Thursday 9 March 2023

White Paper on Singapore’s response to COVID-19

Singapore flags errors, good calls and lessons from the ‘complex and wicked’ COVID-19 pandemic
By Salma Khalik, Senior Health Correspondent, The Straits Times, 8 Mar 2023

Singapore has looked at how it performed in its fight against Covid-19 and concluded that while it got several big calls right, it slipped up on a few aspects.

The White Paper on the nation’s performance, released on March 8, was not a self-congratulatory exercise but an effort to understand how it can build on its successes and avoid the errors committed in the fog of war, when the next big pandemic knocks on its doors.

The 92-page document listed eight things that Singapore did well, such as not letting the healthcare system get overwhelmed and saving lives and livelihoods, six where there was scope for improvement, including over-calibrating safe management measures which were not always consistent, and near disastrous stumbles in handling outbreaks in migrant workers’ dormitories.

There were also seven lessons listed in preparing for the next crisis.

An important lesson which was weaved in throughout the paper was to not rely on past pandemics to provide the road map for dealing with the next one, but instead, to be flexible enough to cope with nasty surprises.

Some of the problems that dogged Singapore’s response stemmed partly from the Government basing most of its actions on the previous major outbreak, the Severe Acute Respiratory Syndrome or Sars – which was caused by a virus in the same family as the one responsible for Covid-19.

The paper stated: “It was soon clear that in building pandemic preparedness on a Sars model, we had not adequately challenged certain assumptions.”

When the first cases appeared in the migrant workers’ dorms, “the prevailing view was that asymptomatic transmission was not possible” – since that was the case with Sars – resulting in insufficient precautions. As a result of that misjudgment, “the dormitory outbreak had every possibility of becoming a major disaster”.

Because Sars did not spread easily, the Government initially said masks were not required unless the person was feeling unwell. This advice was also spurred by the shortage of masks which the Government wanted to keep for healthcare workers.

The White Paper said we could have been less definitive in our position on mask-wearing. Instead, when masks became mandatory in April 2020, the public viewed the policy as a U-turn, contradicting the Government’s earlier position – which “undoubtedly affected public trust and confidence in our handling of the crisis”.

Deputy Prime Minister Lawrence Wong, who co-chaired the multi-ministry task force on Covid-19, said at the release of the White Paper: “So while the lessons will help give us a better sense of preparedness, we must never fight the last war.

“We must not allow the lessons to become hard coded into a certain doctrine that might lead us down the wrong path, especially if the next virus turns out to be very different in character and nature from what we have experienced so far.”

Mr Wong noted that while Singapore is now better prepared, it can never be complacent.

But there are things Singapore can and will do to prepare for the next pandemic, no matter how different it might be. These include building strong public health expertise, institutionalising the use of science and technology, strengthening forward planning, and reviewing stockpiling strategies and further diversifying critical supplies.

When the next pandemic hits – and it will, said Mr Wong – the Government needs to decide on what to prioritise and adapt quickly to changing situations. The focus should be “broader brush but more implementable measures, and to guard against the instinct to aim for unrealistic standards of perfection”.

In a complex and fast-moving crisis, the normal government machinery does not have the bandwidth to plan future operations. So a dedicated forward planning team will be set up to ask the “what if” questions, and prepare ahead for situations which have not yet arisen and perhaps may not arise at all.

Covid-19, said Mr Wong, “has been a very complex and wicked problem on a grand scale, with many twists and turns and disruptions and surprises along the way. We had to operate in a fog of war. We had to make decisions amid conditions of incomplete information.”

With the benefit of hindsight, “we probably could have handled certain situations differently”, he added, pointing to the foreign worker’s dormitory outbreaks as one of the most challenging difficulties faced during the pandemic.

This was also highlighted in the White Paper, which draws on an internal review led by former head of civil service Peter Ho. It said: “There were a few close calls, the most dangerous being the outbreak in the migrant worker dormitories that put more than half a million migrant workers at risk with the threat of the infection spilling over into the wider local community.

“Had that happened, Singapore could have experienced a devastating surge of infections that would have overwhelmed its healthcare system. Mortality rates would have been catastrophic. The economy would have suffered even more with a significant proportion of the workforce out of action.”

