My isolation cell felt like a scene from A Clockwork Orange. Three white walls. Grey concrete floor, a white plastic chair. A bottle of pink hand sanitizer at the entrance, a white curtain tied to one side. Overhead, white fans whirled frantically, working together with other strategically placed ventilation units to fend off the ninety-degree tropical heat in the tented screening area. Six feet across from me, a man in his sixties coughed. A few minutes later, a young doctor arrived, fully suited up in plastic, eye goggles, and respirator. She stuck a long cotton bud further and further up the man’s nose, so far in at one point it felt like the entire thing would disappear inside his head. I let out a sigh of relief as she pulled the bud out and stuck it inside a test tube, twisting it shut. At least he didn’t scream.
A week earlier, on the 3rd of March, I had flown home from San Francisco to Singapore. The plane was almost empty: I had the entire row to myself, got bumped to the near-empty forward cabin, and the kind stewardess plied me with chocolate and other snacks. No one in early March wanted to travel to Singapore, which at one point in February had dominated the top of COVID-19 infection charts globally with a hundred-odd cases.
Who knew the tables would turn so quickly? As COVID-19 exploded in the West, Singapore kept infections largely under control, earning praise from public health experts as the “gold standard” for containment of the virus. Over the past month, Singapore’s pandemic response has been covered in dozens of flattering news reports, often listed with a handful of other countries in Asia praised for ‘flattening the curve.’
I am not a fan of nationalist takes on pandemic response, which take our attention away from the real science and public health questions that need answering. Defeating the virus is not an individual Olympic sport. It’s also fairly obvious that Western countries were caught flat-footed by not taking the virus as seriously when only Asian countries were affected. Nor are we past this virus, not by any chance—Singapore has seen a flood of imported infections, mostly from returning Singaporeans and long-term residents fleeing Europe and North America. On March 22nd, Singapore, a major Asian air-hub, made the surprise announcement to close its borders to visitors for the first time ever, after increasing numbers of infections—almost 90% on one day—were being traced to Singaporeans returning from the U.S. and Europe, especially from the United Kingdom. Singapore Airlines, our flagship carrier, grounded nearly 95% of flights. Rows of planes sit empty along Changi Airport’s hangars, while the indoor monorail, bereft of passengers, continues to motor across the man-made jungle and waterfall at the dazzling new Jewel Mall, an apocalyptic version of the future without human life.
Singapore has been pursuing a strategy of aggressive containment since the first COVID-19 case was detected on January 23rd. At first, the level of infections appeared under control, with daily new cases reduced to single-digits at one point. But despite the travel ban and increasing social distancing restrictions, local unlinked cases (where Singapore’s much-feted contact tracing teams are unable to find the source of transmission) continued to increase. On April 3rd, the government announced that all workplaces except essential services would be closed for a month from April 7th, with all schools and day cares to close the next day. Rather than using ‘lock down,’ ‘shelter-in-place’ or ‘emergency,’ Prime Minister Lee Hsien Loong described the measures as a ‘circuit-breaker.’ In a few days’ time, Singapore will step into the unknown. But will this be enough to break the chains of transmission?
Every day in the war against COVID-19, we seem to be writing a new page of human history. An hour feels like a day, a day feels like a month, sometimes even a year. A month ago, I arrived home on flight SQ 32; never did I expect commercial flights from the U.S. to Singapore to be shut down before the month ended.
This is the last SQ flight to Singapore, the pilot announced on the last Singapore Airlines plane leaving America. This is the last flight to Singapore.
I started coughing two days after returning home from America; on the plane, my throat started feeling scratchy, although I felt otherwise fine. Frankly, I was not surprised. During my two week stay in Oregon and California, there were far more sick people around me than back home. The sore throat and sniffles went away in a day and there was no fever, but the cough went on and on. I stayed at home for four days, and on the fifth, booked myself an appointment at a PHPC or public health preparedness clinic.
Observers of Singapore often make sweeping statements like ‘authoritarian’ or ‘surveillance state,’ failing to notice how finely calibrated the public healthcare system is, how many levers the government has, and how much thought has gone into the entire process of preparing for a global epidemic. It was not something I grasped either, until I was thrown into the system.
