September 2016

The Zika outbreak caught most of us by surprise, with the number of local cases increasing rapidly. Do you think Singapore is ready to handle such epidemics?

1st Place - Joshua Goh

Given Singapore’s global interconnectedness, we are fated to share in the world’s blessings and also its curses. Epidemics, be they viruses or antibiotic-resistant bacteria, rightly put the Singapore authorities on alert, wherever they may occur. Therefore, the outbreak of the Zika virus in Singapore was treated as the unfortunate manifestation of what was always a relative likelihood as opposed to a breach of Singapore’s health security. However, it was the spread of the virus that caught many of Singaporeans by surprise, with local transmissions of the virus increasing and the number of local clusters increasing. Does this signify a failure on Singapore’s part to effectively manage and control such outbreaks of contagious illnesses especially given our recognised efforts in combating SARS and H1N1 Flu in recent years? The answer is not as simple as it seems.      

 

The current efforts to combat Zika should not be too readily compared against our previous efforts in dealing with SARS in 2003 and the 2009 H1N1 Flu outbreak, Singapore’s war against pandemics have been modelled on the previous wars that it has fought, therefore to state that Singapore is unable to handle pandemics based on its current performance and previous accomplishments ignores the fundamental issue that not all infectious sicknesses are created equal and the spectrum encompassing how such sicknesses are transmitted is very large. Hence we should not view the current Zika outbreak as a reflection of Singapore’s poor preparation for such epidemics on the level as that of SARS, but rather against our longtime local foe, the dengue fever, which bears much more resemblance to Zika than SARS or other recent viral outbreaks. It also serves an important lesson to us that preparations against such outbreaks can never be watertight and despite long-time precautions, the ability of viruses to mutate and the Singapore’s interconnectedness with the world are reminders of the dangers and likelihood of a pandemic outbreak in Singapore.

 

Zika is not your average virus

 

The main differences between Zika and previous viral outbreaks in Singapore that are relevant for this piece, aside from the fact that fatality rates are significantly lower, is that the Zika virus is transmitted by mosquitoes and not human-to-human contact. Mosquitoes, acting as the vector for the Zika virus, are responsible for the formation of clusters. Therefore, it only takes one infected person to enter Singapore and the mosquitoes will do the rest, by biting the infected person and then other people, it transmits the virus across a population. Unlike the SARS epidemic where the solution was to cut off the sources of the virus; humans, by quarantining them, the solution here is not as simple.

 

Attempts to eliminate Zika transmissions are essentially attempts to eradicate the Aedes mosquito, the only vector of the Zika virus thus far. The Aedes mosquito however has proven very versatile in more ways than one, also having the dubious distinction of being the carrier of multiple viruses such as the Dengue virus and the Chikungunya virus. Dengue itself has been a thorn in the side of Singapore health authorities for many years

 

Zika, like Dengue and Chikungunya, are vector-borne diseases that are inherently harder to control as opposed to Air or Droplet-Borne Diseases such as various Influenza viruses that pass easily from human to human. Vector-borne diseases are problematic because the question of prevention boils down to curtailing the impact and ability of the vector to spread the disease. The strategy used in Singapore is vector control. Hence mosquito-fogging is rather common and government bodies such as the National Environmental Agency are given special powers to inspect personal properties and penalize owners if mosquito-breeding is found. Singapore’s progress in this area has been remarkable given its high urban density and the ability of the Aedes mosquito to thrive in such built-up areas. In recent years there have been outbreaks of Dengue Fever in various areas of Singapore, however none as large as to warrant severe countermeasures such as en-masse fogging. Thus when compared to Singapore’s fight with Dengue, Zika is not something that Singapore is totally unprepared for. However why is it that Singapore has been perceived by some to have failed to detect and properly manage the Zika virus thus far?

 

Why Zika is confounding Singapore?