Although several things could have been done better, the paper concluded: “The quality of governance throughout the crisis has been generally high. Through a strong Whole-of-Nation response to the pandemic, we have effectively preserved lives and livelihoods.”

Singapore’s procurement and roll-out of vaccines for the entire population was a high point of its response, said Mr Wong. It was among the first countries in the world to get the mRNA vaccines, with the first batch arriving in December 2020.

Vaccination was clearly such an important way out of this pandemic for the world and for Singapore,” he added. “Overall, our whole vaccine strategy from procurement, to the rolling out of the vaccines, to the communication to actually delivering jabs to people, I think we have generally done well, and that has enabled us to get through this pandemic.”

With $72.3 billion spent on fighting the pandemic over three years, the resident unemployment rate was kept below 5 per cent, students could continue their education at home with 35,000 computing devices loaned out to them in 2020 and 2021, while the case fatality rate was kept to less than 0.1 per cent. This is among the lowest globally, with the average of about 1 per cent worldwide.

Mr Wong said this spending is being reviewed by the Auditor-General’s Office as he, too, as Finance Minister, wants every dollar accounted for.

So how would he grade Singapore’s fight against the pandemic? His reply: “I can’t possibly give a grade because I was being examined. So it’s for people to examine me and give me a grade.”

The White Paper, on the other hand, concluded: “This crisis of a generation showed us, and the world, what Singaporeans are capable of when faced with a severe existential test.

“It marks a certain maturity of Singapore as an economy, as a people, and as a nation. We can be proud of how far we have come. And we will learn from the experiences of the last three years to be better prepared for the next pandemic.”

The White Paper is available at It will be debated in Parliament later this month.

Vaccination kept Singapore’s COVID-19 death rate low; outbreak in dorms could have been disastrous
By Joyce Teo, Senior Health Correspondent, The Straits Times, 8 Mar 2023

With one of the highest Covid-19 vaccination rates in the world, Singapore had its ticket out of a terrifying crisis that has claimed more than 6.6 million lives globally. The overall Covid-19 case fatality rate in the nation is one of the lowest in the world, at less than 0.1 per cent, compared with the average of about 1 per cent worldwide.

While it did well in protecting lives and livelihoods, the nation’s journey towards living with the virus was fraught with challenges. The 2020 outbreak in migrant workers’ dormitories, for one thing, nearly did Singapore in, according to a just-released White Paper on Singapore’s response to the pandemic.

“It’s very hard to distil such a complex crisis into one or two things. But if we look overall at the experience, vaccinations were clearly such an important way out of this pandemic, for the world and for Singapore,” said Deputy Prime Minister Lawrence Wong in an interview on Tuesday.

“And, overall, our whole vaccine strategy, from procurement to the rolling out of the vaccines, to the communication to actually delivering jabs to people, I think we have generally done well, and that has enabled us to get through this pandemic.”

Singapore recognised early on that vaccines were its most promising exit strategy, but it could not wait till vaccines were approved to buy them, because it would not stand a chance of getting them early due to the low volume of orders.

Instead, it had to place bets, at substantial cost, on potential game changers, said the White Paper.

“The only way a small country like Singapore could gain timely access to the vaccines was to sign advance purchase agreements and make early down payments on the most promising candidates,” it said.

Vaccination centres were also set up in a matter of weeks, among other moves aimed at facilitating the vaccination roll-out to the entire population.

Said Mr Wong: “We had one of the lowest Covid-19 death rates in the world. We have safeguarded livelihoods and kept supply chains open... and importantly, we have emerged from this crisis more united as a nation than before.”

The outbreak in the dormitories was one of the biggest challenges, he said.

“It could have possibly been a major disaster for us. But fortunately, with the help of the SAF (Singapore Armed Forces), everyone working very hard, we were able to manage the situation and keep our dorm workers safe,” added Mr Wong, who was co-chair of the multi-ministry task force set up to tackle the pandemic.

The first dormitory case in the country was detected on Feb 8, 2020, not long after the first Covid-19 case surfaced in Singapore on Jan 23.

The Government’s initial response was to follow the procedures instituted during the Sars (severe acute respiratory syndrome) crisis in 2003, believing them to be adequate as the prevailing view then was that asymptomatic transmission was not possible.

