Covid-19 : Was Singapore well-prepared as the govt claimed?

Currently, the tiny country of Singapore has the deprecating honour of being the country outside of China to have the highest number of cases of patients tested positive for Covid-19. The reasons could be a high Singapore-China traffic, high density city, pure chance contagion, fumbled crisis mismanagment, or it could simply be superb detection capability.

The Prime Minister has said that Singapore has learnt much from the SARS outbreak of 2003 and is better placed to manage Covid-19. The government has taken a series of steps as the epidemic progressed, ensuring much care not to raise panic. It has drawn flak from armchair critics who see official reaction as stoicism driven by a preponderance not to upend the economy. in short, erring on safety in deference to business as usual. On the other hand, the government's actions have been praised by WHO officials. Some said Singapore's action is a model worth following.

How prepared actually is Singapore for a pandemic such as Covid-19? In the Globa Health Security project  conducted by the Nuclear Threat Initiative and John Hopkins Center for Health Security, Singapore came out 24th placing (over-all rating) out of 195 countries in the inaugural GHS Index 2019. The report shows the world is generally unprepared for a pandemic. Singapore's 24th placing, whilst respectable, is not much to shout about as the score is barely above the passing mark, What is most interesting is that Thailand is in the remarkabe position of 6th (overall score) and Singappore is a laggard behing Thailand and Malaysia.

GHS performance is based on 6 categories. Drilling down on the Asean countries throw up some surprises :

1. Detection (capacity for early detection & reporting of potential international concern) - Singapore lags behind Thailand Malaysia, AND Indonesia, Laos!
2. Compliance ( commitment to improving national capacity financing and adherence to norms) - Except for Laos and Brunei, all other Asean countries fare better than Singapore. 
3. Risk (overall risk environment and country vulnerability to biological threats) - Surprisingly, this is the only category where Singapore tops Asean. This is competely contrary to common presumption that the high human traffic of a tiny global city with a million PRC Chinese foreigner population, makes Singapore exceedingy exposed,

The GHS report card is a black eye for Singapore. The expectation for Singapore's pre-eminence in most performance indicators is shattered. It has the best brains in Government, the financial capability other countries lack, a small territory to manage, has great technological resources and infrastructure, ease of crafting legislation, vast experience for SARS in 2003, and educated and disciplined population, all the ingredients for staying in front of biological pandemics. Yet it scored ""F"" in (E) Compliance and (D) Health system (Sufficient robust heath system to treat the sick and health workers). Other Asean countries out-perform Singapore in the respective categories. On the world stage Singapore ranks a miserable 101th for Compliance, a reluctance to spend where it matters.

Singapore profile:

The GHS is a remarably expansive private domain project that is deep in scope and wide in coverage. One can drill down further to individual countries and examine further factors of assessments and specific comments. Some of the highlights for Singapore are .

Indicator : Biosecurity
Issues relate mosty to lack of pubicly available evidence that govt has implemented certain requirements. SG does not specify whether there are records of faciities that can hande especially dangerous pathogens. Licensing conditions have no provision for vetting security personnel with access to dangerous pathogens, toxins or biological materials with pandemic potential.


Indicator : Biosafety
Perfect score, #1 ranking.
This looks at the biosafety systems in the country specifically on legislation, governing & enforcement agencies, and training standards. SG does well here.

Indicator : Dual use
Lack of evidence that assessment has been conducted that there is no research of dangerous pathogens for dual use - peaceful and non=peaceful.


Indicator : Epidemology workforce
No applied emidemology training programme exclusively for animal health professionals.

Indicator : Data integration between human- animal - enironmental health sectors
Perfect score, #1 ranking
This looks at the importance of data sharing. SG's One Heath Framework came up for praise, but GHS could not find a copy (documentation weakness?)


Indicator : Emergency preparedness and response planning
A general plan is contained in a section in The Joint External Evaluation of IHR Core Capabilities of SG. DORSCON is general guideline for public. No detailed national public health emergency response plan. There is no mechanism to engage private sector assistance.

Indicator : Exercising response plans
No dry runs have been conducted to assess gaps and shortcomings in the plans

Indicator : Public health and security authorities linked for biological event
Perfect score,  #1 ranking
SG has the SOP which was tested in 2017 by National Emergency Response Team for Biological Incidents. However GHS could not sight a copy. (Documentation weakness?)

Indicator : Risk communication system
Perfect score, #1 ranking
MOH Disease Outbreak Response System is the preparedness plan. DORSCON (Disease Outbreak Response Condition) framework is a colour-coded alert respunse and risk communication system for assessing public risk and impact. Govt has many platforms to disseminate info to public and has whole-of-govt resources to produce comunication materials fast.

Indicator : Trade and travel restriction
Perfect score #1 ranking
This deals with whether in the past year (2018) the country had any incident of having to restrict movement of peope or eport/import of goods that imposed risk of major disease outbreak. There was none for SG.

