COVID-19 SPECIAL

Weighing Singapore's response to the Covid-19 pandemic

Did Singapore overlook Covid-19 cases in foreign worker dormitories; give wrong advice on mask-wearing; and is it too lax in its circuit breaker measures?

The plaudits had come early for Singapore in its fight against the coronavirus.

Around the world, epidemiologists and media reports held the country up as a model to emulate for bringing the outbreak under control with a strategy of aggressive testing, meticulous contact tracing and strict isolation.

Yet, from being hailed by some as the "gold standard" in tackling the virus, the Republic is now referred to by others as a "cautionary tale" of how potent the coronavirus is as well as the risks of easing up on measures to contain it.

This has led some to question the approach taken in recent weeks: Did the Government overlook the situation in the dormitories? Should mask-wearing have been mandated from the start? Could an earlier and stricter lockdown have prevented the current situation?

Often, this is done with 20/20 hindsight. But with what is known about the virus being debunked week to week and the situation evolving daily, it is normal for people to feel uncertain and wonder if the authorities have got it right.

BLINDSIDED BY BUG

The most pressing situation now is the one playing out in the purpose-built mega dormitories and factory-converted dorms housing over 320,000 of the 720,000 foreign work permit holders (excluding foreign domestic workers).

An explosive growth in Covid-19 cases in these compounds has led to 19 of them being declared isolation zones as of Monday, while all other purpose-built accommodations housing foreign workers have been placed under partial lockdowns.

Yesterday alone, close to 1,100 cases were recorded among foreign workers, and health experts warn that if the spread is not curtailed fast, deaths will almost be certain, and hospitals will be overstretched.

Could this disaster have been prevented? Some critics believe so.

The workers sleep 12 to 20 to a room, with even larger numbers sharing facilities like bathrooms and kitchens, and migrant worker groups have lobbied for better living conditions for years.


The most pressing situation now is the one playing out in the purpose-built mega dormitories and factory-converted dorms housing over 320,000 of the 720,000 foreign work permit holders (excluding foreign domestic workers), with close to 1,100 additional cases recorded among foreign workers yesterday. PHOTO: EPA-EFE

On March 23, Transient Workers Count Too, or TWC2, had warned of a cluster possibly breaking out, given that the workers live in such close quarters that it is impossible to practise safe distancing.

The non-governmental group had alluded to how this could be averted - it would require the rehousing of hundreds of thousands of workers. But it acknowledged that it is unrealistic for additional dormitories to be built in mere weeks or months.

With attention at the time focused elsewhere, especially with the flurry of Singaporeans returning home from abroad having to be kept apart from the rest of the population to prevent the spread of the virus, it is doubtful that the public would have appreciated the need to peremptorily expend huge resources to rehouse workers from dormitories at the time.

Yet, in the recent weeks alone, thousands of workers have had to be moved out of dormitories and into alternative housing at military camps, floating hotels and vacant Housing Board blocks, with more areas such as sports facilities and hotels set to be converted for such use.

So inevitably the question has arisen of whether it could have been done before the super spreading event at Mustafa Centre seeded the infections in the dormitories.

Several factors may have informed the decision to manage outbreaks as they happen, say experts.

The first Covid-19 cases involving foreign workers in February had been successfully contained, and never "exploded into big clusters", in the words of Minister for National Development Lawrence Wong, who co-chairs the multi-ministry coronavirus task force.

Professor Teo Yik Ying, dean of the National University of Singapore's Saw Swee Hock School of Public Health, said this suggests that responses put in place such as testing, contact tracing and isolating cases were adequate.

Also, precautions were already being taken at the compounds, with temperature checks, increased cleaning of shared spaces, and hand sanitisers for workers to use.

Prof Teo said the current crisis at the dormitories was the result of what epidemiologists call a super spreading event that is difficult to predict.

"This is what we mean by a very unfortunate event that, in hindsight, people will say we should have known," he added.

 
 

Such events have driven epidemics and once they happen, it is crucial to quickly recognise and understand them to arrest the spread.

On this count, Nanyang Technological University's Lee Kong Chian School of Medicine visiting professor Annelies Wilder-Smith believes the Government is on the right track in thinning out the dorms. But she warned that it is now a race against time and the infection could "spread like a fire, and Singapore has to move faster than the speed of the virus".