 

Since the first local case of Zika was confirmed on 27th August 2016, there have been 342 cases in Singapore as of 14th September 2016. However to put this number into perspective, on the 18th of February 2016, the Ministry of Health released an estimate that unless immediate measures were taken to suppress the Aedes mosquito population, the number of Dengue cases in 2016 may exceed 30,000 which is higher than the record of 22,170 cases in 2013. The report attributed this to the El Niño weather phenomenon and the replacement of the DENV-1 virus serotype with the DENV-2 virus serotype as the dominant virus, which has historically been associated with a sharp rise in Dengue cases. Currently for the week ending on the 10th of September, there have been 242 Dengue cases, not too far off the rise in Zika, keeping in mind both use the same vector.

 

Perhaps Zika is boosted by this perfect storm, where the vector for its spread is also experiencing a boost in numbers. Most Singaporeans would attest to the hardiness of mosquitos, having suffered their presence when outdoors. Nonetheless the fact that measures are in place to eradicate the same vector for Zika as Dengue; the Aedes mosquito, might suggest that such measures are, despite their success so far, still inadequate in preventing the spread of Zika?

 

The interesting thing about Zika is that it is not a “new” virus that recently jumped over from its origin point, apparently Zika has been around since the 1960s and the Ministry of Health has been aware of that. Dr Hoe Nam Leong, an infectious disease specialist, speaking to the Center for Infectious Disease Research and Policy, stated that:

 

“The laboratories in Ministry of Health and Ministry of Environment have been doing surveillance on this illness for several years, and we have not isolated Zika in patients or in mosquitoes… We suspect a significant mutation occurred that conferred [the virus] an advantage in spreading from person to mosquito to person. Previously, reports of Zika are far and few in between.”

 

 

Furthermore the strain of Zika in Singapore has been identified as a separate strain from that plaguing Brazil and the Americas which further boggles experts as to how this strain has suddenly arisen in Singapore, with speculation that it has mutated to a form that has become more readily transmissible among the urban population.

 

What can Singapore do now?

 

Given that the entry of Zika into Singapore was a matter of time given our status as a global hub for transportation and general interconnectedness with the global economy, the focus is now on preventing its spread within the city-state. Spot-checks on potential mosquito-breeding sites have been stepped up by the National Environmental Agency and in March 2016, the National Environmental Agency initiated the practice of implementing a $200 fine for homeowners if mosquitoes were found breeding on the premises, regardless of whether the property was in a dengue cluster or not, this is part of its regulatory powers which it has broadened in a bid to prevent the spread of vectors in the community. Outreach programmes have been stepped up in many constituencies, with phrases such as the “10 Minute Mozzie Wipeout” becoming familiar across many neighbourhoods in Singapore. Thus programmes that are already visible yearly have been given greater impetus in light of the Zika outbreak. Therefore it seems that whatever that can be humanely done is being done given current resources has already been done. Nonetheless there are several more ideas that are currently being tested or worth being implemented that could enhance Singapore’s preparedness.

 

There have been criticisms that construction sites, given the large amount of materials lying about, are key breeding sites for mosquitos. This notion was boosted when news broke that a Zika cluster had formed around the construction site of Sims Urban Oasis, leading to 37 reported cases among constructive workers on-site. However in Parliament, the Minister for the Environment and Water Resources Masagos Zulkifli stated that during recent checks in the first half of 2016, half the total mosquito-breeding habitats found were in homes, while only 5 per cent were at construction sites. It should also be noted that the National Environmental Agency possesses the power to issue Stop-Work Orders for construction sites that are found to be breeding mosquitoes and enforces this stringently.

 

 

However the question here becomes one of effectiveness, how effective are such spot-checks and are there easier ways to detect and destroy mosquito breeding sites? Fogging is a common remedy for this situation, however the high urban density of Singapore makes fogging difficult especially for high-rise residences that might be out of reach. Furthermore fogging might become too expensive given the size of urban residences and the frequency of such fogging might be too high for sustainable expenditure given that mosquitoes breed at a fast rate.

