Migrant workers have traditionally and widely been deemed a cost-effective means to our society's ends – an invisible presence that is readily replaceable if "defective" in any way. How can we change this narrative, and see and treat them as one of us?
The medical community tends to know HealthServe as a "charity clinic for migrant workers". Co-founded by Dr Goh Wei Leong in 2006 and based on Christian values, we started as a small general practice clinic within a repurposed school compound along Geylang Lorong 23.
In our early days, the clinic served all segments of vulnerable populations, be it construction workers, domestic helpers, sex workers, the old or the poor. Caseworkers supported injured workers who had strained relationships with their employers. Not only were these workers evicted, they also often had their medical care reneged on and were threatened with repatriation before proper medical treatments or workmen compensations could be awarded.
In the early 2010s, HealthServe pivoted to focus on the most vulnerable of low-wage migrant workers; there were after all other agencies caring for patients from the other sectors. These low-wage workers would in recent years be reclassified as work pass holders in the Construction, Marine and Process sectors.
In time, dentists, specialist doctors and allied health volunteers stepped forward to support our growing services for the increasing number of patients, marking the start of HealthServe's journey towards professionalism. Two additional clinics were set up at Westlite Jalan Papan and Westlite Mandai dormitories.
Recognising that depression and psychosocial distress were common but often overlooked issues among migrant workers, we launched our mental health programme in 2019. The team engaged employers and workers to build awareness, looking to open doors for conversations and early intervention programmes.
There was, however, little interest until COVID-19 hit in 2020.
The power of partnerships in a pandemic
"If you want to go fast, go alone; if you want to go far, go together".
The Disease Outbreak Response System Condition Orange level dealt us an unprecedented blow – overnight, HealthServe effectively lost almost all our volunteers to movement restrictions imposed on healthcare professionals. From three clinics, we hunkered down to one centre at Geylang.
Unfazed, the handful of doctors available strove to keep our evening clinics running. I recall nights where we sent the last patients off after 11 pm, well past our usual 9.30 pm closing time. This, we knew, was unsustainable.
The Ministry of Health's quick approval for our pivot to a hybrid telehealth practice in early March 2020 was a godsend. Doctors could then dial-in from the safety of their homes or clinics via Zoom, facilitated by other volunteers onsite. This has allowed us to continue serving the migrant workers visiting our clinics till today.
Still, there was only so much a tiny organisation of 20 staff could muster in a crisis of tsunamic proportions, but the flotilla of friendship, goodwill and support was soon on its way.
The first time I met Dr Tam Wai Jia (founder of Kitesong and project lead of My Brother SG) was with the National University Health System team at ground zero on Good Friday. The recce trip to Sungei Tengah Lodge opened our eyes to the magnitude of the fear and sense of doom the migrant workers were experiencing. We were also linked up with the National Healthcare Group-National Centre for Infectious Diseases and SingHealth teams, which opened up engagement opportunities with more migrant workers across Singapore and allowed us to exchange clinical notes and share best practices in a rapidly evolving situation.
It was also with the support of like-minded partners and donors that we were able to deliver immediate aid across the island in all forms and manners. Emergency rental support to avoid migrant workers being evicted and homeless, large-scale care pack distribution, and dormitory visits in full personal protective equipment were just some of the more visible social assistances and engagement efforts provided. Behind the scenes, the team was also handling inbound calls for assistance around the clock, scheduling tele-counselling sessions and referring workers to other agencies for help, just to name a few.
So began a chapter of new partnerships and collaborations that has enabled HealthServe to support even more distressed migrant workers during the pandemic.
Increased chronic disease management needs
Employers are mandated to provide all forms of in- and outpatient medical care for their workers. This includes chronic medical conditions including hypertension, diabetes and dyslipidaemia.
However, most workers are fearful to be seen by their employers as sickly, lest they are replaced by younger "disease-free" compatriots. Many will self-medicate or procure medication from back home because unsubsidised healthcare in Singapore is unaffordable – an S$18/day basic wage remains commonplace.
The closure of international borders due to the pandemic put an abrupt stop to in-country medication supplies. Workers developed health complications and ended up in hospitals during the circuit breaker; many others presented to frontline medical teams with high blood pressures and glucose readings. While no official figures have been conclusively collated, the prevalence is estimated to be anywhere between 5% and 15%.
We publicised our GP services (with a flat fee of S$15 inclusive of consultation and chronic medications) for frontline care teams to refer or discharge migrant workers to us. Behind the scenes, we lobbied for more support, as we knew the load would be untenable. Our joint efforts with hospital counterparts paid off – we were glad (and relieved!) when government agencies and their appointed vendors soon came in to provide for the workers.
Moving ahead, the Ministry of Manpower (MOM) has requested for the private sector to propose a new self-sustaining primary care system for migrant workers, broken down into six sectors and premised on a capitation model. This is a clear departure from the pay-as-you-use outpatient service that Singapore is familiar with, and recognition that it is untenable to build a skilled (and older) workforce that has no chronic disease burden.
For our migrant workers, a capitation model is expected to significantly improve their access to medical care, a laudable development indeed. After all, if the employer has already paid for the service, why stop the workers from utilising it?
