This pandemic—the new disease Covid-19, the virus SARS-CoV-2—is not Singapore’s first epidemiological nightmare. In 2002 and 2003, Severe Acute Respiratory Syndrome, the original SARS, tore out of China and through Asia, killing 33 people in Singapore and sparking wholesale revisions to the city-state’s public health system. “They realized they wanted to invest for the future, to reduce that economic cost if the same thing were to happen again,” says Martin Hibberd, an infectious disease researcher now at the London School of Hygiene and Tropical Medicine who worked in Singapore on SARS.
So Singapore instituted new travel controls and health infrastructure. Then, in 2009, it got hit again—with H1N1 influenza, the so-called swine flu. “Pandemic flu came from Mexico, an Americas event, and Singapore tried to put in place in 2009 what they learned with SARS,” Hibberd says. “But flu was much more difficult to contain than SARS was, and they realized what they thought they’d learned didn’t work. It was another lesson.”
When Covid-19 came around, Singapore was, it seems, ready. Along with Hong Kong, Taiwan, Japan, and South Korea, Singapore instituted strict travel controls and protocols for identifying sick individuals—to get them help as well as to find the people they’d been in contact with. The Singaporean government posted detailed accounting for how many people had been tested for the virus, and the locations and natures of those people’s social contacts. All these governments instituted strict social distancing measures, like canceling events, closing schools, and telling people to stay home. As a result (at least in part), all have lower numbers of infected people and lower fatalities than China or Italy, proportionately. They “flattened the curve,” as public health experts now say—lowering a probable spike of infections, perhaps pushing that surge of seriously ill people further out in time so that health care systems don’t get overburdened.
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The lessons these countries learned could be instructive for places further out on the timeline—like the United States or most of Europe, which still lags a couple of weeks behind the virus’ spread through Italy, where there have been hundreds of deaths and the hospital system is so slammed with seriously ill people that it’s beginning to institute triage measures. These places offer models for what to do next, laying out best practices for how to respond to the pandemic with fewer deaths, to get a case fatality rate closer to South Korea’s apparent 0.8 instead of Italy’s 6.6.
Detailed data can also tell epidemiologists what to expect about the dynamics of the disease, helping guide more targeted responses. “Highly detailed surveillance data will be critical for understanding the outbreak,” says Justin Lessler, an epidemiologist at the Johns Hopkins School of Public Health. “It is this sort of detailed analysis that will be critical for answering key questions about the role of asymptomatic people and children in transmission.”
Here’s how those Asian countries are doing it: According to a new article in The Lancet, Hong Kong, Japan, and Singapore all developed their own tests for Covid-19 as soon as the genetic sequences for the virus were published, and ramped up production of the materials necessary for those tests. (That’s a sharp contrast with the US, which still doesn’t have enough tests for nationwide use, and may actually be running out of the materials necessary to make them.) Each country instituted controls over immigration (a controversial move that the WHO recommended against, but that they did anyway). They rejiggered their national financial systems to make sure people didn’t have to pay for tests or treatment. (Easier in places where most health care is already nationalized, to be sure—and in some more progressive American states like California, Washington, and New York. In fact, New York Governor Andrew Cuomo even ordered paid sick leave for quarantined people and free hand sanitizer.)
Taiwan actually combined its national health care and immigration databases to generate automated alerts based on travelers’ potential for being infected. On January 20, when China had reported only a few cases of the disease, Taiwan spun up a Central Epidemic Command Center—created after SARS—to coordinate the national effort. Among other things, the CECC put limits on the prices of personal protective equipment like masks, and deployed military personnel to manufacture more. In the US, mask shortages led the Food and Drug Administration to relax the rules on what kinds of masks health care workers can use; on January 20, Taiwan’s equivalent of the Centers for Disease Control and Prevention announced that it had “44 million surgical masks, 1.9 million N95 masks, and 1,100 negative pressure isolation rooms” ready to go, according to an article in the Journal of the American Medical Association.
People in Singapore, for now, get information from multiple government websites, frequently updated, as well as from a government WhatsApp account. People get their temperatures taken before they can enter most buildings, including businesses, schools, gyms, and government agencies, because fever is one of the main symptoms of Covid-19. (According to my sister-in-law, whose family has lived in Singapore for six years, everyone whose temperature is normal gets a sticker, and people are expected to acquire two or three stickers every day.) Hibberd, who’s in Singapore now working on the new coronavirus, says, “On every lift I ride, there’s a notice saying what I have to do. Everywhere you walk there’s information … There’s a confidence in that information, in the government and what they’re saying, and there’s an expectation you should follow it.” The country gives a bit of money to people who don’t have the kinds of jobs that support being out of work—and fines people who don’t follow the rules.
In at least one hospital, the experience of SARS led to a complete reimagining of the ways physicians deal with patients. One article from personnel in the radiology department at Singapore General Hospital describes keeping teams of health care workers separate from one another in case one has to be quarantined, and physical separations for different kinds of patients—all sorts of seemingly small systematic changes that limit the spread of an infectious disease. As one Singaporean researcher told The Guardian, “We don’t do anything different, we just do it well.”
These countries all have social structures and traditions that might make this kind of surveillance and control a little easier than in the don’t-tread-on-me United States. But then, none of those countries are China, either, with its full-on surveillance state. “Copying China would have a big impact on the economy,” Hibberd says of Singapore. “But everybody getting the disease quickly and the country panicking would also have a big impact on the economy.”
So Singapore is taking a middle path, he says. Of course, if the disease continues to spread, that approach might get more draconian. “If Covid-19 turns out not to be controllable,” Hibberd says, “then the containment process will change, to not looking for every case but identifying and supporting those cases at most risk of severe disease instead.”
Even that data will be helpful in a broader way, though. Wide-scale testing, as these countries are doing, sweeps up mild cases, people who don’t go to the hospital. That increases the denominator, so to speak. It gives a better picture of how fast and how far the disease spreads overall, which can be compared to the number of people who get sick or die, allowing for a more accurate calculation of the case fatality rate, or CFR. It’ll also bring more clarity to questions about which people are more vulnerable—so far, older people seem much more likely to suffer complications from Covid-19, but is that due to lung damage, immunological weakness, or something else? “That said, we have to be very careful not to generalize case fatality rate estimates from any one country to another,” says Maia Majumder, a computational epidemiologist at Harvard Medical School and Boston Children’s Hospital. “As much as the CFR is a function of case-finding, it’s also a function of quality of care and population demographics.” Singapore’s health system is much better than, say, the one in China’s Hubei province, which got overwhelmed early, and seeing what was going on in China allowed all these other countries time to prepare.
Singapore, Hong Kong, Taiwan, and South Korea all share the characteristic of using their experiences with prior outbreaks to build a system—and then sustaining it. None of them had to deal with the fear of being a first-mover, of being the first city or country to institute seemingly severe countermeasures. Their countermeasures were already in place, waiting to be reactivated. In the United States, all the people ringing the bell the hardest for a Singapore-like approach hope they’ll be heard, and that it’ll work—and so, by next autumn, they’ll seem like fools for having been so worried.
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