Our country, Singapore, has managed to contain the spread of the SARS-CoV-2 virus within its borders, as have mainland China, Taiwan, Hong Kong, and South Korea. Commonalities of these successful responses include extensive preparation in the wake of the severe acute respiratory syndrome (SARS) outbreak in 2003, aggressive testing and transparent case reporting to both domestic and international stakeholders, swift and decisive interventions to promote or impose social distancing, and frequent and consistent public health communications.
Singapore was one of the earliest countries to detect Covid-19 and in early February was near the top of the confirmed cases list by territory. Yet there has been no exponential rise in cases to date. Some of the reasons for these are unique to the Singapore system, which invested heavily in outbreak preparation and building health care infrastructure capacity building after the SARS wake-up call. Others, however, offer more broadly generalizable lessons that we have learned at the disease level as well as at the community, health system, and national levels.
As doctors who served as frontline physicians at Singapore’s Communicable Disease Center during the SARS outbreak and are now involved in responding to the Covid-19 challenge in the country, in the spirit of international cooperation we are sharing our experiences and observations that may be of benefit to other countries, systems, and individuals during this global challenge.
A whole-government response
Beginning in 2003, Singapore built a task force across multiple government agencies to coordinate interventions and messaging during any future pandemics. This task force was tested in 2009 during the H1N1 pandemic and again in 2016 during the Zika outbreak. It was reassembled by January 2020 for SARS-CoV-2.
One clear example of essential inter-agency cooperation was between the contact tracing teams of the Ministry of Health and the Singapore Police Force for the purposes of rapidly determining links between individuals with confirmed Covid-19 and their contacts.
Singapore’s biomedical research and laboratory community was similarly mobilized. Over the years, the Singapore government has consistently prioritized the development of innovative clinical diagnostics, with the creation of a national Diagnostics Development Hub in 2014. With this integration between researchers, technology transfer offices, and industry, a test kit was successfully created through this avenue for clinical service by Feb. 9.
Scaled screening using public health preparedness clinics
Testing every citizen may not be feasible and can overwhelm labs. Finding a way for the health system to manage its volume to quickly identify and triage the highest risk patients is vital.
Singapore did this primarily through designated public health preparedness clinics. These private clinics — there are approximately 1,000 of them across the country — provided primary care physicians with additional training and preparation for outbreaks. Patients displaying respiratory symptoms receive government-subsidized treatment and medication at these clinics, including up to five days of medical leave for them to stay home and avoid transmission to others.
The government covered costs of testing and treatment
High-risk Singapore residents with suspected Covid-19 undergo diagnostic testing at no cost to them. All health care costs for Singapore residents with confirmed cases of Covid-19, including hospitalization, are borne by the government, which reduces barriers for individuals seeking help.
Aggressive but targeted quarantine measures
Quarantining close contacts of those diagnosed with Covid-19 and the use of “stay home notices” for workers returning from countries with community transmission of SARS-CoV-2 have limited or broken viral chains of transmission. These targeted actions have helped reduce the pressure on the health care system.
Stay home notices are unique to Singapore. They are similar to quarantine orders, in that they are legally enforceable, but are used as a precautionary measure for residents of Singapore who have returned from territories with active community spread of the virus, rather than those who are close contacts of an infected person. People who flout these notices may be prosecuted under the law, although the penalties are not as severe as for those flouting quarantine orders. To relieve the financial impact of quarantine, the government provides a daily SGD 100 ($75 US) allowance to self-employed individuals. For employees, quarantine is classified as paid hospitalization leave.
An emphasis on public health communication
Public health communication has been rational, transparent, and frequent, with uncertainties and gaps in knowledge specifically acknowledged. Multiple communication approaches have been adopted in both traditional and social media channels.
There is ongoing engagement between the public and leaders of civic society. With a national level WhatsApp group for one-way messaging, the government delivers trusted information frequently and consistently to the citizens of Singapore. Other instant-messaging groups have been created allowing two-way discussion between frontline clinicians and Ministry of Health senior officials.
When public anxiety and panic buying peaked on Feb. 7 after the announcement of a heightened state of alert regarding SARS-CoV-2, the prime minister gave a televised address to the nation that was calm, analytical, and reassuring without pulling any punches. This quickly allayed public anxiety.
Rally around health care workers
During an epidemic, we fight a war against disease, and health care workers are the soldiers. Everyone must rally around their efforts.
As physicians, the two of us directly witnessed the impact of SARS on the health care community in 2003. Health care workers were initially shunned by the public as possible carriers of SARS. But as health care workers became infected, and some died, public sentiment changed and generous donations post-SARS led to the creation of the Courage Fund, which was aimed at providing relief to SARS victims and health care workers.
In the Covid-19 pandemic, the public has rallied around health care workers from the beginning, with an outpouring of gratitude and encouragement via social media and physical gifts (including food and thank-you cards). The Courage Fund has also been substantially topped up by corporate and individual donations.
The most likely scenario is that SARS-CoV-2 will continue to spread around the world for the foreseeable future, perhaps eventually becoming endemic. Its threat will not be completely eliminated, even in the optimistic scenario where a safe and effective vaccine eventually becomes commercially available. Sustainability over the long term is crucial, as fatigue is inevitable.
Even in Singapore, the current efforts are an adaptive response that will need further calibration as the pandemic evolves.
Li Yang Hsu, M.B.B.S., is the program leader for infectious diseases at the Saw Swee Hock School of Public Health of the National University of Singapore. He is the former clinical director of the National Centre for Infectious Diseases and former director of the Singapore Infectious Diseases Initiative, and published the first SARS case series from Singapore in 2003. Min-Han Tan, M.B.B.S., is the founding CEO and medical director of Lucence, a molecular diagnostics company headquartered in Singapore and Palo Alto, Calif.
While Singapore’s public health response to Covid-19 has been exemplary, I wonder if the exceptionally slow spread of the disease compared to other countries may not also be due to other factors. High temperatures and particularly high absolute humidity have recently been identified as retardants of virus spread: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3556998.
It’s possible Singapore has benefited from being located in the tropics. Indonesia, with a much more primitive health system, but also large exposure to the Chinese epicenter, has also registered few and slowly growing case numbers (if indeed the numbers are credible).
Hey world! Learn from Singapore!
Like in politics, learning from the past is crucial; and the “Singapore Approach” seems to be the best possible. But eliminate freedom in a radical way, to boost security and health will not and can not solve this and other Problems.
And amazingly Singapore is not on “lockdown”, unlike countries such as the UK which have imposed more serious measures such as shutting small businesses. Hopefully those measures work out though they come too late. Better to start out restricting a little, than to have to scramble like the UK now.
Why do you have 54 new cases today?
Mostly imported by people returning from the US and UK. Read the news!
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