News analysis

The call on lifting Covid-19 restrictions is not easy in Singapore's transition phase

Customers queueing to buy food at Block 448 Clementi Market and Food Centre on May 29, amid a ban on dining in.ST PHOTO: KELVIN CHNG

SINGAPORE - The last few days have shown exactly why Singapore opted for a two-step easing of the restrictions put in place during the heightened alert to control Covid-19 cases.

When the authorities announced that some curbs would be lifted on Monday (June 14), Singapore had reported single-digit new infections for five straight days.

Further restrictions on higher-risk activities such as dining in, masks-off workouts in gyms and singing in live performances or during religious services were to be lifted next Monday. But cases have spiked to double digits for the past few days, fuelled by the growing Bukit Merah cluster that includes a market and food centre.

The authorities now have the flexibility to decide whether to go ahead with relaxing the curbs as planned, or keep them in place for another week or two.

It is a tough call - and it's a political call rather than a public health one.

It's also all about timing.

If this had happened three months back, there would have been no easing of measures. In fact, the measures might even be tightened.

On the other hand, three months from now, the decision would likely be to lift the curbs.

The big difference lies in the proportion of the population that has been vaccinated.

Three months back, only about 300,000 people here were fully vaccinated, while three months from now, most of the eligible population would have had at least one dose of the vaccine.

Experts say it is almost impossible now to eradicate Covid-19, which they see as becoming endemic. This means infections will continue to occur, and people will have to learn to live with that.

So what are the factors that need to be taken into account in deciding whether to ease or tighten restrictions, or maintain the status quo next Monday?

Vaccination

Central to any decision Singapore makes is the number of people who have been vaccinated.

Vaccination protects against severe illness - the primary worry in any pandemic.

Latest figures from the Ministry of Health (MOH) show that 98.6 per cent of people fully vaccinated, 93.6 per cent of those who have had one dose of the vaccine, and 90.8 per cent of those who have not been vaccinated have mild or no symptoms from Covid-19 infection.

These are figures since April 28. Last year, when most of the vulnerable had not been vaccinated, the percentage of unvaccinated people with serious illness would have been much higher.

Today, close to half the population has received at least one dose of a Covid-19 vaccine, with about two million people - more than one in three - fully vaccinated.

Associate Professor Hsu Liyang, an infectious diseases expert at the National University of Singapore Saw Swee Hock School of Public Health, said half the population with one dose of the vaccine is not enough protection.

"British data suggests only 33 per cent protection from symptomatic disease for the Delta variant with a single Pfizer dose," he said. He would like to see at least 60 per cent of the population fully vaccinated before one can breathe easy.

It is also important to see just who has been vaccinated.

Among the people who are fully vaccinated are the more vulnerable seniors who, should they get infected, are more likely to suffer from severe illness, and even die .

Unfortunately, not all who are 60 years and above have chosen to get vaccinated, even though they can now do so without an appointment. Meanwhile, more than one million people, many in their 20s and 30s, are waiting for their first dose of the vaccine, and for peace of mind.

After all, the risk of severe illness in younger people, while very much lower, is still there.

That said, the vaccination drive is on track and Singapore will be a far more protected country some months down the road.

Healthcare system

Dr Asok Kurup, who chairs the Academy of Medicine's Chapter of Infectious Disease Physicians, said more important than the number of infections is whether the healthcare system can cope with them.

Professor Ooi Eng Eong, an expert in emerging infectious diseases at the Duke-NUS Medical School, agreed: "It depends on the healthcare resource that can be allocated to Covid-19 cases without affecting access of other cases needing intensive care, ventilators, etc."

As things stand right now, the number of seriously ill patients requiring oxygen or intensive care is low, at a dozen or fewer in the past week. So there is no threat to the healthcare system.

For asymptomatic patients, which means they are not sick at all, or those who suffer only mild symptoms, the issue is ensuring that they do not pass the virus to others.

What's important is that as few people as possible get severely ill.

A concern is that unlinked cases - and there were 18 in the past week - could lead to more clusters being formed, and perhaps even a surge in cases.

But the more people who get vaccinated - and that's happening with 50,000 getting their jabs daily - the less likely this scenario becomes. Those who have been vaccinated serve to break the chain of transmission.

Said Prof Ooi: "Singapore is now in the zone where we could get local cases, but they would not become large clusters that would trouble our healthcare system."

Lives versus livelihoods

Since the start of the pandemic more than a year ago, many people have lost their jobs, businesses have failed or are struggling with government help, and the economy has stagnated.

Since Covid-19 is likely to become endemic, the question becomes, how many infections is Singapore willing to accept in order for life to return to normal for the majority of the population?

Said Prof Dale Fisher, a senior infectious diseases consultant at the National University Hospital (NUH): "Initially increasing numbers, especially unlinked cases, was a serious health threat.

"Now we expect more unlinked cases as vaccination makes the disease milder. Monitoring severe disease matters more than the number of cases."

As the threat goes down, people will demand that life return to normal.

The question is whether the threat has gone down sufficiently to allow for further easing of measures next week.


A concern is that unlinked cases could lead to more clusters being formed, and perhaps even a surge in cases. ST PHOTO: JASON QUAH

Associate Professor Alex Cook, an expert in disease modelling at the NUS Saw Swee Hock School of Public Health, said: "The Delta variant is more transmissible. If we want to keep the daily cases from growing, we can't expect phase three measures to suffice, even if we get the cases down temporarily.

"We either need to impose more restrictions, or accept that cases will rise until herd immunity kicks in.

"Given that the highest-risk individuals were all offered vaccination already, one has to wonder why letting cases rise is so unpalatable that distancing measures are preferred."

Prof Fisher explained that Singapore is in a transition period where many, but not all who want it, have been vaccinated.

"It is tricky," he said. "We still need to look after people who haven't had the chance to be vaccinated yet."

The question of curbs

So should Singapore ease restrictions further, as planned, next Monday?

There are several arguments for the easing of curbs.

The most vulnerable groups have already been vaccinated and those that have not are at much lower risk of severe illness if infected.

The healthcare system seems well-positioned to deal with the people who might fall severely ill.

Tens, perhaps even hundreds of thousands of jobs and businesses are on the line.

Against this, one must weigh the risk faced by those who are still waiting to be vaccinated. Singapore has just extended vaccination registration to Singaporeans aged 12 to 39 years old. The chances of them getting infected rise if the curbs are relaxed, though they are less likely to fall severely ill, on account of their age.

Plus, the curbs could be hurting their livelihoods, too.

The authorities will have to weigh the risks and rewards of restrictions, at least till October, by which time everyone who wants to should be vaccinated.

Which decision would be more politically palatable? Seeing a rise in infections, the bulk of which are mild, or enduring more weeks of heightened restrictions to bring down the number of infections?

With half the population having at least one vaccine dose, perhaps it is time to change strategy from one of containing the virus to one of living with it.

At the very least, the dining in restriction should be lifted as there are business repercussions to not opening up the food and beverage sector.

With compulsory spaced out seating, restaurants would actually be safer than markets like the one at Bukit Merah, where people tend to mingle more freely.

Eventually, while Singapore will likely continue to track all cases, it will no longer need to test and trace them. Its borders, too, could open before year-end to countries where infections are low, and to people who have been vaccinated.

Until then, the balancing act will go on, and at least some measures, such as wearing of masks and social distancing, must remain.