 

The National Environmental Agency, in a bid to find an easier solution to the problem, has embarked upon a pilot test project to release male Wolbachia-carrying Aedes aegypti mosquitoes into the environment. The Wolbachia bacteria prevents successful reproduction between Aedes mosquitoes with the result that after male Wolbachia-carrying Aedes mosquitoes mate with female Aedes mosquitoes without Wolbachia, their resulting eggs will not hatch. Though environmentalist have raised concerns over the impact of such a project on the environment, the project is being conducted under guidelines issued by the World Health Organisation and the National Environmental Agency has declared that this “mosquito suppression strategy is species-specific. Release of male Wolbachia-Aedes aegypti will only impact the Aedes aegypti population in the field, and not other insects.”

 

Therefore concerns that the current response to Zika is insufficient is simply unwarranted because of the nature of the Zika virus, how it is transmitted and how such transmission is cut. Personally I do not think that the current Zika outbreak reflects the inability of the authorities to respond to pandemic outbreaks. One has to look no further than the government’s response plan to influenza outbreaks in Singapore.

 

Controlling Infectious Diseases in Singapore

 

Zika, for all its concerns over its transmission by mosquitoes and its ability to cause microcephaly in newborns, is nothing compared to other viruses that Singapore has seen, the SARS outbreak in 2003 killed 33 people out of 283 infected while the H1N1 outbreak in 2009 killed 18 people, Zika by comparison has not proven fatal in Singapore yet. The economic fallout of such viruses is much higher since prevention is effected by reduced human contact necessitating the closure of schools such as in 2003 and 2009 and discouraging people from going to crowded places. All this places a toll on the economy by disruption of daily routines and business. Be too slow to effect such precautions and the disease might become entrenched in the community and prove harder to remove, however jump the gun too early and you might create economic disruption in the absence of an ascertainable viral threat, affecting both the economy and public confidence. Therefore when certain netizens began questioning why the news of Zika’s spread in Singapore was only released when nearly 40 cases were reported, the dilemma between maintaining public confidence and preventing unnecessary escalation of tensions within society came to the forefront. Thankfully since then, daily reports of Zika have emerged, which has led to praise by the World Health Organisation with its Outbreaks and Emergencies Head Peter Salama highlighting Singapore’s progress in tracking and containing the spread of the Zika virus and that “[w]e really have to congratulate the transparency and quick reporting the Government of Singapore has implemented in the case of this outbreak and hope that all other countries can do the same."

 

The measures that Singapore has taken to combat Dengue and Zika so far are hardly the limits of its arsenal. A key piece of legislation in Singapore is the Infectious Disease Act which gives tremendous power to the Director of Medical Services to order the medical examination and treatment of any person suspected to be a carrier or contact of an infectious disease and also prohibit meetings and public entertainment to combat the spread of any infectious disease. This is merely part of the large machinery that our health services possess in order to prevent the spread of infectious diseases and the government has not been afraid to enforce these responsibilities. In September 2016, a man was jailed for absconding from mandatory tuberculosis treatment in Tan Tock Seng Hospital's Communicable Disease Centre. The Ministry of Health has also come up with the MOH Pandemic Readiness and Response Plan for Influenza and other Acute Respiratory Diseases and continues to update the plan, the last being in 2014.

 

Thus the machinery to implement effective management of epidemics in Singapore does exist, however the main concern is not whether Singapore can effectively wield it as we have already demonstrated in the past, but whether we are able to anticipate and adjust our efforts to evolving pandemics. The SARS outbreak was a watershed moment, not just for Singapore but for the entire world in learning how to deal with influenza viruses, thereby allowing for a more effective management of the H1N1 virus. It is fortunate that this time round, Singapore’s efforts in combating Dengue have allowed the city-state to intensify instead of laboriously duplicating its efforts to deal with Zika.

