Singapore: What We Can Learn From a High-Risk Country’s Response to COVID19

I was born in Malaysia, but left my family for the promised land of Singapore at the age of 12 under a scholarship program known as the ASEAN program. I lived more than half my life in that country, and have long since become a Singaporean. I currently manage a major Singaporean life sciences VC fund from a San Francisco Bay Area office.

Since the first confirmed case was identified in Singapore 55 days ago, the country has done a remarkable job of containment and mitigation. As of this writing, there have only been 313 confirmed COVID19 cases in Singapore with no COVID-related deaths. Those are remarkably low numbers compared with South Korea, Italy, Iran and other countries.

While Singapore is bracing itself for a spike of cases (more on that later on), what has worked well thus far?

The Beginning

Having lived away from home since I was a child, I make it a point to return to Malaysia and Singapore every year for the Chinese New Year festivities in late January / early February. It makes my parents and family happy. It brings me joy, too.

This year was no different. My fiancé and I flew back to Singapore, and took a rental car across the border to Malaysia. We landed January 23. That was the day Wuhan city was locked down to curb the spread of what was then just called the “novel coronavirus.” That same day, Singapore reported its first confirmed case of the illness we now call COVID—19. The coronavirus was all over the news in the ensuing days. Fear and confusion about the virus loomed over our lunar new year festivities.

Three days later, when my family crossed the border from Johor Bahru, Malaysia to Singapore, things had changed. On January 26, after the first FOUR confirmed cases of COVID19, we were told that every single traveler entering Singapore by plane, by foot or by car will have his or her temperature taken.

Something You Should Know About us Singaporeans

Before I go any further, there is an interesting Singaporean concept I need to introduce to our readers: it is called “Kiasi.”

“Kiasi,” in Hokkien (a common dialect in multi-lingual Singapore), literally means “afraid of death.” Those familiar with the history of the country would understand why. Singapore was kicked out of Malaysia in the 1960s in the post-colonial times, and was left to fend for itself with no clean water supply and zero natural resources. It is no wonder that this mentality of “the need to survive,” or the “fear of death,” has been core to the survival and later on, the flourishing of this nation city.

And this national mentality has, despite its derogatory connotation with cowardice, served us particularly well in times of crisis. I remember vividly living through the dark days of SARS in 2003. We lost 33 precious lives out of the 238 confirmed cases. Many in the US and elsewhere might scoff: “33? Did you say 33? Does this small number matter?”

Yes, to a small nation with a “Kiasi” mentality, IT MATTERS. Ever since SARS, Singapore has become much more crisis-ready.  

Learning from our SARS experience: There Is No Time to Lose

The SARS experience, and, more importantly, the willingness to learn from the experience, is now paying off. The country is bracing itself now for the worst of COVID19 spread. Singapore is particularly vulnerable, given that it is one of the most densely populated city states in the world. with 5.6 million inhabitants in 278.6 square miles — about 25% more densely populated than San Francisco. It’s also one of the top destinations visited by tourists from Wuhan, the epicenter of the outbreak. Given what we know about where the infection started, and how it spreads in densely populated spaces, Singapore is in a particularly vulnerable position.

In recent days, I had the opportunity to chat with a long-time friend, Dr. Jeremy Lim, co-director of Global Health at the Saw Swee Hock School of Public Health at National University of Singapore (NUS). He and his colleagues are doing incredible work treating migrant workers pro bono at a non-profit clinic. Dr. Lim has been at the frontline of Singapore public health policies for most of his career.

He shared that Singapore’s multi-ministry COVID19 task force was formed BEFORE the country even had the first confirmed case. This decisiveness and strong political will in taking forceful actions have been key. Public health and top political leaders have been aligned since the start on a fast, systemwide effort to prevent a pandemic.

It is also noteworthy that the country, despite its dense population, has been able to control the COVID19 situation without a city/countrywide lockdown. While it remains to be seen if the city state can hold out much longer before taking that type of draconian action, it does warrant some attention to review what have worked well to date.

It is not that interesting nor helpful to list out every single measure in boring technical detail, so I would like to discuss them thematically instead:

1. Concerted Political Effort and High Level of Transparency

Instead of wasting precious time politicizing the issue, ignoring the issue, or pointing fingers at our neighbors who might or might not have started or worsened the COVID19 crisis, the Singaporean government focused since the early days on mounting a concerted effort with strong political will in ensuring its success.

For example, a 14-day quarantine in Singapore for those who have been suspected to have been exposed to the virus, is not a “we are advising you to stay at home and we think you most likely will” type of exercise. There are at least THREE daily spot checks done by video conferences at random hours every single day to ensure that households under quarantine are indeed staying at home. Punitive measures are taken against those who violate these quarantine rules. The government is not fooling around with this and the administration executes its plans with exceptional efficiency.