The White Paper also noted that the Government lacked a consolidated picture of migrant workers who may have sought treatment for acute respiratory infection symptoms from different service providers, including non-governmental organisations.

But the virus spread like wildfire in the migrant worker community, forming clusters that threatened to spiral out of control. There were also concurrent clusters in various places, including nursing homes.

To prevent the country’s healthcare system from being overwhelmed by the surge in cases, the Government announced a Singapore-style lockdown – known as a circuit breaker – in early April 2020.

By the end of that year, nearly half of the roughly 300,000 migrant workers residing in dormitories had caught Covid-19. However, many never showed any symptoms and were found to have had past infections only through serology testing to detect antibodies formed after infection. There were only two fatalities.

Had the infection spilled over into the wider community, Singapore could have experienced a devastating surge of infections which would have overwhelmed the healthcare system, leading to catastrophic mortality rates, the paper noted.

And the economy would have suffered even more, with a significant portion of workers out of action.

But it was only from June 2022 that migrant workers no longer needed an exit pass to visit most areas, and the long period of confinement took a toll on their mental well-being.

Deciding when and how to relax movement restrictions for the workers was a difficult judgment call, the Government said in the White Paper. It could have eased some of the restrictions earlier, especially after most of the workers had been vaccinated and boosted, but there was fear of a high reinfection risk, given the communal living arrangements in the dormitories.

“We should have probed deeper and conducted better and earlier ground surveillance, such as by doing dip-stick testing on sample populations to make the most of limited testing resources,” it said.

The Ministry of Manpower has since set up a new primary healthcare system for migrant workers, with clinical teams equipped with multilingual translation capabilities, at least.

With the benefit of hindsight, Singapore could have had fewer disruptions and deaths, Mr Wong added.

“But that’s like asking for the impossible because no one would have been able to have that perfect information, even at the very start of the pandemic, nor would we have the solutions at hand. It was not possible to have vaccinations ready from day one.”

Mr Wong said: “The purpose of this review is not so much to pass judgment on, but to learn. To learn and to ask ourselves, from all these experiences, how can we be better prepared when the next pandemic comes?”

There were times when the public was confused by frequently changing and sometimes inconsistent instructions, the White Paper noted, and the Government will learn from these episodes, especially in the way it designs policies and how these are then communicated.

Throughout the pandemic however, clear and transparent public communication kept people informed and reassured, and psychologically prepared for what lay ahead, said the Prime Minister’s Office in a statement.

“We will build on this foundation, and consider how else public communications could be leveraged to shape the national psyche in support of important shifts during a crisis,” it said.

It added: “In this crisis of a generation, we mounted a strong whole-of-nation response. The public, private and people sectors banded together to deliver the best outcomes for our people and country.

“From healthcare workers and other essential personnel working on the front lines, to private companies and community organisations who contributed their time and resources, as well as the many ground-up groups and volunteers who stepped forward to provide support to those in need – all went beyond the call of duty.

“The Government would like to put on record our appreciation for the dedication and sacrifices of all who were part of our multi-year fight against Covid-19. We also thank all Singaporeans for displaying considerable fortitude in abiding by the measures imposed at different phases of the pandemic.”

Tackling ‘crisis within a crisis’ and other COVID-19 lessons for future pandemics
By Zhaki Abdullah, The Straits Times, 9 Mar 2023

On Wednesday, the Government released a White Paper on its response to Covid-19 over the past three years and the lessons learnt for future pandemics. Here are the key points:

1. Early access and smooth roll-out of vaccines

Singapore signed advance purchase agreements and made early down payments for the mRNA vaccines from Moderna and Pfizer-BioNTech, a risky bet as both were still undergoing clinical trials.

When the vaccines arrived, ultra-cold chain logistics were put in place and vaccination centres were set up across the island within weeks, enabling the population to get their shots.

Why it matters

Singapore’s bet meant it was the first country in Asia to receive doses of the Pfizer-BioNTech vaccine, and by late August 2021, had vaccinated 80 per cent of its population. This ensured that the Republic had one of the lowest fatality rates in the world, at less than 1 per cent, a tenth of the global average.

In future outbreaks, Singapore aims to be able to administer vaccines to all aged 50 and above within three to four weeks by tapping primary care clinics if needed.

