Coronavirus: Fighting a psychological battle

With spread of the virus, the battle has to be on both the medical and psychological fronts. We must shift our mindsets to avoid paranoia and prejudice.

Anxiety is creeping up as the virus which originated in Wuhan spreads around the world, showing no sign as yet of abating.

Singapore is at code orange in its Disease Outbreak Response System Condition, a crisis management system drafted and refined after Singapore's experience of tackling the severe acute respiratory syndrome (Sars) outbreak in 2003.

It was at yellow for days before being raised to orange on Friday evening, after a few local cases emerged without any links to previous cases or travel history to China.

Will it move to red, which would mean the virus is severe and spreading widely?

From what is known publicly, the coronavirus appears to be more infectious than Sars, which hit Singapore in 2003 from March to May, infecting 238 and killing 33.

Sars infected more than 8,000 people worldwide over several months, and killed about 774.

However, the coronavirus appears less deadly, with a mortality rate of about 2 per cent, compared with Sars' 9.6 per cent.

The Middle East respiratory syndrome virus in 2012 infected about 2,500 people worldwide but was deadlier, with a fatality rate of 34 per cent.

With the coronavirus, as of yesterday, more than 34,000 have been infected since December, and more than 700 have died in China.

In Singapore, there are 40 infected persons as of yesterday.

Outside of Hubei province, where Wuhan is located, the mortality rate is only 0.2 per cent so far, while seasonal influenza has a death rate of 0.1 per cent. This makes the new virus much closer to influenza than Sars.

Sars was spread by people after they developed symptoms like fever; 2019-nCoV, as the new virus is officially known, appears to be sneakier, and can spread from an infected person who shows no symptoms.

This makes the coronavirus harder to detect and easier to spread. The odds of it spiralling out of control within the community are thus higher than with Sars.

However, initial reports suggest that it does not make people as sick as Sars did. Some doctors are already predicting that this coronavirus may be more like influenza - many people could get infected with mild sickness; a small proportion (now 15 per cent) will get seriously sick but will recover; and a tiny fraction (now 2 per cent) may die.

In May 2009, the H1N1 outbreak from the United States surged into Singapore. By the time it came under control in February 2010, 415,000 people here had been infected, and 420,000 had been vaccinated.


In the end, 18 people here died of the H1N1 virus, which remains the dominant flu strain globally and in Singapore. It is highly infectious, but people have come to terms with living with it, as it has a low fatality rate of 0.02 per cent.

Will the coronavirus turn out to be a highly infectious non-event? Or a fast-spreading virus that kills a large number in its wake?

So far, several experts have predicted it will be the former.

Meanwhile, China is patenting a drug found to be highly effective in treating the disease. Many labs around the world are also vying to be the first to develop a vaccine.

Singaporeans should educate and update themselves on the virus so that they can make rational, sensible choices for themselves and their families.

In Singapore, it is clear that political leaders are trying to prepare Singaporeans for the long haul. No one can predict for sure how this virus outbreak will pan out. But the experience of Sars gives some pointers.

I am the author of a book on Sars. Titled A Defining Moment: How Singapore Beat Sars, it was published in 2004, and it details Singapore's whole-of-government, whole-of-society approach to battling the virus. (The book is out of print, but can be borrowed from the National Library.)

Drawing from what we went through with Sars, we can better prepare ourselves for the long battle against the coronavirus.

One key takeaway from that experience is that when there is wide community spread, the battle against the virus will be as much about mindsets as it is about medicine.

The psychological aspect came to the fore over the weekend, as many people in Singapore, young and old, stripped supermarket shelves of essentials like noodles, rice and even toilet paper, in a frenzy of stockpiling. This was despite assurances from government leaders and retailers that there are stocks aplenty in warehouses.

SPH Brightcove Video
In the face of the coronavirus outbreak, the Ministry of Health's contact tracing teams work two shifts, seven days a week, to find close contacts of patients. This is how contact tracing is carried out.

Singapore is a small, close-knit society, and prone to the herd mentality and mass behaviour.

