By Jeremy Lim, MD, MPH
Many Singapore public health professionals including myself* have been interviewed multiple times by foreign media to try to understand what exactly Singapore did and what lessons or experiences may be relevant to other countries.
This article is an effort to put pen to paper and summarize my thoughts thus far on what Singapore has done.
Before jumping into COVID-19 specifics, it’s probably useful to paint a little context:
01. National psyche
Singapore is a small, compact, very densely populated city-state of just over 5.5 million residents. It was unceremoniously kicked out of Malaysia in 1965 and forced to survive on its own. With no economic hinterland to call her own, Singapore went against the conventional wisdom of the day, eschewing import substitution and instead embracing a multi-national corporation fuelled, export-driven economic strategy. A single dominant political party, the People’s Action Party has governed Singapore since independence and remains firmly dominant, and importantly expects to be in power for the next decades. The sense of ‘paranoia’ and insecurity about national survival persist to this day and even as recently as 2013, Singapore Prime Minister continued to describe Singapore as a little ‘sampan’ (Malay for little boat), conjuring an evocative visual of a tiny vessel caught in the waves of a tumultuous and unforgiving ocean.
02. SARS (Severe Acute Respiratory Syndrome)
This hit Singapore badly in 2003 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 (NCID), designed for such future outbreaks, was built to add 300+ beds to the national surge capacity and doctors were sent to the World Health Organization and the US Centers for Disease Control and Prevention’s Epidemic Intelligence Service to build up the human expertise. National exercise such as Exercise Sparrowhawk which involved over a thousand healthcare professionals were also conducted to heighten awareness and test preparedness and Singapore even had national plans for an influenza pandemic. Many of our infectious diseases physicians also added public health training to their skill sets, including current NCID Executive Director Dr Leo Yee Sin and my Co-Director in the Global Health program at our School, Dr Hsu Li Yang. Both have been prominent leaders in the current COVID-19 pandemic.
Now onto COVID-19!
Singapore was one of the first countries outside China to be affected with the first case reported on 23rd Jan, and as of today Singapore has documented only 345 cases. It is too early to pop the champagne though and it is clear from the adjacent infographic from Channel News Asia that Singapore is expecting a ‘second wave’ of imported cases, with the number of cases sharply on the ascent. In fairness, with multiple countries enacting indefinite ‘lockdowns’, thousands of Singaporeans based overseas for work or studies have hurriedly returned home with many found to carry the coronavirus.
Of the 40 new cases diagnosed yesterday (20th March), 30 were imported [29 citizens and other long-term residents]. Of the remaining 10, 7 were linked with only 3 unlinked, which gives concern of some unchecked community transmission.
The ‘first wave’, largely due to cases imported from Wuhan, Hubei which has direct air connections with Singapore (and Singapore is a popular Chinese New Year long holiday destination for Chinese tourists), was successfully mitigated.
What helped Singapore? There are many interlocking reasons, which I will attempt to distill into three key factors:
a. Early and effective government-led, multi-agency response
Singapore established a multi-agency task force chaired by 2 ministers (health and national development) with representation across the entire public service including ministers in charge of trade, manpower, education, communications etc. 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 (https://www.nytimes.com/reuters/2020/03/13/world/asia/13reuters-health-coronavirussingapore-tracing.html) and BBC (https://www.bbc.com/news/world-asia-51866102) and I don’t need to go into details. Suffice to say, the impressive statistic of 40% of COVID-19 infections detected through contact tracing while still asymptomatic is testament to the speed and thoroughness!
Effective containment measures go much beyond identifying contacts and tracing them down- processes and schemes need to be set up to ensure sufficient quarantine facilities and adherence to home quarantine orders. Singapore with the previous experience of SARS 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 to come forth, or at least not disincentivized from coming forth if testing warranted and the government did well to announce early on that all medical expenses related to testing and treatment would be covered, and that SGD 100 per day would be provided to compensate for any loss of income during quarantine.
It is a balance of carrots and sticks. Singapore, true to form, announced heavy penalties for defying quarantine, isolation orders and in a widely publicized case, took away Permanent Residency status from a man who had breached a ‘Stay Home Notice’ and permanently barred him from Singapore (https://www.channelnewsasia.com/news/singapore/covid19coronavirus-pr-stay-home-notice-barred-12471954).