The PHPC scheme, what our Ministry of Health calls “an important line of defence during public health outbreaks,” are general practitioner clinics that are heavily subsidized, to encourage the public to see a doctor the moment they feel unwell, instead of staying at home trying to self-medicate and save costs. Treatment, including medication, only costs S$10, while for those above 60 years of age, the total cost is S$5. In addition to subsidizing treatment, all patients with flu symptoms receive five days (paid) medical leave to rest at home. If their symptoms deteriorated, they were advised to go back to the same doctor or go straight to the hospital. Instead of allowing the virus to lurk undetected, the PHPC scheme acts as a dragnet, flushing out the virus and containing it as early as possible. This ‘early warning system’ works like a tsunami-warning system: a network of buoys that sense the waves before they come crashing, in effect protecting our hospitals from what has convulsed Wuhan, Italy, Iran and now New York: the ICU surge.
I entered my postal code into PHPC’s website (https://www.flugowhere.gov.sg/), a directory of over 900 clinics, and the search turned up 47 clinics within two kilometers. At the clinic, I tell the doctor my symptoms and my travel history to the U.S. None of it excites him, until I tell him that a friend I sat next to at a conference later messaged us to say she had pneumonia. His ears pricked up. The next thing I knew, he was asking me to take off my flimsy surgical mask and put on an N-95 respirator. His eyes flickered with fear, and in his fear I realized what it means to feel ‘diseased.’ Go to the nearest A&E, he said, and give them this letter:
Patient confessed to meeting 1 colleague with pneumonia in USA. ? if covid.
Despite my indignation at the word ‘confessed’—had I not done the socially responsible thing?—I promptly reported to the nearest emergency department, and as a potential COVID-19 case, was directed straight to the screening area. I ventured up a long ramp where a nurse in scrubs, goggles, and face mask greeted me, taking my vitals. My oxygen saturation rate was close to 99%. What does that mean? I texted a doctor friend. Good! she replied. I was ushered to an isolation cell, where after waiting for almost an hour, the attending emergency doctor arrived. But unlike the PHPC doctor, she did not seem concerned about my friend in the U.S. with pneumonia. “Common cold,” she pronounced after a physical check-up, promptly sending me home.
During my stay in Oregon in February, I happened to discuss the then unfolding COVID-19 crisis in Asia with my American host. Singapore was in control of the situation, I said, because Singaporeans trusted the government. It wasn’t an issue of trust, my host countered, but community. In assessing how different regions survived Hurricane Katrina, it was towns with the strongest sense of community that best survived disaster. In other words, the towns where neighbors knew Mrs. Jackson was in a wheelchair and needed help leaving her house, or if you had too many eggs but knew your neighbors well enough, you would just share (and receive) whatever excesses you had. But aren’t those ties, too, founded on trust? Trust in other human beings, whether at a local level or national level, is what lifts us above the flood.
As San Francisco and other counties in the Bay Area became the first in America to announce lockdown measures, I stared at the traffic outside my office window, overlooking a prominent retail street in Singapore. Japanese housewives pushed prams laden with groceries on hooks, Caucasian kids on scooters dodged bumps on the pavement, a group of Singaporean and Bangladeshi workers in hard hats gathered around some roadworks. Perhaps America needed more forceful rulings because they didn’t have in place the kind of ‘soft’ movement control measures Singapore had implemented for weeks, together with aggressive containment, early detection, contact tracing, and a brand new Infectious Diseases Centre.
If we think about human interaction as a series of intersecting circles, Singapore initially adopted a ‘soft’ approach towards social distancing, working to make the circles smaller and smaller instead of a ‘hard’ lockdown. Schools and daycares remained open for more than two months during the initial containment phase of Singapore’s response. In late January, when the DORSCON (Disease Outbreak Response System Condition) alert was raised to ‘orange,’ my children’s daycare began restricting visitors: parents were banned from stepping into the school, and could only pick their kids up outside. At larger primary and secondary schools, activities were split by years or building floors, with teachers and students restricted to separate floors, again to try and reduce the intersection of activity circles. The same guidelines apply for hospitals, where doctors and nurses have worked in split teams for almost two months already, with interaction minimized at all times and social activities canceled. These restrictions have grown in scale as cases increased, with the government most recently introducing a one-meter social distancing law requiring all restaurants and food-and-beverage outlets to maintain a one-meter distance between customers.