 

Moving Forward

 

Therefore Singapore is prepared on the medical front, to fight the last war. However the nature of such pandemics is that they are constantly evolving and mutating and no new virus or bacteria is quite like the other. For instance, the Zika virus has the additional nasty suspected effect of causing microcephaly in unborn babies. However the Zika virus does raise the question of how Singapore will deal with future deadlier vector-borne diseases; perhaps a virus that is just as deadly as SARS but transmitted by mosquitoes instead of human-to-human contact. Given that experts have recently expressed skepticism at the prospect of completely eliminating the Aedes mosquito, complete eradication of such vector-borne diseases seems an unlikely proposition.  Therefore Singapore’s current efforts against Zika are fair given that mosquitoes have proven a consistent scourge of mankind that have survived all efforts thus far to eradicate them. Ultimately with all new infections, the initial spread will cause confusion and fear and Zika is no different. The main issue now for Singapore to adopt a level-headed response that attempts to determine how to further improve its efforts in combating vector-borne diseases while Zika’s non-lethality allows us to, however the next infection may not be so kind.

2nd Place - Calvin Lee

Singapore was struck by yet another epidemic due to the Zika outbreak in August 2016 after similar epidemics in the past such as H1N1 in 2009, Hand Foot Mouth Disease in 2012, Dengue Fever in 2013 and of course, Severe Acute Respiratory Symptoms (“SARS”) in 2003. A prudent mind would not chalk up this string of epidemics to mere luck, and the evidence only points towards Singapore being susceptible to similar epidemics in the future.

 

This essay departs from the distinction in the question of whether enough has been done or whether there is yet more to be done, because arguably more can always be done towards combating an epidemic. Preparing for an epidemic, as with any emergency of other kinds, is a never-ending process that requires constant evolution to keep up with evolving threats through evolving means. Instead, this essay will consider the reasons for Singapore’s particular susceptibility towards epidemics, and conclude with an examination of 3 reasons for Singaporeans to be optimistic about our readiness towards handling such epidemics when (and not if) they should occur. This essay concludes that while more can still be done, enough has already been done.

 

Reasons for Singapore’s susceptibility towards epidemics

 

The primary cause exacerbating Singapore’s susceptibility towards epidemics is its geography, in 2 aspects. First, Singapore receives a high influx of visitors due to its position as a travel hub. The SARS epidemic in 2003 is understood to have originated from a visitor from Hong Kong, and the H1N1 epidemic was also world-wide in its spread. With Changi Airport’s passenger traffic increasing by 2.5% in 2015 to 55.5 million, this trend will not abate in the near future. Singapore’s susceptibility to pandemics (i.e. epidemics of a worldwide nature) due to this factor is inevitable since the alternative of reducing Singapore’s accessibility is an unfeasible solution, due to the extent of the economic detriment that will be thus incurred. This issue of balancing appropriate measures against other socio-economic needs is a recurrent theme in this analysis: Singapore can be doing much more to combat such epidemics, but at what cost?

 

The second aspect of Singapore’s geography that exacerbates its susceptibility towards epidemics is its small size, which results in highly concentrated population centers that increase the rate at which diseases are spread. Based on 2015 statistics, Singapore is ranked 3rd globally in terms of population density with 7,967 people per km2. The majority of the population also congregate in a multitude of socially concentrated public institutions, such as public schools, public transport and shopping malls. This is a vital aspect of Singapore’s infrastructure, and can only be circumvented at immense social cost. For example, the closing down of public schools due to the SARS crisis in 2003 remains significant because of its rarity, in recognition that the need to protect public health should be balanced against the importance of other social goals, such as education. If even more drastic measures were to be imposed, such as the shutting down of the public transport system, Singapore’s economy would be all the more severely crippled. In addition, a severe side-effect of such measures would be the social panic that it would cause; the rarity of such measures means that the measure, if implemented, would signify the extent of the government’s concern about the atypical severity of that particular epidemic. Since Singaporeans have already demonstrated a tendency to resort to hoarding tendencies in epidemics (e.g. the buying-up of face-masks during the haze or mosquito repellants during the Zika outbreak), one worries about the extent that Singaporeans would go to if an even more severe epidemic was anticipated.