At the same time, gazetting the worst-hit dorms as isolation areas is necessary to keep the infection from spilling over into the general population.

Prof Teo cautioned that this should not be misconstrued as "discrimination", adding that such a classical public health response was also employed in Hong Kong during the severe acute respiratory syndrome (Sars) epidemic, when an entire apartment block had to be closed off.

As long as workers are also being cared for and protected in the dorms, this is probably the best way to control the dormitory outbreak, said Professor Wilder-Smith.

Both experts said that a lesson to take away from this is that the spread of Covid-19 can quickly go out of control in situations where people live side by side, not just in dormitories, but also in old folks' homes.

 
 

TO MASK OR NOT?

Another issue that is hotly debated now is whether the Government was wrong to urge people not to wear masks in the initial phase of the outbreak.

Then, ministers had discouraged people from using masks, citing advice from the World Health Organisation (WHO) and other experts on the Sars-CoV-2 virus being spread through droplets and not aerosols.

Officials also noted that in the light of a global shortage, it was best to conserve the use of such protective gear to ensure that it is available to medical professionals when they need it to care for patients.

As more became known about the disease, the Government has in the past weeks changed its stance, distributing reusable masks to everyone and mandating the wearing of masks in public. While the WHO has maintained that healthy people do not need to wear masks, officials have acknowledged that it may become common practice.

Some have called it a flip-flop.

Others have attributed the rise in cases in Singapore to people not wearing masks, pointing to how in places like Taiwan, Hong Kong and South Korea, where the practice is commonplace, the numbers of infections have been kept low.

But experts point out that these regions have also espoused other key public health responses to the pandemic such as rigorous testing, comprehensive contact tracing and strict isolation.

Has not wearing masks been detrimental here?

Prof Teo said this is not borne out by the data on community transmission.

Up until March 24, there had mostly been fewer than 10 cases of such transmissions a day, he said, adding that the numbers would have spiked by February had the limited use of masks been a big factor. With such small numbers of infected people roaming around in the community, the chances of people catching the disease when going about their daily life were also small, and there was thus no need for the widespread adoption of masks early on, he added.

He likened the wearing of surgical masks in the early days to people wearing motorcycle helmets everywhere they go.

 
 

"Does the helmet protect one from head injury? The answer is yes. But why does one not wear it to, say, FairPrice to shop? Because we perceive our risk of getting a head injury from grocery shopping to be very low," he said.

"Similarly, when there is very little transmission, wearing a face mask is similar to wearing a motorcycle helmet while buying groceries. We need to manage or perceive risk in an objective way."

With a shortage of N95 respirators and surgical masks worldwide, experts believe that every country's priority should be to maintain inventories of such protective equipment for doctors, nurses and first responders.

If healthcare workers get infected or die in large numbers, healthcare systems will collapse, causing panic in society.

Thus, encouraging the use of masks has to be balanced with the preservation of the limited resource. If three-quarters of the 5.6 million people here use just two surgical masks a day, Singapore will expend more than 58.8 million masks a week.

Now, with scientists discovering that pre-symptomatic and asymptomatic infected people might unwittingly spread the virus, the advice on mask-wearing has changed, and people are encouraged to wear a reusable mask in public so as to protect others.

Ironically, it has been an uphill task to get everyone to comply, and it has not been hard to spot people without masks in public.

LAISSEZ-FAIRE LOCKDOWN?

The third issue is whether an earlier and more complete lockdown would have helped Singapore avoid the current situation, where daily Covid-19 cases have breached the 1,000 mark.

From the get-go, Singapore has taken a calibrated approach to managing the outbreak, with measures changing as the situation evolved.

While testing, contact tracing and quarantining have been a constant, the Government has preferred a proportionate response in implementing safe distancing measures gradually, instead of having a more draconian total lockdown.

For some, this calibrated approach, with rules changing on a daily basis, has seemed wishy-washy and confusing.

If Singapore had taken a more cut and dried approach, imposed a police-enforced lockdown with curfews and stopped public transport as some countries have done, could it have eradicated the virus?

Debate on this topic has intensified as lockdowns take their toll on economies and public life around the world, and countries contemplate the loosening of restrictions to allow some modicum of normal life to resume.

