Singapore had a major fright in 2003 when the SARS virus infected 230 and killed 33 people, including many health care professionals. Ever since then, the country has been preparing for the next big one, weathering the MERS and H1N1 outbreaks, and now facing the Covid-19 emergency.
Covid-19 emerged at the perfect time in China to ensure rapid global spread. Singapore relies on international trade and commerce for its survival and is well connected to the rest of the world. Like Heathrow, Singapore’s Changi Airport is a key air hub, with more than 68.3 million passengers each year. Of the five million people who left Hubei before Chinese New Year, over 10,000 flew to Singapore. Some stayed while others went on to other destinations. Infectious diseases do not respect borders, especially ones like Singapore’s.
Singapore has been preparing for this outbreak since 2003. The experience of SARS had prompted much investment in emergency preparedness for infectious diseases. We’ve improved our surveillance and detection systems at borders and through our regional networks, enhanced response capabilities in public hospitals (including the implementation of visitor management systems), trained health care professionals in infectious diseases, developed a primary care response infrastructure (including public health preparedness clinics) and launched the national centre for infectious diseases in purpose-built premises.
SARS raised the public awareness of infectious diseases and the important role that the public can play in assisting with the fight against such diseases, such as following quarantine and isolation orders as well as good hand hygiene and social distancing – habits we’ve seen discussed more globally in recent weeks.
Singapore takes the Covid-19 emergency very seriously, as evidenced in leadership messages like the Prime Minister’s speech to the nation on February 8 and daily ministerial press conferences. Our whole-of-nation response saw measures, both pre-planned and innovated, put in place across government, public and private organisations, and communities and residences.
- Temperature and travel screening at border points, schools, workplaces, health facilities, tourist attractions, religious places and events.
- Rapid identification of possible cases at public health care facilities and public health preparedness clinics.
- Rapid identification of potential cases at entry points, including swab test checkpoints for suspected cases at Changi airport, with a three to six hour result turnaround.
- Contact tracing of cases and their contacts, mobilising not only Ministry of Health staff but also members of the police and other partners.
- Regular recalibration of case definitions to optimise catchment of cases without overwhelming our facilities with low probability cases.
- Quarantine orders and stay-home notices to isolate suspected carriers or close contacts (violation of such a notice in one case resulted in the removal of visa status and barred re-entry).
- Travel declarations at schools and workplaces.
- Daily updates from the Ministry of Health and advisories across all sectors.
- Daily messages to the public from a government WhatsApp group and constant messaging on hand-washing and what to do if unwell.
- Parallel messaging through non-tech platforms (e.g. cartoons, print-media, posters).
- Rebuttal of fake news (in one case invoking our Protection from Online Falsehoods and Manipulation Act).
- Funding of research and development related to Covid-19.
Continual learning, reflection and adaptation
Singapore has been praised for its response, but much must be said for the factors that make it somewhat easier. It is a small island state with strong borders, a previous terrifying experience of SARS and the natural reaction to never be caught out again. It also has a culture that supports and actually welcomes many of the containment measures, a strong economy with adequate resources, and a political leadership that has been stable over decades and which is generally trusted by the population.
Having said that, things have not been perfect. “No battle plan survives contact with the enemy” and there have been unexpected challenges. Most evident would be the panic buying of masks, groceries and commodities when Singapore raised its DORSCON to Orange, as has happened in other parts of the world. There was perhaps insufficient education of the public on the epidemiology of the virus, compounded by our well-known local risk-averse culture. There were other complaints and disquietude, for example by parents when their children’s hostel rooms were taken over as quarantine facilities. Execution will always be messy.
More seriously, we have rescheduled much of our normal health care delivery and do not yet know the health costs for the rest of our patient population. Our preparations have focused somewhat more on how the health care community should respond to an international infectious disease emergency, and less on how the rest of the economy, especially our small and medium enterprises, would. Once the dust settles and we’ve had time to reflect, we will likely think of other improvements to make.
Academic and government partnership
One way we found ourselves less than prepared has been in the surveillance of the scientific literature. Each virus is different with unique characteristics, and time is needed to develop effective point-of-care tests to support case management and isolation, to determine which treatments currently in clinical trial may be effective, and to develop vaccines. Some aspects (like diagnostics, vaccines and therapeutics) may be difficult to monitor continuously and to be prepared for any outbreak, but other responses (like containment measures and business continuity measures) would have been more amenable.
In any case, we found ourselves short of ready summaries of all of them and our School of Public Health found ourselves actively amassing and maintaining a knowledge base to support policy-making – producing the Covid-19 science reports for the Chief Health Scientist of the Ministry of Health that are shared across government and the region. We also actively support the Ministry of Health in other ways (like modelling the epidemiology of the virus) and other agencies as well such as the Enterprise Singapore, a government agency that supports Singapore companies locally and as they operate in the region.
A school of public health cannot be on the front lines of this war but there are significant roles to play still when academia and government work closely together. At this challenging time, it is critical that we learn fast from what works and what doesn’t work around containment, mitigation, treatment and prevention. Rapid research will play an essential role in driving policy-making to reduce the impact of Covid-19.
Associate Professor Jason Yap heads up the Public Health Translational Team at the Saw Swee Hock School of Public Health, National University of Singapore. Ruth Lewis is from the United Kingdom and joined PHTT as a research associate after her family relocated to Singapore on international assignment.
Please note that views expressed in guest articles on our website are the authors' own and do not necessarily reflect the views of the Nuffield Trust.
Jason CH Yap and Lewis RF (2020) “Covid-19: The response in Singapore”, Nuffield Trust guest comment.