Indicator : Health capacity in clinics hospital & community care
Score 56.6% #15 ranking
Doctors per 100,000 : SG 227.6 (Cuba highest 820; all EU countries higher than SG)
Nurses, midwives per 100,000 : SG 712 (Monaco highest 2,030; most EU countries higher than SG)
Hospital beds per 100,000 :: SG 240 (Japan highest 1310; all EU countries higher than SG)
SG highest in Asean in a 3 indices.
SG has capacity to isolate patients with highly communicable diseases. The High Level Isolation Unit in the National Centre for Infectious Diseases is a state--of-the-art facility.

Indicator : Medical countermeasures and personnel deployment
- SG meets both criteria regarding stockpiles and emergency procurement. MOH has established a MOU with a global manufacturer based in Singapore for procurement of medical countermeasures and has established an Advance Purchase Agreement for the supply of vaccine during crises. Singapore has stockpiled sufficient medical countermeasures assessed as difficult to procure during crisis for pandemic influenza, chemical, biological, radiological and nuclear incidents and civil emergency for the whole population.
- There is no evidence SG has a plan, program or guidelines in place for dispensing medical countermeasures for national use during a public health emergency (ie antibiotics, vaccines, therapeutics and diagnostics)?
- There is no public plan to receive health from othet countries

Indicator : Health care access
Score 40.8%;; #95 ranking
- SG has a universal healthcare system as defined by the World Health Organization, ranked second in the world for healthcare outcomes.
- SG does not have legislation, a policy or a public statement committing to provide prioritized health care services to healthcare workers who become sick as a result of responding to a public health emergency.
(Strange why the score is so low. Perhaps the negative weightage of the 2nd point is high)

Indicator: Communication with health care workers during public health emergency
There is no communication system between public health officials and health workers.

Indicator : Infection control and practices and availability of equipment 
Score 50%; # 6 Ranking
SG has licensing terms that all health institutions maintain one weeks stockpile of PPE (personal protection equipment)


Indicator : IHR reporting compiance and disaster risk reduction
There is no national risk reduction strategy for pandemics.

Indicator : Cross border agreements on public health response
SG has no cross-border agreements, protocols or MOU with neighbouring countries for public heath or animal health emergencies.

Indicator : JEE and PVS
SG has not conducted a Performance of Veterinary Services assessment nor a gap anaysis in the last 5 years.

Indicator : Financing under EE and JS report and gap analyses
The Joint External Evaluation of IHR Core Capabilities of Singapore report does not have a provision for funding to address areas that require improvement. The Joint External Evaluation of IHR Core Capabilities of Singapore report does not have a provision for funding to address areas that require improvement.
Govt has access to emergency public financing in a public health emergency.  No external funding support neeeded. Ministries have access to both annual block funding for routine activities, emergency supplemental funding by request and a dedicated funding stream in ministries and govt agencies for preparedness activities.

Indicator  Comitment to sharing genetic and bioogica data speciments
Beyond infuenza SG does not share biological or epidemological data or clinical specimens with world organisations or other countries.













Conclusion :

The actual reason for the high infection rate in SG may never be known and chance may well have been a good part of it. Armchair critics are quick to blame the govt's delayed action to bar visitors from Wuhan and advising the public that wearing of mask is not necessary if one is not unwell. The govt makes calculated decisions with information the public do not have in a dynamic situation as events unfold. Many critics wipe the floor with public officials with the wisdom of hindsight and taking the most sejf-preservation attitude.

The public is confused with the high rate of infection in Singapore and the praises from WHO officials on the way the epidemic is handled in Singapore. The comments of WHO relate mostly to the "Rapid Response" category of GHS Index in which SG rating is fairly good. It's all about executing planned procedures, communication and maintaining calm. 

Rather than making ten social media postings a day on the unfortunante 'face mask is un-necessary' advisory and the taped audio of a minister's Singlish utterances, there are better returns for Singaporeans to focus on the govt working on short-comingns in its GHS roadmap. The issues that seem to require attention are documentation of SOPs, stockpiling and countermeasures of medication, equipment, PPEs.  Communication is also an area to be worked at. Public lack of appreciating DORSCON Orange led to the panic buying.

There is a failure of understanding human behaviour in an emergency health event, DORSCON was not properly explained, adequacy of govt stockpiles of essential items, the supply chain being uninterrupted, and the need to ration masks - all these were never publicised until panic buying struck.

Far from being well-prepared the govt has its work cut out for them to improve on the many areas of deficiency highighted in the GHS Index 2019.



Addendum:

The govt came under heavy criticism for running out of face masks. While the govt has no control over commercial inventory, it seems the national stockpile was insufficient. However, the public is wrong to lambast the govt for this situation. It is financially and physically impossible for any govt to maintain 100% stockpile level. Just like cash. If everybody were to go to banks to withdraw their deposits there will never be enough for everyone. A bank run will create more panic. The govt tried to ration the mask as best as it could. It tried in vain to prevent a mask run.

The govt has procurement contracts for biological emergency event. But it is finding out a global pandemic is a force majeure that prevents the foreign vendors from performance. This is a lesson learnt in this epidemic and a soution will have to be worked at.