Ironically, some commentators were citing Singapore as the model of what a less stringent lockdown might look like. With the surge in numbers now, Singapore is also pointed to as an example of the risks that premature easing up might entail, making it plain that no easy, one-size-fits-all solution exists for this very unusual outbreak.

Prof Wilder-Smith believes that for some countries like Singapore and New Zealand, completely locking down is possible and can potentially bring infections to zero.

But she added that this would include ringfencing the country from even its own citizens who are overseas and want to return.

Also, such a total lockdown would have to be maintained for some time for infections to be kept out, as the world has missed the boat on containment and infections can easily be reintroduced once Singapore opens its borders.

"Four weeks ago, I would say every country should go for containment. But worldwide, we have missed that chance," Prof Wilder-Smith said. "If it's one or two weeks, we will all gladly do it. But we don't know how long this situation will last and a total lockdown can mean long-term suffering with very strict restrictions for months and months to come, which also causes major damage."

As for an earlier lockdown, Prof Teo said data in the early days did not justify it.

A lockdown reduces physical interaction and helps to break chains of transmission. But with the number of cases spreading in the community in the double digits daily at most, a lockdown would have been akin to using a sledgehammer to crack a nut, bringing unneeded disruption to life when cases could have been controlled through strategies like contact tracing, testing and isolation.

Elsewhere, in Wuhan, where the virus had first emerged, and in Italy, one of the worst-hit European countries so far, lockdowns substantially reduced the number of new cases for a time.

But experts now agree that it is mostly a delaying tactic, and believe that cases will rebound when the restrictions are lifted.

So far, lockdowns are estimated to cost a staggering total of US$7.8 trillion (S$11.2 trillion) worldwide. In Singapore, the economic toll of the current partial lockdown is predicted to be around $10 billion. As people work from home and children stay away from school, there have also been more reports of domestic abuse and mental health issues.

After just 15 days of the circuit breaking period in Singapore, there are also signs of "lockdown fatigue", with people venturing out and crowding the only places where they are now allowed to visit such as supermarkets and parks.

This is why governments around the world have struggled to find the right balance between imposing strict restrictions to resolve the pandemic and not causing irreversible harm to the economy and society.

At the same time, for a calibrated approach to work, rules have to be kept simple. For now, caveats and exemptions for mask-wearing and enlisting the help of grandparents for childcare support, for instance, have caused confusion and led to non-compliance.

LONG ROAD AHEAD

In an interview with CNN on March 29, when asked about Singapore's success, Prime Minister Lee Hsien Loong had cautioned against complacency, pointing to a long road ahead, as other ministers had also done. Indeed, several had said early on that the outbreak could last into 2021, raising some eyebrows at the time.

"I hesitate to talk about success because we are right in the midst of a battle which is intensifying," said PM Lee. "With great effort, I think it (Singapore's measures) has helped to keep the number of cases down, but I am under no illusions that we have won. We are just going in, and there is a long battle ahead."

His words have rung true and Singapore is in the news again, this time as a cautionary tale.

Harvard University professor of epidemiology Marc Lipsitch, who had praised Singapore's approach in a research paper, said, when asked, that while Singapore has done admirably well in how long it was able to maintain a degree of control while keeping up significant economic activity, he never believed with certainty that the epidemic would be kept under control here.

He told The Straits Times: "But I see the failure of containment after a significant period of time as reflecting the strong challenges of this virus (even more than Sars, for example) rather than the failure of any specific location."

Prof Wilder-Smith said: "So Singapore looked good three weeks ago and not so now... We should not be too early in making judgments and should maybe wait until the end to compare."

With scientists predicting that lockdowns might have to last until next year, and new information indicating that recovering from the infection may not confer immunity for long, governments will have to be careful about allowing hubris or complacency to set in while a vaccine is being developed.

This is yet another fine balancing act.

Prof Teo said: "Definitely we should not be arrogant and we should not be mocking the efforts of other countries... Equally, it does not mean Singapore is arrogant or smug if we share our experiences with other countries.

"In a crisis faced by the whole world, sharing those experiences becomes crucially important as a case study of what has worked and what hasn't."

 
A version of this article appeared in the print edition of The Straits Times on April 22, 2020, with the headline 'Weighing Singapore's response to the Covid-19 pandemic'. Subscribe