Reporting of Daily Cases- Is Singapore’s approach objective or obfuscating?

[This is written in my personal capacity but my views are clearly influenced by my experiences as a board member of HealthServe dealing directly with the dormitory and migrant worker issues and also as a public health academic involved in a number of COVID-19 related projects]

Gist of the post- The breaking up of the daily cases into different categories based on work pass type and residence is reasonable given the different strategies to address outbreaks in each of the sub-populations although there is risk of downplaying the need for a concerted 'whole-of-Singapore' effort and also risk of inciting ill-feelings towards the migrant worker population

The above taken from the Ministry of Health website (29th April 2020, 10.25 am) is typical of the daily reporting and case breakdown. The pertinent points are:

1.      Total number of cases = ‘Imported’ (self-explanatory) + Work Permit holders (not in dormitories) + Dormitory Residents [Who are typically Work Permit holders] + ‘Community’ (which is defined by exclusion: everyone else not in any of the earlier categories)

2.       The Dorm Residents and Total graphs have the same axis- 500, 1,000, 1,500 and not 20, 40, 60 etc, signalling very clearly the majority of the cases are from the Dormitories with small, niggling numbers from the Community and Imports

Positives of Reporting in this Way

1.      From an intervention perspective, it clearly shows where the major challenges are; this is also consistent with the view that the Dormitory setting is so fundamentally different from the Community that different strategies are needed

2.      The Work Permit holders who are not in Dormitories typically reside in private apartments scattered throughout Singapore but mainly concentrated in Little India, Eunos and Chinatown. They thus interact with the wider community but with the imposition of Stay Home Notices (equivalent to a home quarantine) on 20th April, they now effectively constitute much like the Dormitories' workers sub-populations with different behavioral characteristics and different support needs

Negatives of Reporting in this Way

1.      ‘Discriminatory’ towards the Work Permit holders and Dorm residents, further separating and marginalizing them from the rest of Singapore society

2.      False sense of security and complacency among Singapore residents in the ‘Community’ that their situation is well under control

3.      Fails to recognize there is still porosity between the sub-populations, e.g. essential workers in the dormitories are still performing their duties and potentially interacting with Singapore residents, Singaporean dormitory operators and security personnel, the many staff involved in catering, the FAST (Forward Assurance Support Team) officers who go home every day to their families

My thoughts

It is not unreasonable to report in this manner given the greatly differing circumstances, challenges and constraints in the sub-populations. Yes, there are risks of downplaying the seriousness of the situation in Singapore nationally and there are risks of fueling discrimination against an already vulnerable population. But what are the alternatives?

Yes, one could argue that the government could share publicly the consolidated numbers only and reserve the breakdown for its officers and those involved in the crisis response who would better appreciate the nuances. However, the scale of the operations is so large and so complex involving thousands of persons that ONE set of publicly released figures, or ‘one source of truth’ would be logistically the easiest to ensure all have the same fact base.

Furthermore, transparency is important in times of crisis to garner trust and confidence and we should acknowledge the efforts by the government to provide the information as plainly and yet as comprehensively as possible. Conversely, any attempt to have different reporting formats may give rise to accusations of ‘covering up’ and efforts at obfuscation.

There are clearly different strategies for different groups and hence separated out reporting enables these groups, and the effectiveness of the different strategies to be individually examined even as national agencies need to piece these together to derive a holistic, integrated 'big picture'.

a.      Imported cases by definition come from outside Singapore, and if they are properly separated from the community through the mandated 14-day quarantine, then the risk of transmission is low

b.      Community cases can come from the ‘reservoir’ of asymptomatic positive cases moving around in the community themselves unaware of their status and their risk to others, the so-called unlinked cases. They can also be linked cases or secondary cases arising from exposure to and infection from known cases as some members of the Community as mentioned above still need to regularly interact with COVID positive cases. The strategy hence of social distancing, mask wearing etc is the right one for the Community. The mental model that everyone is a potential positive case including oneself is the right approach and the resultant behaviors will need constant reinforcement by persuasion, incentives and penalties.

c.      Dormitories cases should transmit mainly to other dorm residents if there is transmission and not by and large into the wider community. Hence they can reasonably be counted separately The Dormitories strategy is an effective lock down of all workers and slow ‘release’ of the workers who test negative and are needed to perform essential services. The lock down protects the Community (where Singapore seniors and other most at risk of poor outcomes from COVID-19 reside) rather than the workers.

The challenge with the breakdown of cases as what the Ministry of Health has done is what happens if and when there are other substantial clusters in other vulnerable groups such as residents of nursing homes. Should we count them separately and add another graph? And if there is still another outbreak in dialysis centers? Or in a major tertiary educational institution with hundreds of cases? Another carve out and yet another graph?

Where there can be criticism would be in the reporting of the number of tests and which populations have been tested. The summary of the number of swabs tested posted on the MOH website is more than a week old (!) as below:

Given the ministerial and senior public servants’ comments on the prioritization of swab tests across the dormitories with high rates of infection, other dormitories, other vulnerable settings such as nursing homes etc, it would be relevant to provide data on these so that the public can better understand and place the top line numbers in the appropriate context.

In this respect, the press release 2 days ago (https://www.moh.gov.sg/news-highlights/details/scaling-up-of-covid-19-testing) is useful in articulating the strategy and principal considerations even if the comparisons of the dorm testing rates were inappropriately compared with national data from South Korea.

Every piece of information released can and does give rise to more questions and casual commentary which will require resources to respond to. In sympathy to my former colleagues in the Ministry of Health, there are many other priorities and I can understand the reluctance to share more and more data. This somewhat narrow task-focused lens does prevent other actors not directly involved who might have useful perspectives to offer and he right balance has to be struck. My view here is that there is sufficient information released for external parties so far, and interested persons can comment usefully, contribute valuable insights or point out useful directions of inquiry.

I don’t think there is necessarily a good or bad way of reporting- simply there is a way of reporting that helps the public to understand and secondarily allows all those involved in operations in some way to appreciate the ‘big picture’. There will be limitations in all ways of presentation and other indices might be useful for those keen to dive deeper. Other measures will also be needed to balance out and compensate for the deficits in the base reporting. Here credit to the government for the website covidsitrep.moh.gov.sg which has a wealth of information presented in multiple different ways:

Finally, I would hope the government welcomes proposals for alternate presentations of the data. There is no monopoly of good ideas and one only needs to recall the revamp of the national train system maps to appreciate that sometimes, others do know better ??.

The Singapore train system map was revamped in Dec last year with public acknowledgement of the contributions of the public particularly in redrawing the 'Circle line' as a circle and making it the focal point of the map (https://www.channelnewsasia.com/news/singapore/cliff-tan-architect-redesigned-mrt-map-praises-lta-version-12179488)

Singapore's approach in presenting data is defensible as there are clear merits to considering the different sub-populations separately given the different strategies for each. That said, there are serious risks in such communications and active measures should be taken to counter or mitigate these. It’s a learning journey for everyone and a smart government will can incorporate the best insights from everyone.