Persons who need to be quarantined or spatially isolated cannot realistically be expected to do so without reasonable access to food and other essentials and here Singapore benefits by virtue of her compactness and relative maturity of e-commerce services. It is not difficult, albeit not inexpensive, to order in groceries, cooked food and so on and with full internet connectivity, remaining in contact with the workplace, family and friends is still very viable. Beyond these, enforcement is still necessary and the adjacent infographic is useful to illustrate how the Singapore authorities check on persons issued with ‘StayHome Notices’.
b. Multi-layered Trust
In this age of cynicism, it is all too easy to scoff at this, but science is difficult and uncertainty high with even experts openly disagreeing on appropriate measures. Laypersons cannot possibly understand fully the complexities and trade-offs, and consequently have to ‘trust’- the public need to trust their leaders are placing their interests above all, politicians need to trust experts are providing unbiased advice with no hidden agendas, and everyone needs to trust each other to be socially responsible in travel declarations, symptom reporting 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 21st March that most Singapore residents (Caveat that n=16) had confidence in the ‘authorities’ whilst over 80% 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?”
c. Clear and Consistent Over-Communication
Here is where I believe the government deserves a lot of credit. It decided very early that clear and consistent information was essential and that even as Singapore battled the viral pandemic, it had to prevail also on what the WHO describes as the ‘infodemic’. ‘Fake news’, wild speculation spreading virally and just plain errors in reporting are the realities of modern living and to dissuade citizens from believing these, people need to know where to obtain trustworthy information, AND have misinformation debunked quickly and decisively.
Minister Lawrence Wong, co-chair of the Multi-Ministry Task Force has been particularly strong here, hosting daily press conferences and explaining patiently and in simple but not simplistic terms the situation and why government actions were decided upon. Beyond these, reminders about public health measures including social distancing and handwashing were and are still daily staples across print and online media. The gov.sg WhatsApp account which hundreds of thousands of Singapore residents have subscribed to is used in real-time to put out at least two to three times daily reminders about public health measures as well as summaries of the number of cases. It is also used to debunk any misinformation and allay concerns. The graphic above shows a message sent out promptly yesterday (20th March) after it emerged that false rumors were circulating that Singapore would be ‘locking down’. Speed is essential in communicating to avoid panic buying and other such unhelpful actions.
Health professionals and especially frontline private General Practitioners/ Family Physicians who helm Singapore’s largest privately operated primary care clinics are critical to keep informed and to in turn listen to for ground challenges and unintended consequences of policies. The Ministry of Health (MOH) has done well here by working with physician-established closed Telegram chat groups with vetted members to obtain feedback and explain in more technical and candid terms the rationale behind policies. One useful ground-up initiative was a ‘MOH friendly updates’ chat group in which a representative from each medical school class (and other groups such as foreign graduates) interacted closely with senior MOH officials to share on behalf of their classes feedback and raise questions or clarify policies. In turn, MOH committed to a quick response time in answering and typically within a day, the issues would be clarified if not fully addressed.
So much has been said about global scientific cooperation that it suffices to say here that Singapore is well plugged in and also contributing usefully with public sharing of our experiences. Singapore’s national ‘Biomedical Sciences Initiative’ started over 2 decades ago with the ambition to make Singapore a hub for scientific research and discovery has paid off handsomely so far in COVID-19 as the expertise could be quickly brought together and organized, leading to early development of diagnostic kits, serological tests and the ability to trial novel drugs for therapy.
Closing Thoughts (For now!)
A final note on the delicate balance in managing the economic and public health aspects of COVID-19. Singapore is an open, trade-dependent economy and reactions to dampen the spread of disease have to take into account the benefits in public health relative to the economic and social disruptions. People are harmed not just from COVID-19 but also from job losses, inability to afford other healthcare and social isolation, and a difficult calibration of measures is needed. In surgery, there is a saying “The operation was a success, but the patient died”. Singapore needs to adroitly manage the pandemic but it needs also to keep the economy alive.
It is early days in the COVID-19 pandemic and for Singapore, only the end of the beginning. We hope that Singapore maintains its generally strong performance and maintains the enabling factors described above that allow her to move quickly and decisively, pivot when needed and take unpopular actions with the trust and confidence of her people. There will be many more cases, hopefully, some and not a lot of local, unlinked transmission, and certainly a number of fatalities. The real test of national resolve and readiness is coming, and I am worried but cautiously optimistic. As an infectious disease, a physician at the forefront of caring for the COVID-19 patients shared, “It’s like seeing the tsunami rising before one’s eyes, and hoping the surfboard will hold”. God bless Singapore, and the world.
In the last week, I’ve been interviewed by Time, the German ZDF, Australian Broadcasting Corporation, Voice of America, Bloomberg News, South China Morning Post, etc and just yesterday morning did a conference call hosted by Mike Milken of the Milken Institute.
Lim 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 a gut microbiome startup and advises ASTAR (Singapore’s Agency for Science, Technology and Research) and a number of private and nonprofit organizations on health-related matters
Links as below where publicly available:
These interviews do take up a lot of time but we as a School of Public Health determined early on that we would actively be receptive to journalists and work proactively with the media to contribute to the efforts to get the facts and figures out to the general public. This would be part of our little contribution to the global COVID-19 response.