Introduction
On 23 January 2020, the first case of a novel coronavirus in Singapore was announced.1 This caused a shiver down my spine, reviving memories of the SARS disaster in 2003, where 8,096 people were infected worldwide, causing 774 deaths. It had precipitated panic buying and impacted the travel and tourism industry, then suddenly disappeared after six months.
The first COVID-19 case in Singapore was a 66-year-old Chinese national who came from Wuhan. The next day, two more cases of this illness were diagnosed, the 37-year-old son of the first case, and a 53-year-old female, both from Wuhan. Initially we dubbed the illness "Wuhan virus", but as there were objections in laying the blame on one city or place, it was renamed COVID-19, referring to the coronavirus and the year in which the respiratory illness was announced – 31 December 2019.2 The virus strain causing this condition was named "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2).
Disease Outbreak Response System Condition (DORSCON)
Initially we were unduly over-optimistic in thinking that Singapore's cases of COVID-19 were only those who had travelled to or from Wuhan. Unfortunately, on 4 February, four Singaporeans who had not travelled to China, but had been in contact with people recently arriving from China, contracted COVID–19.3 This meant that COVID-19 could be transmitted fromperson-to-person without overseas travel. Therefore, on February 7, the Minister of Health raised the DORSCON level from yellow to orange.4
The immediate reaction to this announcement was a frenzy of panic buying. Some of my family even joined the long lines queuing up for toilet rolls, tissue paper, rice, instant noodles and bottled water. I went to the pharmacy intending to buy surgical masks and hand sanitisers, but they were already sold out on the very first day. This stampede sprouted a number of smaller shops engaging in profiteering by price-gouging and scalping.5 I regularly pass by one store that sells hand sanitiser and surgical masks for exorbitant sums and am astonished by the queues of people who allow themselves to be exploited.
How did Singapore do?
From February to March, when COVID-19 first appeared in Singapore, we did several things right. This enabled us to fight it effectively, and we even earned praise from the World Health Organization (WHO). These included the foresight several years earlier of building a new centre, the National Centre for Infectious Diseases, to cope with epidemics. We also quickly developed an accurate test for diagnosis, the polymerase chain reaction test using nose or throat swabs. We activated a speedy efficient contact tracing programme, initiated a policy of travel restrictions, and stay-home and safe distancing measures quite early on.6
So, what went wrong? Several things. We discouraged asymptomatic members of the public from wearing face masks and only reversed the policy later. We were a bit slow in closing schools, shops, entertainment centres and sports facilities, and we did not stop people from eating at restaurants and hawker centres until the number of cases continued to rise. But the major problem arose in the third month (April), when we diagnosed hundreds of foreign workers with COVID-19. This was attributed to overcrowded dormitories. Fortunately, most of the migrant workers were asymptomatic or mildly symptomatic.7
Circuit breaker
This new term was introduced on 3 April 2020. It describes measures to stop the spread of COVID-19. It intensified safe distancing and isolation by closing schools, shops and non-essential businesses, enforced by fines and other punishments. Unlike a complete lockdown seen in other countries like South Korea and Italy, it allowed some movement out of the home and essential businesses were allowed to operate. Visually, one could compare the completely empty streets in countries with total lockdown measures with the Singapore streets where you could still see people walking their dogs, jogging or cycling without masks. Thus, the circuit breaker is only a partial lockdown. It was originally scheduled for four weeks, but was extended for an additional four weeks due to the rapidly rising number of infected migrant workers.8
Air travel
To prevent the further spread of COVID-19, many countries stopped foreigners from entering their borders.9 Air travel came to a standstill and many airlines are facing bankruptcy.10
My family had booked a holiday to Taiwan for February 2020. But the moment we heard that a 55-year-old female from Wuhan was diagnosed in Taipei with COVID-19 on 20 January,11 we immediately cancelled our trip. Unfortunately, we only got a partial refund from the airlines and the hotels. I have since heard from a number of my friends who were barred from travelling to South Korea and North Italy, and they did not get refunds for their air tickets.