2. Outbreak in migrant worker dormitories

Early on, insufficient measures taken in migrant worker dormitories resulted in nearly half of the 300,000 workers living in such facilities getting infected with Covid-19 by end-2020, though many showed no symptoms.

Extended restrictions on migrant workers even after most had been vaccinated and boosted helped keep them – and the broader community – safe, but took a toll on their mental well-being.

Why it matters

The White Paper noted that this “crisis within a crisis” was the most dangerous of the close calls Singapore had, as it could have spilt into the wider community and overwhelmed the healthcare system, which would have led to many deaths.

The experience underscored the need for more comprehensive medical support for migrant workers, and the Manpower Ministry has since established a primary healthcare system for these workers, with clinicians who can communicate in their languages.

3. Covid-19 rules and safe management measures

Some safe management measures were frequently changed owing to the evolving pandemic, with the public confused by instructions that were overly elaborate as well as difficult to operationalise and explain. Among these were rules governing events such as weddings, which included pre-event testing and restrictions on mingling.

There was also some unevenness in treatment when the Government defined rules for different categories of businesses after the circuit breaker period.

Why it matters

At times during the pandemic, Singapore “allowed the perfect to be the enemy of the good” when it over-calibrated some of its safety measures and treatment protocols. This highlights the need for the authorities to be more flexible in a crisis, and to go for broader brush strokes with more implementable measures.

To strike the right balance between precision and ease of implementation of public health protocols, the country needs to avoid ”unrealistic standards of perfection”.

4. Public communication through the pandemic

Public trust was maintained through regular press conferences, daily case updates and a dedicated WhatsApp channel, with the authorities also tackling misinformation that could have caused panic and sapped confidence in the battle against Covid-19.

However, the Government’s change in stance on mask wearing in April 2020 after evidence emerged of the asymptomatic spread of Covid-19 was seen as a U-turn, and undoubtedly affected public trust and confidence in its handling of the crisis.

Why it matters

Accurate information was put out in a timely fashion through trusted channels, and the Government was upfront in communicating any bad news. Such transparency kept citizens informed and prepared for difficulties ahead, and was critical in addressing public concerns.

In hindsight, the Government could have been less definitive about masks early in the pandemic, given that clinical evidence was still evolving then. The country will also review how indicators of crisis severity such as the Dorscon (Disease Outbreak Response System Condition) alert level are designed and communicated so as not to cause undue anxiety.

If you have a few more minutes…

1. Reviewing the “insurance” Singapore buys

The pandemic highlighted the need for Singapore to strengthen its supply chain, with the authorities planning to review stockpiling strategies, build a more comprehensive list of critical items and expand source countries. The Republic may also diversify the sources of migrant labour, though it noted that the costs of buying such “insurance” will have to be carefully considered.

2. Dedicated forward-planning team, centralised assigning of crisis-time roles

A dedicated forward-planning team will be created for future pandemics, with the bandwidth and expertise to better anticipate and plan for situations that may arise. In addition, a more centralised system will be created to allow for crisis-time roles to be tagged to suitable individuals, who will be trained in advance to be redeployed quickly when mobilised.

3. Increasing flexibility of Infectious Diseases Act

Noting that the Infectious Diseases Act caters only to the binary scenarios of peacetime or emergency, the White Paper said the law was too constraining to calibrate public health measures as the situation evolves. The law should be reviewed to allow for more flexible and effective responses to the changing circumstances of a pandemic.

4. Better use of digital technology solutions

Digital technology solutions can be better employed in the next pandemic, with agencies such as the Smart Nation and Digital Government Office and GovTech activated earlier to integrate digital solutions with ground operations. Additionally, cyber security must be enhanced, given the increasing dependence on digital tools in crisis operations.

5. Developing effective data-sharing system

The Government will invest in data-engineering capabilities and interoperable systems across its agencies so that data from multiple sources can be tapped to quickly obtain a common picture of the ground situation in a pandemic. More effort will also be put into identifying important data from the private healthcare sector and how it can be effectively shared.

6. Differentiated approach to long-term pass holders

Travel restrictions created significant difficulties for some long-term pass holders who endured prolonged family separation and work disruptions. Future pandemics should see a more differentiated approach to border restrictions based on considerations such as keeping families together. This means Singapore must build its ability to quickly ramp-up quarantine capacity to safely accommodate those who need to return to the country.


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