScientist or its staff.