Lessons from Singapore in a Time of Corona

Singapore is widely praised as one of the countries that reacted quickly and effectively to the rise of the current epidemic. Despite close ties to China, where COVID-19 originated, Singapore managed to keep daily cases below 50 for two months since the first case on Jan 23. Subsequently, cases spiked as borders were closed and Singaporeans and permanent residents fled home carrying the virus home from the US, UK and Europe. More worryingly, the virus has recently proliferated in worker dorms, where workers live in close proximity to one another.

What are some lessons we can learn from Singapore and its experience?

Learn from history

In 2002-2003, Severe Acute Respiratory Syndrome, the original SARS, spread from China to the rest of Asia, killing 33 people in Singapore. SARS was deadly but not especially contagious outside hospitals with lax infection protocols. In 2009, Singapore was hit by H1N1 influenza or swine flu which originated in Mexico. Swine flu was less fatal but far more contagious compared to SARS. As a consequence, government agencies facilitated a strong working relationship between scientists and the public health community, added to healthcare capacity, expanded and upgraded both medical facilities and research capabilities, created preparedness plans and adopted a whole-of-government approach. The National Centre for Infectious Diseases, was built to handle future pandemics, with more than 300 beds added to the national surge capacity. Doctors were sent to the WHO and the US CDC to acquire pandemic expertise.

All of these led to a rapid response when the Cocid-19 epidemic was at an early stage. Singapore quickly imposed travel restrictions, screened arrivals, implemented a test-trace-quarantine regime, with temperature checks in schools and workplaces. 40% of infections were detected through contact tracing while the individual was still asymptomatic, efficiency levels the world will need, as it contemplates re-opening. Social distancing measures were progressively introduced, allowing businesses and people to plan for restrictions, a luxury made possible by its rapid initial response. Contrast this with the big-bang approach in India (four hours before a severe lockdown) and dizzying and contradictory messages prior to shelter at home in the US and UK.

In terms of economics, Singapore built fiscal space during good times by running budget surpluses. This gave it sufficient fiscal tools and ammunition to cope with the massive ongoing economic upheaval. The current stimulus plan exceeds S$50 billion (15% of GDP), drawing on national reserves for the first time since the global financial crisis in 2009. Other countries paradoxically pursued austerity in harsh times (Germany, UK) and giant tax cuts during booms (USA).

Value expertise and competence

Expertise was quickly brought together and organized early. Multi-ministry task forces, various government agencies, local universities, the private sector, and grassroot workers were rapidly deployed, according to their competence and expertise. Public-private partnerships were quickly initiated for the development of diagnostic kits, therapeutics, serological tests, analyzing the virus genome, mapping its spread and developing telemedicine.

Second, the competence of leaders matter. In ordinary times, it may be tempting to put a reality show person in charge of the country or a person who we would love to go to the pub with. But as Warren Buffet famously said "Only when the tide goes out do you discover who's been swimming naked." Singapore is best known for its effective, technocratic, non-corrupt, government who adopt a long-term perspective. The same is true for New Zealand, South Korea, Taiwan, Germany and New Zealand. The key differentiator is expertise and competence and not autocracy vs. democracy. The state of Kerala in India is another striking example.

Pay attention to incentives

If tests are expensive, people will not show up for tests. So Singapore created an extensive network of free-access and specialized clinics. If hospitalization and treatment is expensive, people will choose to quarantine at home, infecting family members and close acquaintances. So Singapore made treatment free with a few exceptions. You have to eat during a quarantine. So the government provided and paid for meals those who were quarantined. Later, employers were mandated to look after the needs of employees, serving stringent stay-at-home notices.

To disincentivize Singaporeans from going to countries experiencing an outbreak, Singapore cut hospital subsidies for Singaporeans, Singapore residents and long term pass holders if they are admitted as suspected COVID-19 patients within 14 days of returning. Non-Singaporeans who violated quarantine had their work permits canceled and some were barred from re-entry, including a permanent resident.

Initially, the government was covering hospital fees for Singaporeans and foreigners alike. Once there was a spike of patients from neighboring countries, short-term visitors had to pay the entire cost of hospitalization and treatment.

If people are fired during a crisis, frictions in labor markets prolong unemployment as firm-worker matches are broken. Therefore, the government, like in many countries, simply paid a portion of employee wages to ensure labor hoarding during the crisis. In the future, Singapore may have to rethink policy design. It is more efficient to create unemployment insurance, instead of relying on a plethora of plans and incentives as substitutes.

Combine digital technologies with human skills

Every day, sometimes twice a day, the government sends a detailed update on Covid cases and updates on social distancing policies. An AI tool translates the WhatsApp update from English to Chinese, Malay and Tamil, the three major languages in Singapore. While the algorithm produces an initial draft of the translation, this is vetted by civil servants before being sent out.

Temperature checks at initial stages of the crisis created snaking queues so the healthtech agency IHiS and a local startup, Kronikare co-created iThermo, a device that scans people’s temperature as they walk by and alerts staff to those with higher temperatures.

Contact tracing of confirmed cases and their contacts was done through painstaking labor-intensive tracking, enforced quarantines and meticulous social distancing. A medical team given two hours to create an activity map for each case. Subsequently, a contact tracing app TraceTogether, using Bluetooth technology was created. The government however remains realistic about the use of artificial intelligence in health care, that AI is not a magic wand. For instance, such apps cannot pick up on nuances that human workers can, such as false positives and negatives. In Israel, for instance, a woman waving at someone through a window was promptly quarantined.