Stay home
My family stayed home but we soon became bored. We tried to keep ourselves occupied by learning to paint, playing the piano, reading more, etc. Although watching movies and other television programmes, in my opinion, is not optimal, we eventually surrendered to these mind-numbing inactivities.
Luckily, modern technology has softened the harsh effects of social isolation. Using social media like WhatsApp, I could communicate with my married children who have set up their own homes, and I would wave and talk to my grandchildren. I also keep in touch with friends and colleagues through these platforms. Much of our discussions centre around COVID-19 and how the world is coping with it. For light relief, we watch and discuss Donald Trump, who must be one of the world's most notorious entertainers, but his advisers have recently stopped his daily public reports.
Some of my friends stuck at home have discovered new hobbies such as gardening, cooking, photography, etc. Some have ordered all their groceries online, with free delivery if you spend more than $150. The lack of exercise and the easy access to food in the fridge have caused some of us to gain excessive weight.
Impact on Singapore businesses
Business is slow. Neighbourhood hawker stalls remain open but have fewer customers because more people are dining at home, and several food stalls in my regular food court have gone out of business. To salvage the situation, the Government has been giving hawkers rental waivers.
McDonald's has been temporarily shut after some of their staff caught COVID-19. Branded bubble tea shops have also been closed as they are considered nonessential drinks, and on the eve of their closure, I laughed at the long queues of fanatics trying to get their last gulp of this oriental pearl. With the hairdressers also shut, my hair looked like a hippie's.
I would normally never get a seat at my favourite restaurants, and now that the seats are empty, we are not allowed to wine and dine. Wedding dinners were postponed, my Lunar New Year reunion dinner and my social club dinners were also cancelled. I miss going out for a meal with my friends.
Other businesses affected
Most retail shops are closed. I cannot buy any clothes, books, magazines, cameras and computers. All bars, clubs, theatres and cinemas, and local area network gaming shops are also closed until further notice. I have been writing musicals for children every year for the past two decades, and my co-writers and I were hoping to stage a new musical for differently abled children this year. But with the closure or postponement of all live theatre performances, we had to push back the performance dates.
Hotel rooms are also empty and tourist resorts are deserted. Tenants in Changi Airport, especially the newly opened Jewel, are empty but they are getting rental rebates. The Government predicts that we are headed for an unprecedented recession.12 Though they are bailing out several industries, which is welcome, it may not halt the impending recession.13
The only businesses flourishing during this crisis may be the manufacturers of toilet paper, surgical masks, antiseptic hand-washing solutions, food delivery services and e-commerce online retailers. Pharmacies are open, but to get your new glasses at the optician or to see a dentist, you need to make an appointment. Lawyers are doing well as there is a surge in clients asking for advice on issues ranging from employee rights and wrongful dismissals to visitation rights for divorced parents.14
Singapore healthcare
All healthcare workers have been affected by the outbreak. As doctors, we are one of the professions privileged to continue with our practice. While the public sector seems overworked, the private sector appears to be quiet. All visitors to my clinic have their temperature checked at the main entrance downstairs, and they fill in a declaratory form which asks if they have travelled overseas. My paediatric patients still come for their vaccinations and minor illnesses. Their caregivers wear masks during the consultation, but masks hide their expressions, making communication a bit more difficult.
Patients with fevers or suspected of having COVID-19 infection are seen in the Accident and Emergency department. To see them, I have to don a special personal protective equipment (PPE) gown and a surgical mask with a transparent protective screen – boiling hot underneath and soaking with sweat. Fortunately, the few children I saw turned out not to have COVID-19.
Telemedicine, where you can consult a doctor via a smart device, is flourishing, because patients cannot catch COVID-19 through mobile phones.15 I regularly get calls from overseas from my old patients asking for advice, but I do worry if this form of remote healthcare carries hidden hazards and legal risks.