2. Transparency, Data availability, and Clear Communication

The government has been extremely transparent in the number of cases confirmed, with full details of the background of the patient, along with the source of the infection. The authorities took painstaking effort in contact tracing. Every single case is laid out clearly on this official website.

The country’s leadership consistently and clearly communicates directly with its citizens, and control local media outlets to carry public messaging of washing hands and social distancing. Singapore has always been under fire for the lack of freedom of speech, but in this crisis, it has helped to curtail the spread of misinformation in Singapore. It has also avoided the entire “this is serious” versus “this is just a flu” kind of public debate. The message is unmistakable to everyone — common folks must do what is socially right to curb the spread of the virus.

3. Strong Fiscal Support for Those Affected

The government was quick to decide that all patients, whether confirmed to be positive or negative, will not have to bear the cost of COVID19 testing. Hospital bills for all confirmed and suspected cases are to be footed by the Ministry of Health. Self-employed individuals who have to be quarantined at home even receive $100 per day from the government. Lastly, it was made a rule that employers are not allowed to deduct paid-time off from employees for their days spent in quarantine.

In times like this, these measures matter tremendously to the affected pool of population and also help contribute to compliance with the quarantine measures.

Even for those households who have not been infected, the government has distributed four face masks to every household. Hand sanitizers were also distributed to support those in need.

4. Strong Collaboration Between the Government and the Scientific Community

China shared the sequences of SARS-nCoV-2 – the virus that causes COVID-19 — with the international scientific community on Jan. 11. Immediately, scientists at all the institutions of Singapore, private and public, were urged to work collaboratively on developing diagnostic tests, which were in dire need. By late January, Singapore-based Veredus Lab announced the development of its VereCoV detection kit. On March 3, Singapore’s Health Science Authority approved the provisional use of the test kit as an in-vitro diagnostic product. This effort was not done solely by the biotech company though, but as a collaborative effort between Veredus and a statutory board under Singapore’s Ministry of Home Affairs.

A research team in DUKE-NUS Medical School developed serological testing that was used for establishing links between COVID19 clusters. This test, based on virus-specific antibodies, has been used by Singapore for effective contact tracing.

There Have Been Mistakes

Not every system is perfect, and neither is Singapore’s. On Feb. 7 (with still only four confirmed cases), officials announced a national alert at the “Orange” level. Orange was the same level of alert triggered by the SARS pandemic, which so many citizens vividly remember.

The Feb. 7 announcement induced a panic, as citizens cleaned out the shelves of grocery markets overnight. This was neither the most gracious nor rational reaction. Singapore’s Prime Minister Lee Hsien Loong had to go on television to urge calm and to tell people that there is “no need to stock up with items such as instant noodles or toilet paper.”

As Jeremy Lim remarked, in hindsight, the upgrade to DORSCON Orange could probably have been better communicated to avoid public panic. 

Moreover, it is unknown whether Singapore is able to scale its healthcare infrastructure and workforce to cater for a “real” spike in COVID19 cases. Unfortunately, unlike China and other countries, Singapore has no hinterland or other provinces/states to draw resources from.

The Crisis Is Not “Over,” Not Even for Singapore

The Singapore government has just mentally prepared its people that numbers could remain high in the coming days, as more Singaporean students and workers return home because of lock downs in cities around the world.

In addition, in a dramatic turn of events, my birth country Malaysia just ordered a countrywide lock down on Mar. 18. This ruling has a severe impact on the 300,000 people living in Malaysia who commute across the border every day to work in Singapore. As a result, there was an insane rush of at least 100,000 people trying to cross the border into Singapore before midnight on Mar. 18. The Singaporean government is now working round the clock to find housing solutions for these 100,000 Malaysians who made it through the borders, with subsidies of $50 a day provided to them.

With this episode of mass border-crossing, it is only to be expected the country will experience a spike in COVID19 cases in days to come. Singapore has not had to impose national lock down so far, and although its containment measures have been reasonably successful, time will tell if this still holds.

I pray for my ENT doctor brother working at the front line in a hospital in East Malaysia, for those being affected back home in Singapore, and to my new beloved home the United States. We have lost precious time. We have to put all our political and ideological differences aside to get over this crisis together with swift and decisive actions.

Disclaimer:

This article expresses the personal views and perspectives of the author. The views and perspectives expressed here do not necessarily represent the views or perspectives of Vertex Ventures HC, or any officer, director, partner, member, manager or employee of Vertex Ventures HC, or any of its affiliated entities.