SINGAPORE: It had been a tough year for Singapore.
Then, as 2020 came to its close, it looked like the country could see a flicker of light at the end of the long COVID-19 tunnel with its transition on Dec 28 to Phase 3 of its reopening.
And in the months that followed, the path to a post-pandemic normality looked to be fairly smooth, with community cases generally running to no more than a few a day.
Plans for events which hadn’t been possible for months started to gather pace. This was in spite of the pandemic continuing to rage worldwide, with a number of countries forced to introduce and then reintroduce measures to curb the spread of the raging virus.
Singapore hadn’t needed to.
Then, very quickly, things changed. Clusters began to spring up, with one emerging at Tan Tock Seng Hospital – the first in a local hospital since the pandemic began. Community cases began to steadily increase.
To tackle the spike, Singapore announced some tighter, targeted measures on May 4.
Places that were considered high-risk, such as indoor gyms and fitness studios, were instructed to close unless they offered low-intensity activities, while fewer people would be allowed at attractions, public libraries, funerals and MICE events.
Limits for gatherings reverted to five people.
But as community cases showed no signs of letting up, measures were further tightened on Friday (May 14) under what the Health Ministry called “Phase 2 (Heightened Alert)”.
Among other initiatives, sizes of group gatherings were further reduced from five to two people, with dining-in at F&B establishments banned. Working from home is also to be the default at workplaces.
The new measures will take effect from May 16 through June 13.
Speaking at a multi-ministry task force press conference on Friday, Education Minister Lawrence Wong noted in particular that "risk settings" for the spread of the virus were indoor environments where people do not put a mask on.
This is why the Government had focused on tightening restrictions in such areas, he noted.
"We have already done so earlier for activities in the gyms and fitness centers where you are unable to keep your mask on," Mr Wong explained.
"And now the next step … is to restrict such activities in F&B establishments, and therefore no more dining in. In other settings – outdoors or when you are in a space but you are able to keep your mask on – we believe with safe distancing, with proper precautions, and safeguards, these activities can still continue."
Health Minister Gan Kim Yong also added that such moves would be part of Singapore's "journey to recovery".
"This is part of a journey to recovery, because every now and then, when there’s (an) outbreak, we have to review our measures, and we need to tighten as we go along. And when infections come under control, then we'll have (the) opportunity to roll back some of these measures, open up the economy, open up the community, so that people can begin to also socialise and interact with one another."
BREAKING THE CHAINS OF TRANSMISSION
As the COVID-19 situation continues to evolve globally, infectious disease experts say that targeted sectoral measures, such as the ones introduced by Singapore, are set to be the way forward.
"Sectoral lockdowns in a targeted fashion (are) likely the way to go, but the thing is that the decision to do that must be quick and fast," said Dr Ling Li Min, who is an infectious disease specialist at Rophi Clinic.
Dr Ling noted that such an approach requires that community cases are not widespread.
"When countries embark on these targeted measures, it is probably at a point in time whereby they feel that they can still control it, meaning that community cases are not widespread, it’s only small clusters here and there," she explained.
"Early on, you can’t keep waiting for the cases to increase, and that can only happen when the community cases overall are still low. If there are a lot of community cases, then your sectoral lockdown isn't going to work."
For such measures to bear fruit, the rest of the community must be "clued in", said Dr Ling.
"The testing, the tracing, (the) isolation must be superb and robust. Some of these countries don’t quite have that – they’re not as swift with that," she noted.
Dr Paul Tambyah, infectious diseases expert and president of the Asia Pacific Society of Clinical Microbiology and Infection, noted that these sectoral measures are likely to remain in place until vaccination rates reach higher levels.
"I think that these measures are temporary until the vaccination rates reach levels that have been achieved in countries such as Israel where the measures are being lifted gradually," he said.
"Similar opening up is occurring in other highly vaccinated places such as the UK and US and UAE. If the WTO (World Trade Organisation) waiver on vaccine patents is granted, then this is likely to happen sooner rather than later all over the world."
As Singapore is one of the world's most globally connected cities, it is likely to need "far higher" levels of vaccination to protect the population than other more “closed or isolated” societies such as Israel or New Zealand, added Dr Tambyah.
As of May 9, about 1.8 million people had received at least one dose of a COVID-19 vaccine, with 1.2 million of them receiving their second dose, Mr Gan had said in Parliament on Tuesday (May 11).
Data compiled by the Our World in Data project at the University of Oxford, shows that close to 60 percent of Israel's population has received at least one dose of the vaccine. The number currently stands at about 30 per cent for Singapore.
FINDING 'MIDDLE GROUND'
One of the reasons why total lockdowns have been implemented in some countries is due to the fact that hospitals are facing the possibility of being inundated, said Dr Teo Yik Ying, who is dean of the Saw Swee Hock School of Public Health.
"A total lockdown is necessary when the health system is at risk of being overwhelmed. That is when you realize that the situation is getting rapidly out of control. And the definition of out of control here is that the infection is spreading so fast in the community, and resulting in a large number of people entering the hospitals," said Dr Teo.