Singapore medical education
Medical students at all three medical schools in Singapore are barred from going to the wards and their lectures are cancelled. They receive distant learning by watching webinars and lectures online. Even their final graduation examinations no longer require them to examine patients in the flesh. No need to palpate lumps, listen to heart murmurs, or do a neurological examination. It makes me wonder whether this will affect the quality of newly graduating doctors. As for selecting medical students, medical schools are no longer conducting face-to-face interviews; one talks to the interviewers via Zoom. Multi-mini interviews, in which one is presented with different scenarios, are still retained at some admission interviews. It would be interesting to see if this method successfully chooses good doctors.
Many of my former students returning home from overseas were placed on stay-home notices. They tell me of their weariness and boredom being cooped up in a room for a fortnight. One student was isolated in a first-class hotel and he appreciated the good fortune of enjoying good food and views. Fortunately, all these students have computers and handphones which allow them to watch YouTube and Netflix movies, as well as engage in virtual interaction using social media, and this keeps them sane.
For practising doctors, our continuing medical education meetings are now webinars where we watch and interact with speakers online. So far, the speakers are quite entertaining and knowledgeable, and I was quite surprised by how enjoyable this form of education can be.
Global perspectives
China announced its first case of the novel coronavirus on 31 December 2019. Since then, it has spread like wildfire to over 200 countries in the world.16,17 Initially many governments failed to take the pandemic seriously; it was only after it had infected hundreds of thousands of subjects, that these countries belatedly tried to curb the dissemination. Often a government would lock down an entire city or state. This froze the economy, causing unemployment, bankruptcies and homelessness. Only food supplies and groceries were allowed to remain open during the lockdown. Countries that have adopted these stringent lockdown measures have succeeded in containing COVID-19, but at the cost of economic chaos.
What about poorer developing countries? They will be hit harder than richer countries.17, 18 Foreign investors have already started to pull out, and these less developed countries do not have safety nets to withstand the economic withdrawal. Demand for their commodities has collapsed, as has their tourist industry. Many of these nations currently do not have piped water or good roads, and their health services are already overstretched. When a deadly pandemic invades these countries, there will be an almighty crisis.
Sadly, the US President has decided to cut off funding for the WHO, which might accelerate the problem.19
What have we learnt so far?
COVID-19 is the worst catastrophe of the 21st century, worse than the 2003 SARS global epidemic that only lasted sixmonths before disappearing. COVID-19 is also a global affliction that has affected the health, economy and geopolitics of the world.20 Nearly all aspects of our lives are being changed. We have discovered that we can work tolerably well at home, and can conduct education and businesses through the internet. Many jobs are disappearing, thus affecting our incomes. We are being taught, the hard way, to be more careful with our spending and hopefully we can learn to save for future rainy days.
Many of us have forgotten that much of our economic success is dependent on migrant workers. We must learn not to ignore the foreigners in our country. They deserve more care and respect. As for the fact that infections spread more rapidly in overcrowded living conditions, this is nothing new. Indeed, there is a local publication from 2017 pointing this out.21 It is imperative that we provide safe and hygienic accommodation for our migrant workers.
We should adopt the credo that one can hope for the best, but one must be prepared for the worst. Pandemics have come and gone over the centuries, and there is no reason to suppose that they will not reappear in another time. Health must come before wealth. Hence, we should ensure that enough is being spent on preventive healthcare for the future.22 Currently we are developing some vaccines and we keep our fingers crossed when they will become available.23
Rising from the ashes of tragedy is not just one, but a whole flock of creative phoenixes. We have seen so many original works of art, satirical cartoons, music parodies, wonderful orchestras and choirs joining from all over the world to create inspiring performances. I hope to see the birth of a new era of all the arts.24
Healthcare workers are at the front line of this pandemic. They have courageously and tirelessly been working to protect us from this disease. We owe them an immense debt of gratitude. Thank you!
Let us join hands to fight this adversary. Together we can overcome!