Singapore recognizes that digital solutions work effectively only when supplemented with manual tracing and human judgment. Intoning digital, AI, creates a false sense of confidence that technological solutions will zoom in to save the day.

Transparency and communication

At the core of Singapore’s success is effective communication and a commitment to transparency. These are needed to build cooperation among the public, to prevent rumors, conspiracy theories, and curtail panic.

Transparent communication is key to an effective response to a public health crisis (or for any crisis). Everyone knows this but few practise it, whether these are political or organizational leaders. Here is PM Lee's first speech, with a mix of calm and humor. He even mentions a run on noodles.

Here is Boris Johnson, downplaying the threat and risk.

And President Trump's speech acknowledging the crisis seriously for the first time, after weeks of claiming it would miraculously disappear. Subsequent press conferences have been increasingly bizarre and farcical.

At least, the US and UK have daily press conferences. Others like India, the Prime Minister does not hold regular press conferences, except one off announcements of major policy changes.

Meanwhile, in Singapore, communication has been clear, transparent, and reassuring from the Prime Minister, from regular updates by various task forces, and 2-3 daily updates on WhatsApp sent to all subscribers since late January.

On April 3rd, Prime Minster Lee announced enhanced measures to limit the spread of the disease. Interestingly, he wears a pink shirt in all major announcements.

Recognizing the long-term commitment needed from citizenry, countries should follow a strategy of persuasion instead of coercion. Going forward, this will be even more critical as people tire and compliance falters.

A marathon and not a sprint

Initially, Singapore held down new cases to a manageable number for nearly two months. However, on April 3rd Singapore announced a "circuit breaker" from 7 April until 4 May, with schools and most workplaces finally shuttered to slow the spread of coronavirus. Singapore, like other countries went into lockdown (called circuit-breaker here). Two shocks lay led to the shutdown. As countries rapidly started closing borders, Singaporeans and permanent residents returned home, inadvertently carrying the virus, especially from the US and UK, the two countries that had very slow responses. Next, an even greater proliferation in the last two weeks originated in dormitories where migrant workers live in tightly packed quarters. Cases in these dorms continue to rise even as the government does extensive testing, introduces quarantine procedures, and builds new accommodation for the virus-free and beds for the infected. Of the 728 new cases reported on April 16, 654 or 90% are residents of dormitories. A single dormitory, accounts for 22% of all cases in the country.

Many countries are seeing a flattening of cases and deaths after 2-3 weeks of lockdown. People are cautiously optimistic that the epidemic is over and that life, markets, everything will revert to normal. But this is only a semblance of normality and Singapore provides a cautionary tale. Like the Spanish flu, we can expect waves of infection and cycles of containment and decontainment. What is critical is that restrictions are lifted cautiously when economies are reopened, with political leaders setting expectations of return to lockdowns. Simultaneously, countries must undertake a warlike effort to build healthcare and testing capacity.

Perils of globalization

Going forward, if we want to return to a world of movement across borders, we need a synchronous end to the epidemic. This is unlikely, since the virus has not yet spread to many countries and continents, and there are vast differences in health care capacity and institutional capability in managing the pandemic.

To minimize the risk of secondary waves of infection, borders must be opened sequentially and to countries where we can be fairly confident that the spread has been successfully contained. This, in turn, implies that a quick return to the previous world of globalized travel is a distant prospect. Instead, we may see a bifurcated world with travel only among a subset of countries that have sufficient healthcare capacity and can effectively carry out test-trace-quarantine procedures. These are likely to be advanced economies and countries with competent leaders and good institutions. Countries where the infection rages will be shunned, falling into a forced autarkic state, denied access to global trade, global value-chains, and movement of people.

Paradoxically, global cooperation, of which we see few signs today, is the only route back to the globalized world.

Perils of inequality

Singapore is a rich country, futuristic enough that the newest season of HBO's Westworld was shot here. But to keep the country gleaming and working, a vast army of workers from poor Asian countries carry out essential work of repair, construction, domestic work, etc. Many of these workers live in crowded dormitories and cramped quarters, sharing rooms and bathrooms. While the government had been monitoring that their salaries are paid on time, the high-density living meant that they were always at risk of becoming virus hotspots.

Now think of slums in developing countries, in India, Nigeria, Philippines, and Bangladesh, where density is even higher, sanitation poorer, and overall healthcare capacity sparse. These countries will struggle to arrest the spread of Covid-19. For many people, from the urban slums in Manila and Mumbai to favelas in Rio, social distancing is an unattainable privilege. Is herd immunity the only option for such places? How will the socioeconomic structure of these countries survive if the poor die in vast numbers while the rich soldier on lamenting the lack of preferred food stocks?

The poor in these countries who usually provide the workforce and services to keep cities running have temporarily migrated back to rural areas. When countries reopen and potentially re-close, reverse migration will be needed. Will economic incentives be sufficient to compel them to continually undertake such moves or do policymakers have to worry about flattening migration curves? The gig workers, in the meantime, are allowing the rest of us to shelter in place, while running infection risks. How long before such workers stop choosing livelihood over lives ?

Unlike the Black Death that reduced inequality and triggered a significant increase in real wages in Europe, the current epidemic is revealing the contours of inequality, across countries and within countries.

Singapore on April 21st extended the lockdown for a month. Many of the choices that it continues to make will provide a window into future for the rest of the world. Only time will tell how the world eventually emerges on the other side of the pandemic. While Singapore can lead by example, its future ultimately rests on choices made and outcomes in the world as a whole, over which it exercises scant control.