These plans did not spring up overnight: in many ways, Singapore, like other Asian countries, has been planning for another pandemic since the SARS outbreak in 2003. I was at college in America during SARS, and remember the news of countless health worker deaths in Singapore sounding so distant, so remote from California’s eternal blue skies. Collective scarring from the SARS outbreak triggered Singapore’s long-term planning. When the long tail of COVID-19 leaves us, how will governments overhaul their public health systems, if at all?
“You came back from America two weeks ago and you’re still coughing? Get your ass in here now,” my friend, an emergency doctor, barked at me over the phone. I dutifully packed a bag—I knew what to bring now—full of books, a phone charger, my laptop, and headed back to the same emergency department. Displeased to see a repeat patient, I was attended to within minutes: whisked away to take my chest X-ray, where the technician nodded with approval (lungs clear). Then came the moment I had been fearing. To call it a nose swab feels like a bit of a misnomer. “Slow and gentle,” I told the emergency doctor, a young man who looked like he was fresh out of medical school. “I might scream.” I had done a laryngoscopy some years back, a procedure examining one’s airway with a tiny fiber-optic camera. The cotton swab followed the same pathway up my nose—and then it broke through the barrier, reaching for my eyes. A visual map of my nasal cavity began to form before me as I experienced sensations in a part of my body I never knew existed before. As I cringed, I concentrated on something a friend had told me: just an ugh, and it’s over. And then it was.
“I see you’re not on the list today,” joked a friend who knew I had been tested for COVID-19. More than half a million Singaporeans have signed up for the government’s daily WhatsApp announcements, which include health information, government warnings, and a daily case total. (Initially, each case was accompanied by a lengthy paragraph describing the patient’s case and travel history, but as imported cases accumulated and the daily total went from single to high double digits, these details were shrunk into a daily spreadsheet.) For several days, I imagined how my own case write-up might look like: 37/F, returned from the United States on 3rd March and developed flu-like symptoms…the more I worried about my results, the more it began to feel like an obituary. But on the third day after the test, a text message arrived:
COVID swab for Sxxxx is negative. If more unwell, pl return to NUH A&E.
Singapore is a tiny island nation-state, with no more than 5.7 million residents—about two thirds the population of New York City on approximately two-thirds the land mass. It has become a knee-jerk reaction for armchair critics in the West to use labels like ‘draconian,’ ‘authoritarian’ and ‘surveillance state’ to dismiss anything Singapore does effectively. Track citizens using their phones? An invasion of privacy! Quarantine incoming arrivals? What an abuse of human freedoms! But what if aggressive contact tracing, social isolation, and centralized quarantine may be the only effective methods to slow the virus down? What if the West’s overriding concern for personal freedom, and preserving the supremacy of the individual, is exactly what has made it so easy for COVID-19 to rampage uncurbed?
I dislike cultural arguments as much as nationalist takes on pandemic response. There may be cultural aspects to why solid, evidence-based epidemic control measures like contact tracing and social isolation work better in more ‘collectivist’ societies which have a stronger consciousness of ‘the greater good’ and ‘social responsibility.’ But in Singapore, as in ‘Confucian’ societies like South Korea and Japan, there have been plenty of rule-breakers: people who flout quarantine orders, even after testing positive. The difference is simply a case of punishment and deterrence: rule-breakers in Singapore have been stripped of their residency status, or had their passport canceled. Is that ‘draconian’ or ‘authoritarian’? You may call it what you like, but as a Singaporean, I call it effective. The day we can shift the conversation about COVID-19 away from political and culturally tinged debates, to a conversation about effective governance and public health measures, is the first step in turning the tide against what will surely be a long and protracted fight against this invisible enemy.