26 April 2020

Was Singapore just unlucky in its coronavirus fight?

For want of a nail?

Singapore's coronavirus response has been lauded as a golden standard for the international community, an oasis of technocratic competence. In as little as 3 months since the virus arrived in Singapore, a massive outbreak has hit its guest worker community and its sterling reputation.

The media narrative paints a compelling story: Singapore is a poster child that merely got unlucky. Its technocrats had the situation in hand by following the protocols it developed from its encounter with SARS 2 decades ago. They had just an unfortunate, single blind spot in an area no one could predict. To use Benjamin Franklin's retelling of the proverb of the nail, "a little neglect" of Singapore's overcrowded and unsanitary dormitories led to the failure of Singapore's battle against coronavirus.

Wallace Tripp, 1973 illustration from
A Great Big Ugly Man Came up and Tied his Horse to Me: A Book of Nonsense Verse
Like claims that Chan Chun Sing did nothing wrong, this narrative works only in a vacuum of context. Singapore's response in the short period before Dorscon Orange was announced and proper measures kicked in was inconsistent, contradictory, falteringand even outright sneering and insulting. Paying close attention to Singapore's handling of the coronavirus from Dorscon Orange on 9 February to the lockdown on 3 April will reveal that this is a far cry from the "golden standard" accolade heaped upon it by the mainstream media.

But what did Singapore do right?

Singapore's coronavirus response is based on the influenza pandemic protocols it developed from its painful and costly experience with SARS in 2002. Sufficient similarities between SARS-CoV and SARS-CoV-2 and strict adherence to this protocol enabled Singapore to keep the rate of transmission to single digits in February and early March.

The SARS protocol consists of measures by both the general public and in hospital settings:
Frequent hand washing is a hygiene measure which directly decreases infection in the public via touch and fomites;
Temperature screening at public areas detects early symptoms and limits access by sick individuals (but aren't useful for a virus with a long incubation period);
Registration to enter public areas facilitates contact tracing;
Twice-daily temperature checks;
Rigorous contact tracing;
Isolation protocols protect hospital staff from infection by aerosol generating procedures critically ill patients and special ventilated rooms for confirmed and suspected patients;
PPE protocols protect medical staff and patients from hospital acquired infections of the virus; and
Independent development of multiple tests by different organisations reduce false positives and false negative rates and misdiagnosis.

What went wrong when Singapore did everything right?

Luckily for Singapore, SARS and Covid-19 are similar enough. Unluckily, it didn't realise there were key minor differences and continued to respond by sticking to its model answer. Evidence from the global phase of the pandemic indicates the coronavirus is more infectious than the SARS virus and has a longer incubation period. Politicians sanctioned expert recommendations insofar as SARS era protocols were concerned but there appears to be resistance to adapting the existing SARS protocols to the novel coronavirus.

Social distancing was seen as part of the quarantine measures an incompetent or unlucky West had to resort to. Yet Singapore's social distancing measures would not have been put in place if a "private group" of karaoke enthusiasts from the ruling People's Action Party's patronage network (the "People's Association" and "Residents' Corners") had not contracted the coronavirus in a lavish Chinese New Year celebration featuring raucous communal food tossing.

When the news broke out of their infection, Singaporeans took umbrage that these beneficiaries of Singapore's patronage system had organised a mass gathering in the face of global social distancing, and a defensive government had no good defense aside from quibbling over minor details and screaming "fake news".

Singapore's elected legislators continued to organise walkabouts and community visits, apparently in preparation for an imminent general election. Even after some weak social distancing measures were announced, politicians (both ruling party and opposition MPs and candidates alike) and their entourages visited multiple locations in a day, with the prime minister of Singapore even dispensing free sanitizers and face masks to crowds.

Composite photo courtesy of The Online Citizen
And right in the middle of the lockdown, MP Dr Chia Shi-lu, a practising surgeon who should know better than any layman, went on a spree distributing masks at hawker centres and apparently took selfies with just about every food vendor he met. He claimed he observed social distancing laws set out by the government. He claimed he wasn't even campaigning, just educating the masses. This not-walkabout has nothing to do with the ruling party's decision a day later to suspend walkabouts. The good doctor should know that social distancing also includes reducing social contacts and socialising, and lockdowns are designed to reduce these to a minimum.

For Singapore's political class, honoring the spirit was clearly far less important than fulfilling the letter of social distancing measures.