Social psychology tells us that in times of anxiety, people tend to conform and follow what others are doing. ("My neighbours are stocking up on food; they know something I don't, so I am going to do the same.")

They also start to worry for themselves and their loved ones. ("Everyone else is stocking up; there won't be any left for me and my family; I am going out to grab my share.")

The best way to stop such thinking is to be rational. ("How many packs of rice do I need? Are rice imports going to stop? Will there be rice stocks next week?")

And then be deliberately pro-social and think of others. ("Do I really need all these alcohol swabs now? What if I buy the last pack of swabs and deprive a sick person who needs it for his daily injection?")

Individual actions have collective impact. We are all in this virus outbreak together, and we stand or fall together.

Right now, most of us still go about our daily lives sans mask, gloves or protective clothing, albeit with more attention to hand washing with soap and water, using hand sanitiser and avoiding touching our faces - infection control tips 101.

But the mood can shift quickly, and we can become a city ruled by fear of strangers and public spaces.

For example, about 30,000 workers from China have yet to return to Singapore from their Chinese New Year leave. There is a risk of infections going up when they return.

As concerns about community spread widen, more people can be expected to take precautions to protect their loved ones and themselves, by donning protective gear or avoiding crowded spaces.

With Sars, once the virus spread, people started fearing being around others, not knowing who might be infected.

They then reacted by shunning those at risk. Many also stayed home, away from shops and eateries, causing businesses to suffer. It took concerted action to shift Singaporeans' mindsets.

The Sars experience reminds us that the battle against the virus is fought on two fronts: medical and psychological.

The medical battle has to do with screening, public hygiene, infection control, diagnosis, treatment of patients, and the race to develop quicker diagnostic tools, better treatment protocols or a vaccine.

The psychological war is about overcoming fear, prejudice and paranoia.

From Sars, we know there are three fronts in the psychological battle.


We must guard against ostracising healthcare workers, who are at the forefront of the fight against the virus.

As the virus spreads widely, more people will be infected and need care. This means healthcare workers will be at greater risk.

During Sars, some Singaporeans reacted by shunning them. This is already happening again. Home Affairs Minister K. Shanmugam noted in a Facebook post on Friday that he had heard anecdotally about cases of abuse directed at healthcare workers.

Nurses have taken to Facebook to share anecdotes of how they were ostracised on the MRT and scolded for wearing their uniforms onto the train as fellow travellers feared they were spreading germs.

This prompted commenters to express support for the nurses, with one post saying: "If you think the nurses and doctors carry lots of germs or if you think that we are dirty, please get your family to nurse you when you are hospitalised."

A young nurse I featured in the Sars book described how, after working hard all day to treat patients at "Sars central" in Tan Tock Seng Hospital (TTSH), she would find herself shunned on the MRT because of her nurse's uniform; neighbours refused to share a lift with her, or shut their windows as she walked past their flats.

She said with a frown: "It made me really angry. Here we were, trying our best to fight for our patients. If we were not there in the Sars wards, who would be there for them?"

Others complained that buses and cabs, and even pizza delivery staff, refused to call at TTSH stops.

The issue was made public by ministers, who urged Singaporeans to change their mindsets.

Within days, people responded. About 500,000 peach ribbons were made and worn by members of the public to support healthcare workers. TTSH received sachets of herbal lozenges for their staff; anonymous donors sent 60 crates of Fuji apples and 1,000 stalks of gerberas. A fund to salute healthcare workers, called The Courage Fund, raised $28.5 million, and fund administrators had to ask the public to stop giving to it.

The change motivated healthcare workers and created a more positive atmosphere nationwide.

This time round, I hope Singaporeans will avoid the shunning and abusive stage and go straight to the stage of appreciating our front-line soldiers in the fight against the virus.

Of those who died during Sars, about 40 per cent were healthcare workers. They put their lives on the line to care for those infected. They are heroes. They deserve our support and appreciation, not our fear and discrimination.

Words, thoughtful acts, practical or heartfelt tokens and social media tributes can all make a difference in rallying our healthcare troops.


The second front in the psychological war is in business.

As the virus spreads and fear rises, the temptation to hunker down and stay home will prove irresistible. But this will affect businesses badly. A shutdown will only harm our own society.

During Sars, Singaporeans went into panic lockdown mode for a few weeks. The mood seemed darkest in late March and early April, four weeks into the outbreak.

In April came news that the virus had spread to the Singapore General Hospital, and then beyond hospitals, to a wholesale market.

But the mood suddenly shifted in the second half of April, and people started coming out to shop.

Clothing retailer Zara's opening on April 23 at Liat Towers attracted hundreds. Best Denki's $99 offer of a bar fridge at its new Bishan Junction 8 outlet drew a queue of 200 by opening time. Concerts went ahead. Pubs and nightspots reported a surge in business.

"It was almost as though the Sars-induced fear had a life of its own - its own incubation period, and its own life cycle. It was as though, after being cooped up for weeks, Singaporeans decided enough was enough and ventured out," I wrote in the book.

What shifted the mood were deliberate campaigns to boost consumer confidence, bolstered by savvy sales promotions (like the $99 fridge).

One important initiative was the Cool Singapore programme to provide a Sars-free corridor for tourists and shoppers by ensuring that places like the airport, taxis, hotels, shopping malls and restaurants were Sars-free.

This was done by introducing regular temperature checks and screening measures at these places. Establishments that met criteria for such screening were audited and certified fever-free to assure shoppers.

The programme was effective, as no case of Sars surfaced at these establishments, since staff with fever were quickly identified and isolated. It also sent a message to the world that Singapore had Sars under control.

If Sars was any guide, people will hunker down first, then bounce back to business as usual if they feel safe and if deals are attractive enough. Reassurances of safety should thus be matched by concrete action like a programme to audit and certify retail joints.


The third front in the psychological battle against the virus lies in our own hearts and mindsets.

It is too easy to blame the victim and lash out with anti-China or anti-Chinese sentiments, as is happening worldwide. In the US, Canada, New Zealand, Australia, France, Denmark and a host of other countries, some people and media reports are targeting people from China, people who are ethnic Chinese or people who look East Asian for abuse because of the virus.

In Singapore, where the majority population is ethnic Chinese, we must not succumb to such racism or xenophobia. We must remember that foreigners are not the culprits; indeed, about one-third of our healthcare workforce, who are risking their lives to fight the virus, are foreign.

China, meanwhile, is putting up a valiant fight to contain the virus, after an initial state of denial. As many have noted, locking down Wuhan and its surrounds to contain the virus was tantamount to sacrificing a province to save the rest of China and the world.


After interviewing scores of people for the Sars book, including patients, nurses, doctors, hospital chiefs, civil servants and government ministers, I came away convinced that the much-criticised Singapore nanny state is impressive in action.

Government authorities nagged about hygiene, cajoled shoppers onto the streets, and enforced quarantine orders.

The state and its apparatus of community organisations, unions, business groups, religious groups, media organisations and grassroots bodies worked together to trace contacts and deliver timely information, thermometers and food to the quarantined and consolation to the isolated.

Each night, a press conference helmed by ministers debunked rumours, keeping the information flow open and smooth.

Today, 17 years later, the Singapore Government should be better prepared than in 2003 to lead the fight against the new coronavirus. Meanwhile, our healthcare workers are highly trained and brave.

It remains for us, as individuals, to realise that what we each do makes a huge collective difference.

Take responsibility for personal hygiene. Wash hands. Avoid touching your face. Observe leave of absence and quarantine rules. Mask up if unwell and seek medical attention.

Act responsibly and avoid panic behaviour like stockpiling food, masks or protective equipment. Doing so increases the chance of shortages for people who genuinely need the items.

Do not shun or shame but be kind to all, including the infected, the quarantined, healthcare workers and those from China.

Most of all, do not give in to paranoia or fear. Keep calm and carry on. Because we are in it together.

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A version of this article appeared in the print edition of The Sunday Times on February 09, 2020, with the headline Coronavirus: Fighting a psychological battle. Subscribe