A total lockdown would serve two main purposes, he noted. The first of which would be to stop interaction so as to cut chains of transmission in the community.
And when such chains are cut, this minimises the infections only to households, he added.
"What that means is that with time, you actually allow the number of patients in the hospitals to slowly go down … Your hospitals now have a chance to breathe," he said.
"That is actually very important because once your hospital is overwhelmed, you realise that anyone seeking care at the hospital, whether it is COVID, or non COVID related, they will be compromised because nurses are overwhelmed, doctors are overwhelmed."
And while Singapore had been forced into a circuit-breaker period – similar to a lockdown – last year, there has not been a need to re-impose that because the healthcare system is not at the risk of being overwhelmed, said Dr Teo.
READ: Stretched but coping: How Singapore’s healthcare system has cranked up efforts to deal with COVID-19
For one, in addition to current bed capacity, there was also the setting up of community facilities around the island last year to bolster capacity, he pointed out.
"After our initial fear that we saw in April (and) May last year, there is now built in place some additional surge capacity. It is not massive, it is never massive, but at least hospitals now have a better way of coordinating their resources to cope with rising numbers," he added.
Speaking to CNA, Dr Dale Fisher, who is senior consultant at the National University Hospital's division of infectious disease, noted that many countries have tried to find a compromise as part of their strategy to tackle COVID-19.
"Many countries have tried to find this middle ground – particularly Singapore obviously – of targeting specific things for specific reasons. So I don’t think it’s new," he said.
"Now if you’ve got good contact tracing, good case isolation, good quarantining, good social distancing, good community buy in, capacity to scale up testing – if all these are in place, then really countries should be less inclined to do the blunt lockdowns."
He noted that aside from countries with a strategy of complete elimination of the virus such as Australia, such a lockdown should not be the first option.
"It should have been a place of last resort, when you really had lost control of the situation. Your contact tracing couldn’t keep up, your quarantining wasn’t effective, or your case isolation was not in place – many countries didn’t isolate their cases," he added.
Dr Tambyah noted that such a total lockdown would be "very drastic" and have "numerous adverse consequences". These include risks of death from falls in older people living alone, mental health problems in individuals who are isolated, as well as increases in domestic violence, among other things, he said.
READ: Possibility of circuit breaker 'not ruled out' as COVID-19 task force announces tighter measures
Going back to such lockdowns would be a very "retrograde step", added Dr Fisher.
"I think that would be a very retrograde step because we want to be pushing forward in opening up to achieve this balance of living with the virus and we don’t want to have to be locking down regularly," said Dr Fisher.
"I think what Singapore is doing is the right way, which is try and nuance your way through it, bring that number back down."
Dr Teo that "personal safe management measures" such as mask wearing and social distancing remain important.
"Once we started imposing face mask wearing, we never changed our stance on that, we never changed our stance on social distance, and neither our stance on group size restrictions. We have always maintained that there is a need to restrict group sizes, because whether it is for dining, coming together for things, those are the activities that have the highest risk of spreading (the virus)," he added.
And Dr Teo noted that acceptance of these measures remain high despite the fact that Singapore has been in this pandemic for over a year.
However, there remain disadvantages associated with such a targeted approach, he said.
"Sectoral lockdowns actually widen inequities. Effectively, you are saying that certain sectors of the economy have to be shut down in order to allow other sectors of the economy to progress," Dr Teo added.
As such, policies need to be put into place to ensure that these sectors are being looked after, amid the closures, he added.
On Friday, it was announced that F&B businesses, which are going to have to deal with the suspension of dine-in business, will get additional financial support.
Regardless of whether a total lockdown or targeted sectoral measures are put into place, Dr Ling noted that there is a risk of fatigue among the public.
"At this point in time, everyone knows that if we don’t do something about it, it’s just only going to get worse. And then it ends up being (a) total lockdown for everyone, which is even a lot worse. (It is akin to) choosing between the devil and deep blue sea, it’s like there's no good choice," she said.
Given that safe management measures are not compulsory in some other countries, this could potentially exacerbate fatigue, she noted.
"In certain countries, it is very difficult to implement safe management measures and implement masking, to make it compulsory. And so when there are a lot of interactions, and when there is slight breakdown in any of these measures, the cases will balloon,” she said.
While other countries aim for a strategy which involves a total elimination of the virus, Singapore is trying to find a compromise between allowing economic activity, and some social activities to resume while trying to keep the public health situation under control, noted Dr Teo.
"It means that we will start to look at some of this dialing up and dialing down of our measures between phase three, phase two, phase three, phase two, even maybe going back to phase one from time to time. This will be something we have to be mentally prepared for," he said.
At the same time, Dr Ling emphasised the need for Singaporeans to be constantly on their toes.
"The community has to be mentally prepared that COVID is going to be here to stay for an indefinite period of time," she said.
"We being part of this community and being part of a global society, we just have to make sure that we try to keep it at bay for as long as we can. And we’re going to have to do whatever we can to do that."
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