Defences overwhelmed – Singapore’s struggle with COVID-19

Despite the lessons learned from SARS and Singapore’s efforts to build a public-health infrastructure able to cope with future outbreaks, the country was badly affected by COVID-19 owing to demographics and geography. Keith Cooper reports

Location: International
Published: Friday 7 August 2020

Singapore hit a high and a low in its early battle against COVID-19, a virus it had prepared itself to defeat.

Weeks after recording its first case in January, a ‘very impressed’ World Health Organization ladled praise, as its cases continued to flatline. The fall from grace came, in April, when it peaked at 1,400 in a day before ‘circuit breaker’ social-distancing measures brought Singapore under some control. Hundreds of new cases each day are still often reported.

This wasn’t supposed to happen in Singapore, a place widely known for cleanliness and business-like efficiency and, in more medical circles, for how it swelled its public-health prowess after being hard hit from SARS (severe acute respiratory syndrome), another coronavirus.

So, what have doctors there learned from its response to this pandemic?

Public health consultant Wong Chiang Yin, council member and past president of Singapore Medical Association, admits some doctors were lulled into a false sense of security.

‘Because our numbers were good, we thought we were doing well,’ he added. ‘Sometimes you must not believe in what other people say about you. The national press was saying, Singapore is the gold standard. We got taken in by that argument and let our guard down.’

Cheek by jowl

Wong Chiang Yin WONG: 'You need to anticipate problems early'

The acceleration of cases in April – and the country’s main challenge still – is owing to its many, and partially regulated, dormitories, which house hundreds of thousands of foreign workers. These range from bespoke campuses with shops, laundries, and recreation areas, to dormitories converted from factories and other industrial buildings.

‘People in some dormitories live in close proximity, 10 or 12 to a room with common dining, recreational, and toilet facilities,’ says Dr Wong. ‘The potential for mixing is like an ocean liner on land.’

Singapore’s ministry of health reports cases for dormitory workers separately from those of its permanent residents and visitors from abroad. Of some 52,200 cases in Singapore so far, a tiny fraction arise outside of them. The small number of COVID-19 patients who have lost their lives, 27 so far, can be mainly attributed to the youth of this workforce.

In response to this disproportionate effect on foreign workers, Singapore’s government plans to build rapidly – in just six months – 60,000 temporary bed spaces for them. A further 100,000 permanent purpose-built dormitories to higher standards will follow within two years. The number of sick bays per 1,000 beds spaces will be increased from one to 15. ‘These efforts aim to make dormitory living and design more resilient to public health risks, including pandemics,’ a briefing outlining its plan says.

Dr Wong says these plans will work to an extent. ‘But is it a panacea or a magic bullet? I don’t think so. Obviously, distancing helps,’ he adds. ‘The lesson to be learned is that you need to anticipate problems early. Measures should be in place early on. These are not new facilities. In the long run, there’s a consensus in society that we need to change some of the living conditions.’

Dry run

Singapore had expected to cope better with another outbreak of coronavirus since SARS.

When it hit in 2003, Dr Wong was the chief operating officer of Singapore General Hospital, which, together with Tan Tock Seng Hospital, ‘bore the brunt’ of that battle, he says. Before SARS, there was no requirement for hospitals to have a public-health function. Singapore had no national centre for infectious diseases. Essential equipment, such as the PCR testing machines, which pinpoint the presence of viral infection, was scarce. 

‘Singapore has come a long way since then,’ Dr Wong says. ‘We have built several big general hospitals, increasing capacity by 40 to 50 per cent. We’ve built the NCID (National Centre for Infection Diseases). We have a lot more infectious disease and public health specialists. During SARS, you could count the number of PCR machines in the country on one hand. Now, we’ve lost count of how many we have.’

Its response has benefited also from more recent changes in primary care, 80 per cent of which is provided by private GP practices. Government-run polyclinics provides the rest, largely for people with long-term conditions, such as diabetes.

In the last six years, hundreds of smaller practices have been organised into a network of ‘public health preparedness clinics’. These are now charged with surveilling outbreaks. ‘During an outbreak the Government activates and funds them,’ says Dr Wong. ‘[PPE] personal protective equipment is given to them weekly.’

SARS vets

One clear lesson from SARS was the need for adequate supplies of the right PPE – and these PPE can then be trusted. After shortages of surgical masks early on in the COVID-19 outbreak, it brought production lines back into the country from abroad. Another lesson learned.

‘After SARS, we knew that the N95 masks were really important so we had a factory making them in Singapore,’ Dr Wong says. ‘We also have a lot of SARS veterans, people in their 40s and 50s. They were there from day one to help the younger doctors. They could tell them, “we’ve been through this with SARS and we’re still here, alive and kicking”. That really helped.’

In the long term, the Singapore Medical Association is keeping tabs on the physical and psychological wellbeing of it doctors, as the pandemic continues. ‘We are more stoic in this part of the world,’ says Dr Wong. ‘We don’t voice our problems and concerns until sometimes it is too late. We’ve been at it for six months, so there has to be some strain taking its toll.’

Like the UK, Singapore has shifted its views on PPE for the public.

The official position, in February, that they were unnecessary, has changed. ‘We now have to wear masks when we step outside,’ Dr Wong says. ‘Sometimes, lack of proof does not mean that there is proof of absence. It’s a heuristic error.’ Unlike some other Asian countries, such as Taiwan and South Korea, there is ‘no culture’ of wearing masks in Singapore, he adds.

No retreat

As with the UK, Singapore has struggled with compatibility issues for its track-and-trace smartphone app, TraceTogether. An alternative, a Bluetooth dongle, has just been distributed to 10,000 of its older people. It can be worn around the neck, like an emergency alarm. ‘It’s safer from a privacy point of view,’ says Dr Wong. ‘The Government has no access to the data unless you test positive. Then you must hand it over. The app data can then be used to see you’ve had contact with.’

Singapore’s geography has created its own complications. ‘It’s a small place, we have no hinterland,’ says Dr Wong.’

‘People can’t go back to the village and plant rice. You can’t disperse the population, like you can in New York, where people can go upstate. There’s no avoiding these terrible negative effects.’

And some of its challenges are similar to those of other countries.

‘The biggest threat is to institutionalised living, where lots of people aggregate and live together, such as homes for the elderly, nursing homes, student accommodation as well as the dormitories,’ Dr Wong says. ‘This is something which we should really pay attention to.’ It’s economy, so dependent on travel and trade, has suffered, like many other countries.

But, as with the rest of the world, Singapore, its public health specialists, and other doctors face a vexing challenge until a vaccine is final found: just how do you unlock a lockdown?

‘How do you unlock the schools quickly?’ Dr Wong says. ‘We know that the poorer kids are the ones most disadvantaged by home-schooling. In poor families, there are maybe three kids sharing one iPad. You need to balance the needs of these people with unlocking your schools, which is a risky venture in itself.’

‘Everybody knows how to lock down a place,’ he adds. ‘But there’s no textbook for unlocking a place. Everybody is trying their best to figure it out in their context, learning from other. How do you unlock London? England? How to unlock Singapore? We’re all groping around in the dark.’