Some observers have expressed concerns over how capitation programmes have historically tended towards under-servicing, to the detriment of enrolled members. But with appropriate technology-enabled supervision and audits in place, clinical outcomes and effectiveness can be readily tracked, mitigating this risk. Other immediate challenges raised include the pricing model, given the lack of precedent utilisation data as well as the propensity for overuse-abuse. There will be other unexpected turns as we forge ahead, but they too can be resolved so long as we as a society believe that migrant workers deserve to live a life of dignity.
Beyond physical healthcare needs
These workers undergoing lockdowns were in a bad place mentally. Swamped with misinformation and pressured to still send money home while effectively jobless, panic, distrust and depression were further stoked by herd instincts within cabin-fever-inducing living conditions.
Our mental health team responded promptly with a tele-counselling service, alongside a new multilingual COVID-19 microsite for migrant workers with the latest updates on factual and official medical information to combat the spread of misinformation. Together with other non-governmental organisation (NGO) partners, ground-up initiatives and friends from the hospitals, we worked with government agencies to push out health messages in various native languages.
Recognising the need to build a clinically sound and sustainable model, an evidence-based psychosocial case escalation framework paired with a structured training programme was also promptly developed. This was led and overseen by senior consultant psychiatrist and HealthServe board member Dr Chan Lai Gwen.
Within a month, an army of more than 100 multilingual volunteer psychiatrists, counsellors and allied health professionals from all walks of life signed up to support our thrice-a-week night counselling sessions for distressed workers.
A poignant moment amid the flurry of Zoom breakout rooms was when a counsellor spoke one-on-one with a worker calling from a toilet cubicle, phone in one hand and a noose ready to hang himself with in the other. After the conversation, the worker thanked us for giving him perspective and hope, and for changing his mind.
These experiences, among others, would form our collective learnings for operating a 24/7 helpline service and its ensuing case management protocols.
HealthServe in the new norm
"The new normal... get there, we will... with no one left behind to fend for themselves and with as few casualties as possible along the way."
– Prime Minister Lee Hsien Loong's address to the nation on 9 October 2021
Today, HealthServe is a member of the Project Dawn taskforce (led by MOM's Assurance, Care and Engagement Group) and the mental health support framework for our migrant workers.
We launched the nation's first multilingual 24/7 crisis helpline dedicated to migrant workers in August 2021, expanding our earlier tele-counselling service. Samaritans of Singapore, with decades of experience operating a suicide helpline, has been an invaluable advisory and training partner.
To further destigmatise mental health issues, peer support leaders are progressively being trained across dormitories island-wide as part of Project Dawn initiatives. Coached in the fundamentals of psychological first aid, these ambassadors are empowered to engage their peers, identify psychosocially distressed colleagues and escalate them for further care early.
There remains much to do ahead, and we hope for more research, preventive health and education. We hope also to engage the young, inspire more ground-up initiatives and innovate new solutions to bridge what many see as two disparate worlds. We are calling out for volunteers – to dream and journey together with us, to inspire more to come alongside as we continue to serve the migrant workers' community in tangible ways.
But ultimately, migrant workers' welfare and well-being are not just MOM's or NGOs' responsibilities. Their welfare is the nation's collective welfare. And the sooner we recognise this, the better off we are as a nation at achieving happiness, prosperity and progress together.
If anything, this pandemic has shown that we all share a common fate with intertwined destinies – regardless of gender, nationality, fences, walls and barbed wires.
How you can help
Should you know of any migrant worker in distress, or anyone who wishes to seek assistance for migrant workers, call HealthServe’s 24-hour crisis helpline for support: +65 3129 5000.
To find out more about volunteering with HealthServe and other ways you can contribute, visit https://www.healthserve.org.sg/volunteer-application or connect with us at https://www.linkedin.com/company/healthserve.
A Personal Experience – Excerpts from an Interview with a HealthServe Beneficiary
Mr Badaat (not his real name) is a patient whom HealthServe assisted following a serious workplace injury in early 2020. The incident involved his hand which required surgical reconstruction.
In addition, there was a persistently painful and swollen left lower limb due to an undisplaced fibula fracture that went undiagnosed for over six months – caused by a series of miscommunication and unfamiliarity with Singapore's healthcare system.
When he finally sought help from HealthServe in October 2020 for his foot pain, our casework team promptly accompanied him to hospital appointments and facilitated obtaining the requisite medical reports and documents to expedite his work injury assessments and compensation claims.
Concurrently, Mr Badaat started intensive occupational hand therapy with HealthServe. While there remains some impairment, he is grateful that we helped him achieve significant functional improvement over the course of one year.
As of this writing, his notice of assessment has just been issued and he is relieved at the compensation that will be awarded.
The following are excerpts of a translated audio interview where he would like to encourage other workers not to be afraid to come forward to seek help for their work injury cases:
"HealthServe actually helped me a lot for one year from lockdown till now. When I first came to HealthServe, I was very scared and lacked courage.
But now, I feel really good, and I find HealthServe very beautiful in the ways that they helped me: through therapy, financial assistance, food, soap, shampoo, helping me understand my case, my insurance claim – in every way basically.
... I simply can't put in words how useful HealthServe was for me. Those of us who were in lockdown and managed to get help from HealthServe had a much easier time... The things we couldn't afford or lacked, [they] helped us fill that void.
... HealthServe is here to help. Hence, I really reaped the benefits from HealthServe. Honestly, the state my hand was in when I first came in, it really improved through therapy, and now my hand is pretty much almost normal and good. My shoulder and back as well have really improved compared to what it was in the past."