Singapore missed or ignored signs that the SARS-CoV-2 virus is far more contagious and infectious. It missed out on early social distancing and did not pay sufficient importance to it. This may explain why nearly a month into Singapore's lockdown, a significant proportion of ordinary Singaporeans still do not take social distancing or even lockdown measures seriously.

But how did Singapore get blindsided by the outbreak?

Singapore's adherence to SARS protocols enabled it to track the growth of the virus in a timely and accurate manner. New infections, critical cases, death counts and contact tracing details were provided daily by the Ministry of Health. Test counts started appearing on 7 April but have not been consistently updated.

However, the presentation of daily data by the Ministry of Health suggests a tension between medical-scientific priorities and PR agendas. In the early months, the daily count was segregated into "imported" vs "local". When numbers started to experience a bump due to repatriated Singaporeans, the media pushed a narrative of a "second wave" of infections from returnees. When guest workers began getting infected, case numbers were then segregated into "foreign workers" vs "local", then "dormitory and long term work permit holders" vs "community", and then at publication time of this article, "community" vs "dorm residents" and "work permit holders not residing in dorms".

The shifting granularity of this data presentation is based on a foundation of sand, not science. This is not the standard presentation of data by the WHO or even the Worldometer. To put it bluntly, this is window dressing and impression management. Impression management is evident from the mode of Singapore's daily coronavirus briefings. Unlike the UK, US, or even Malaysian daily briefings, Singapore's is generally not televised or streamed for the public. They are chaired by a panel of a gaggle of ministers and just 1 solitary expert, with the ministers doing most of the talking - the opposite from say the sterling UK daily briefings. In Singapore, journalists listen to talking points and craft the message of the day for a public that isn't trusted to know better or to be invested in the developing crisis. This mode of communication is not merely elitist or patronising; it has the effect of divorcing the public from the coronavirus fight to the extent that they become apathetic and eventually resistant to adhering to protocols that may need to be implemented in an instant, such as a lockdown.

Everyone participates in the danse macabre, highborn or low, spiritual or earthly their domain
This attempt at impression management by segregating numbers is not justified by science. Whether an infected person is "imported" is irrelevant. They are or were physically in Singapore, interacting with its physical environs and interacting with the public in public settings like international conferences and social gatherings and commercial exchanges. Whether a person has returned from a different country where they were infected is irrelevant. They are now in Singapore, sometimes breaking quarantine orders to eat bak kut teh. Whether a person is a foreign worker residing in a dormitory or otherwise is irrelevant. Guest workers are physically in Singapore. They may return to their dormitories at the end of the day but they work here, are supervised by local or permanent resident foremen, take public transport, take naps at void decks, pray at local places of worship, shop at local malls, occasionally eat at local coffeeshops. What part of "community" do they not belong to? This segregation is just plain wrong given the epidemiological understanding of community.

Yes, guest workers are part of the community both in a social and epidemiological sense. They constitute a distinct sub-community but one that, to anyone familiar with epidemiology and network science, is intermeshed with "locals".

This impression management is not just unnecessary and wrong, but harmful. Presenting a count of less than a handful of new "local" cases a day takes away the urgency and seriousness of the pandemic fight. People may not be in a state of constant panic, but they were certainly lulled into an apathy instead of being alerted into proper levels of concern. This again may explain why nearly a month into Singapore's lockdown, a significant proportion of ordinary Singaporeans still do not take social distancing or even lockdown measures seriously.

This misplaced obsession with impression management and dressing up of case numbers blinded Singapore's coronavirus task force to the true second phase of a pandemic—the phase known as community seeding. Early global trends indicate a pattern of 8 to 10 days of case numbers doubling and the start of an outbreak. This tipping point was reached in the middle of March, where numbers had doubled twice in the space of a fortnight.

Doubling pattern as depicted by ChannelNewsAsia
But remember, the lockdown in Singapore only began on 3 April. From the numbers, Singapore's lockdown came 2 or 3 weeks too late. The dormitory outbreak began on 9 April. As incubation of the virus can take up to 14 days, it can be posited that delaying the lockdown directly led to the infection and massive outbreak in the dormitories of guest workers.

While the politicians played games with the real numbers produced by the medical experts in the coronavirus task force, community seeding and a massive outbreak occurred right under their noses.

Nero and a burning Rome

No comments: