It has been 14 weeks or so since the first case of Covid-19 virus landed on our shores. A lot has happened since, with a wave of returning citizens bringing home the virus from epicentres in the United Kingdom, Europe and the United States. These 579 imported cases unfortunately spawned community spread and the outbreak in our migrant worker dormitories.
The community spread led to unlinked cases that started from nine daily to as high as 31 daily before we had to impose “circuit breaker” measures. With the initial and further stricter measures, we have now brought the unlinked cases down to an average of 11 daily in the last week.
To date, Singapore has reported 21,707 Covid-19 cases in total, with more than 19,000 of those being migrant workers in the big dormitories and smaller factory converted dormitories. There are 200,000 workers in the big dormitories that can house up to 20,000 workers each, and 100,000 workers in the smaller factory dormitories that house as few as 20 workers.
The dormitory outbreak has challenged our nation in many ways. The logistics challenges are huge; agencies have had to deploy medical posts in the 43 big dormitories, impose restrictions on movements within these dormitories, swab huge numbers of sick migrant workers, move and house them in communal facilities to monitor them through their illness, and as they are recovering, move them to recovery facilities. The numbers in communal facilities total 10,000, a tally that is steadily rising and could soon double.
The agencies involved in such herculean efforts comprise both private organisations and public agencies. This private-public cooperation is heartwarming to see, as Singapore Inc mobilises under threat from this invisible enemy. There has been criticism of the living conditions of the dormitories but I cannot think of any other nation that has mobilised in such a manner to look after their migrant-worker population.
The other challenge is the healthcare system and the effort to protect it from being overwhelmed. All the herculean effort on the dormitory scene is really to flatten the curve of the epidemic to prevent a massive surge of cases that may overwhelm the ICUs, high dependency units and oxygen points.
Though we have reduced the number of unlinked cases in the community, we are concerned that an outbreak in nursing homes will mimic that in the dormitories. The migrant workers are young and fit due to the nature of their job. The data shows that of those who are 30 years old and below, less than one per cent will need oxygen of any sort.
Hence the huge numbers of migrant workers who have caught the virus have not translated into huge demand on our ICU beds. But a sizeable outbreak in nursing homes will be of a different nature. On the testing front, the number of swabs has increased from 3,000 daily to 8,000 daily currently, and the number of swabs will be further increased five-fold. This is a huge ramp-up, with laboratory workers working non-stop at breakneck speed since January, and the shortage of reagents and disposables as there are limited suppliers globally.
The swab processing is a laborious process; it involves extracting and amplifying minute amounts of viral RNA and takes six to eight hours to execute. The antibody test that can be rapidly deployed and which is as simple as a pregnancy kit has been disappointing. The antibody test detects the viral antibody effectively only after 11 to 14 days of symptoms.
Good ICU care
On the ICU beds front, we have the capacity to double or triple the number needed. Our ICU care is good and we have a low mortality rate so far, although the 20 patients that have perished is one too many. Hence for a drug treatment to be effective, the drug has to perform much better than our ICU care or stop patients from entering ICU. There is a lot of hype around remdesivir.
Trials failed to show that it reduced mortality, but it did reduce the recovery period from 15 to 11 days. To find a drug off the shelf and then to repurpose it for a novel virus is a difficult ask. It is likely that we need to develop a new drug from scratch. As for the vaccine, there are three phases: the first involves 10 to 30 patients and you are looking for immune response and safety; the second phase is with larger numbers of 100 to 300 patients and you are still looking for safety and immune response. The third phase is real-world deployment with placebo-controlled randomised trials.
Realistically, this will take 12 to 18 months, and anything can go wrong during the three phases; then it is back to the drawing board. The race is on between the US and China for a vaccine, making this a geo-political race for prestige and prowess. This pandemic is a combination of health, economic and psychological crises all rolled into one. I would leave the economic aftermath to the economists and have a word about the psychological state of our globe. I like what author and public speaker David Kessler has said about this crisis – that it is a grief reaction.
Mr Kessler and his late collaborator Kubler Ross gave us the definitive stages of grief reaction.
The grief we feel is that of loss of normalcy, fear of economic loss and loss of connection to our social circles. The nature of the fear we feel is somewhat in the future; we dread the fear in anticipation. It is sort of like when a loved one is diagnosed with cancer – we dread the future of the disease and what it brings for us.
The stages of grief starts with denial, where we are sure the virus will never reach our shores and will go away. The next phase of anger results in us blaming that person for coming too close to us, or blaming another nation for the pandemic. Bargaining makes us think if we take pills or supplements, it will not infect us. Sadness permeates us as we wonder when it will all end. The penultimate stage is acceptance where we decide we have to take control of the situation; we have to execute a series of actions of washing our hands, masking universally and working from home.
When we have a plan and execute it, we regain control and fulfil acceptance. There is an ultimate phase of grief reaction and that is to find meaning. We have encountered a once-in-a-lifetime event that has disrupted our lives, halted the economy dead in its tracks and left us hiding in our homes in a curfew-like situation. The virus has infected millions globally, killing a quarter of a million, decimated mighty economies and left the world in fear, grief and resignation.
Yet there are silver linings. The skies are blue, the local PSI has halved, the dust on surfaces has reduced and wildlife and migratory birds have re-emerged. Our family life has become central, there is daily bonding over family meals, young children are amazed that parents are home daily, and exercising with children is a norm. Working from home has made workplace hierarchies less relevant, savings have accrued from reduction in transportation, meals and clothing; staff may actually need less renumeration with reduced costs, office space may shrink as most work can be done from home with today’s technology enablers. The need for helpers and the disincentive of the helper’s levy should be revisited.
That work is also a social need is important; offices may well become meeting places rather than workplaces. With the gradual reopening of the economy and the new normality we have to accept that there will be pain and loss of jobs, assets and destruction of value. This is a time to rally the nation round to face the hardships and the uncertainties the future holds. We have to form alliances, and we have to seek other nations to rebuild our economies together. Our leadership has to pull this off and navigate us through these uncharted waters.
The old adage is true – in the midst of crisis, there is opportunity to re-examine, realign and re-energise our values, our priorities and our prowess.
The race is on to seize the day.