Letter from Singapore – Dr Christopher Ng (B2 1983-87)

Covid-19 : The Singapore Experience from a frontline healthcare worker perspective

After leaving Marlborough College in 1987 and then qualifying as a doctor from St Mary’s Medical School, Imperial College in 1995, I returned home to Singapore to pursue a career in Obstetrics & Gynaecology (O&G). In 2003 when I was working as an O&G registrar in KK Hospital, this was when SARS (Severe Acute respiratory Syndrome) broke out in Singapore which infected 238 people and claimed 33 lives including doctors. This was my very first real experience as a frontline health worker fighting an outbreak that put health workers as well as patients at risk. We had to learn how to don PPE gear and N95 masks in order to protect ourselves and to attend to sick patients. As luck would have it, I happen to be the senior gynaecologist on call when the one and only positive SARS pregnant patient present to my hospital A&E. We had to quickly transport her to the designated SARS hospital and the whole on-call team had to be quarantined at home for 2 weeks.

The SARS ordeal lasted 3 months and this really affected our society and economy greatly so much so that we had to reorganize our healthcare system so as to better control future outbreaks. I left institutional practice to start up my own private clinic, GynaeMD Women’s & Rejuvenation Clinic in November 2007 at Camden Medical Centre. In 2009, H1N1 influenza pandemic came which proved harder to contain but it allowed Singapore to fine tune its strategies and protocols even further so when Covid-19 epidemic emerged in Wuhan China, all the lessons and experiences gain from SARS and H1N1 epidemics were rapidly put into place. The Singapore government set up a multiagency task force (consisting of Ministry of Health, Manpower, Trade and Industry, Home Affairs, Transport, Education, Army, Police, etc) to better coordinate protocols in order to effectively battle Covid-19 should the infection ever come to Singapore.

The Covid-19 infections in Singapore pretty much can be divided into 3 waves. The first waves of patients were the imported cases from Wuhan China. The first case of Covid-19 in Singapore was detected on 23 January 2020 and these early cases were primarily tourists from China. It lead to several clusters which were quickly isolated and shut down. Our local transmissions then began to spread in February and March. The Singapore government’s strategy was very clear from the start and it centred on leaving no stones unturned. All suspected cases were tested and the infected cases were then sent to hospital for treatment and isolation. All close contacts were laboriously traced and closely monitored (with the help of several teams working in shifts 7 days a week) to see if they were infected too. The government was very strict in enforcing “home stay notices” for close contacts and quarantine for people who returned from overseas. Anyone found in breech of these were quickly charged in court with some even jailed. Singapore developed our own Covid-19 test kits and manufactured masks for domestic use and exports. From past experience, we had also stockpiled PPE gear and N95 masks to ensure that we had enough to protect our frontline healthcare workers. In order to improve our efforts in contact tracing, the government developed the TraceTogether App for iPhone and android phones which uses Bluetooth technology to establish close contacts rather than GSP to get round the privacy issues and all Singaporeans are encouraged to use it. Following the Singapore example, Germany, Australia and New Zealand have decided to develop similar tracking Apps. We managed to isolate and break the route of transmission for the known clusters with some restriction to public life to a certain extent without having to resort to strict lock down measures as the numbers were still manageable. There were frequent press conferences by our Ministers in charge of the multiagency task force and addresses by our Prime Minister to establish good lines of communication in the hope of building up trust by the general public which in turn would ensure compliance and make it easier to implement our containment strategies.

Our second wave of infections came from returning Singaporeans / permanent residents who decided that they were safer to return to Singapore than to stay overseas when Covid-19 pandemic appeared to begin to spread out of control for the rest of world. We had to also close our borders to the rest of the world in an effort to stem the spread at great expense to our economy which success story was always based on free trade of goods, services and people. Our strategy of screening, detection, treatment, isolation, contact tracing and containment remained the same. Even up to 20 February, Tedros Adhanom Ghebreyesus, chief of the World Health Organisation (WHO) praised Singapore’s effort in combating Covid-19 and was held as the “gold standard” then with the ability to contain the spread but yet keep the economy and “normal” life going without having to resort to drastic lock down measures.

Unfortunately, Covid-19 proved much harder to contain and our third wave of infections involved our “army” of foreign workers (at least 300000 of them) who came to Singapore to take on jobs that locals were not willing to do (construction, ship yards, sewerage services for example). They basically built the infrastructures and buildings of modern Singapore. Once the infection spread to these foreign workers who resided in crowded dormitories, our Covid-19 cases began to rise exponentially. There were already warning signs that these foreign worker dormitories would potentially be powder keg of Covid-19 infections just waiting to explode but the authorities were a bit slow to mobilize our national resources to try to prevent the spread even though the possibility was realised. Several international headlines now paint Singapore as a “cautionary tale” and a lesson to the world that even the best-laid strategies may be derailed by the highly contagious coronavirus. With this third wave of cases along with an increasing number of unlinked community cases, the Singapore government had no choice but to implement stricter “circuit breaker” measures on 7 April in an attempt to break the rate of community transmission and more importantly to control the spread amongst the foreign workers residing in the dorms.

Two different strategies had to be employed to control the spread amongst the general population and the foreign worker dormitories because of the diversity in living conditions.

1. a) For the general public, these circuit breaker measures involved stricter movement controls (no leaving the house unless to buy groceries or food or seek medical attention or work in essential services), safe distancing in public areas, exercise alone and only within your neighbourhood, closure of most businesses leaving only the essential services to operate but with limited capacity and school closures (with home base learning) for example. There was to be no visiting of family members especially if they did not live in the same household. The government had previously provided all households with 4 surgical masks (to be worn only when ill) and hand sanitizers but with the recent circuit breakers and the realisation that Covid-19 is airborne and aerosol transmitted, everyone is now required by law to wear masks whenever they leave the house. To facilitate this, the government provided everyone with reusable face masks to wear.
2. b) The strategy for the foreign worker dormitories was to initially test all those with symptoms and then eventually the asymptomatic ones. All workers are not allowed to leave their dormitories to prevent spread to the general population. The workers who work in essential services and who are not infected are quickly identified and moved into temporary housing so that they can continue to work and not get infected. Those which are tested positive for Covid-19 are then moved out of their overcrowded dormitories into specially prepared facilities where they can be safely cared for by medical staff. They are provided with meals everyday along with toiletries, SIM cards to make phone calls and free Wi-Fi to surf and to keep in touch with their family members back home. All foreign workers are also expected to receive their full month’s pay during this circuit breaker period even if they are not working so that their livelihoods and their families back home would not be affected. As most of the foreign workers are healthy and young, most can be cared for in these temporary medical facilities until they have fully recovered to be discharged. Those that do require more medical attention or even ICU care will then be transferred to our designated Covid-19 hospitals for step up medical attention. In this way, even if the infection rate amongst our migrant worker population is high, we can treat the ones that require more help and our medical hospitals will not be overwhelmed. We can then hopefully keep our mortality rates low. This ambitious exercise to test all 300,000 foreign workers will take weeks to months to finally accomplish and is a monumental effort requiring various government and private sector agencies but the government is determined to make sure that we isolate and treat all affected workers. We owe it to them as they helped build modern Singapore and this would send a powerful message to future migrant workers contemplating of working in Singapore knowing that they will be well taken care of should they fall ill. We are increasing our daily testing capabilities to match our ability to house and care for all these newly infected workers.

Singapore has just passed our 100 days of battling Covid-19 on 30 April. Just to put things into perspective, on 1 April we had approximately 10 infected foreign workers living in the dormitories and 1000 cases in our community. As a result of the rapid outbreak and aggressive testing in the foreign worker dormitories, we have officially 17,548 Covid-19 cases in Singapore with 16 deaths and 23 still in ICU as I write this article on 2 May 2020. 15758 (89.8%) are foreign workers living in dormitories and factory accommodation with 1790 (10.2%) community cases (Singaporean, permanent residents, expatriates and imported cases). We have so far managed to keep our mortality rate low (0.09% which is one of the lowest in the world) because we have been able to prevent wide spread infections in nursing homes (where the elderly are) so our hospitals and vital ICU beds have not been overwhelmed coupled with the fact that the majority of our infected cases are relatively young, healthy foreign workers. With our stricter circuit breaker measures in place since 7 April, our daily number of new community infections have decreased. By 1 June, we hope that we will be able to get this figure down to single digits and then we can start implementing sustainable long term strategies to reopen our economy and define what the new norms will be until a cure or vaccine can be found. This would be our next major challenge and the trick is how to achieve this without risking another wave of infections.

How this has impacted me as an obstetrician & gynaecologist in private practice is that my staff nurses and I are required since January 2020 to wear a surgical masks for the whole day in clinic which can become very uncomfortable at the end of the day. We look forward to our lunch breaks which gives us a chance to temporarily remove our masks. Lunch breaks are staggered so that we eat at different times and eat in different rooms in my clinic in order to reduce social interactions to the bare minimum. Since the stricter circuit breaker measures were implemented on 7 April, as we are considered an essential service, I can continue to see my patients but only limited to those who are pregnant and those with emergency / urgent gynaecology problems (miscarriage, ectopic pregnancies, restricted infertility treatments, infections for example). All elective operations have to cease until the circuit breaker period is over so that vital resources (staff and hospital beds) can be utilised to fight Covid-19. I also have to restrict my gynae surgeries, obstetric deliveries and admission of patients to only 1 hospital in order to reduce the risk of interhospital transmission. When I operate, I have to wear the N95 mask and protective goggles in addition to my operating gown just in case I operate on an undiagnosed Covid-19 patient which of course makes it increasingly hot and uncomfortable. I am only allowed to drive to work and have to return home once my clinic closes. When I arrive home, my wife (who also happens to be an obstetrician & gynaecologist) and I do not hug, kiss or greet our 2 children but immediately proceed to have a long shower first. Only then will we dare to interact with them so as to reduce the risk of inadvertently bringing any infection home. (I have attached a photo of myself attending to a patient at Glenealges Hospital A&E who needed urgent gynaecology surgery about 4 weeks ago. As she had returned less than 2 weeks ago from overseas, the hospital could not take any chances with her so it was mandatory to attend to her in full PPE gear).

At the end of all this we will all have to reflect and take a comprehensive review of this pandemic. We will have to learn from our mistakes and to see where we could have done things better with the benefit of hindsight with the aim of improving so that the same mistakes will not happen again. For now though we should focus on bringing this outbreak under control, to take care of our community and migrant workers and to figure out how we can exit from the circuit breaker and resume normal activities safely. This will not be easy for a country like Singapore in which it is almost taken for granted that everything works efficiently like clockwork. When we finally recover from all this and as we pick up the pieces and mend our shattered economy we will have to summon up courage, persistence and collective wit to reshape our future. In the meantime, I wish everyone good health and stay safe.

Dr Christopher Ng (B2 1983-87)