 

Reasons for optimism about Singapore’s resilience towards epidemics

 

The above paragraphs have painted a bleak picture of Singapore’s chances, but this essay also proffers 3 reasons to be optimistic about Singapore’s chances towards handling such epidemics. First, as with most other issues of governance, Singapore boasts a remarkably well-prepared and equipped government to handle such situations. For example, the government stands ready to mobilize large pools of manpower to spread awareness on a door-by-door basis, both on a salaried and volunteer basis. During the 2013 Dengue outbreak, the NEA immediately recruited more officers to conduct routine checks at all homes in the active cluster zone in Woodlands, and the People’s Association also recruited 10,000 volunteers to assist NEA officers during house visits as ‘dengue fighters’. During the recent Zika outbreak, even the Members of Parliament (“MPs”) were mobilized to spread awareness on taking precautions to prevent Zika, such as Pasir-Ris Punggol GRC MP Sun Xueling, who was herself 7 months pregnant. Singapore also enjoys substantial economic resources to provide medical aid for such unplanned emergencies. For example, Singapore has arranged for those who have Zika symptoms or whose male partner is Zika-positive to receive free Zika tests at public healthcare institutions, as well as at private hospitals and clinics. In contrast, Brazil’s fragile social services system to support children and families affected by Zika has been globally lambasted.

 

Second, the Singapore’s government’s measures are efficient and effective because of the government’s tight centralized control over key institutions. For example, the closing of all classes up to the pre-university level from March 27 to April 6 in 2003 due to the SARS epidemic was executed with only 1 day’s notice following the same-day event of a first recorded local death due to SARS, despite this drastic decision affecting up to 600,000 students and countless other teaching support staff. Another example would be the National Environmental Agency exercising unprecedented legislative powers to engage locksmiths to open 10 homes to eradicate pools of stagnant water during the 2013 Dengue outbreak. The benefit of such legislative efficiency should not be underestimated, as it is not uncommon in other countries for legislative bills to be bogged down in Parliament due to frivolous politicking. Whatever the social costs of a dominant single-party state, it is clear that the Singapore executive benefits from such decisive legislating. Furthermore, the Singapore government has become increasingly prepared for epidemics with each passing one, such as the Ministry of Health adopting a whole-of-government approach by developing a Disease Outbreak Response System Condition framework which provides a “quick reference to agencies and the public on the current disease situation and what needs to be done to respond to prevent infections and reduce its impact”.  Lastly, the Singapore government has demonstrated commendable flexibility in addressing each epidemic. For example, while the SARS epidemic was addressed with tight quarantine of affected individuals, it was noted that numerous Zika carriers were asymptomatic, and hence not easily identified for quarantine. Instead, a focus on vector control was adopted, trying to eradicate the breeding of mosquitoes. This is an example of why Singapore can never be completely prepared for an upcoming epidemic, as the unique nature of each challenge has to be uniquely addressed.

 

Third, and most crucially, Singapore’s experience with past epidemics can only lead to a buildup of psychological resilience, which is crucial towards negating the negative socio-economic externalities of government measures to address epidemics. Present measures are also always compared against the drastic measures of the past, with citizens recognizing that present epidemics are ‘not as bad’ as that SARS situation. It is crucial that the Singapore populace remains calm and recognize that “life can go on as normal” (as described by MP Sun Xueling in response to the Zika outbreak), because a state of social panic would reverberate throughout Singapore’s socio-economic spheres as well. For example, the SARS crisis during the 2nd quarter of 2003 resulted in a 7% contraction in Singapore’s GDP, with the fields of employment and tourism suffering most severely.  With psychological defence being recognized as one of the 5 pillars of Total Defence, it is important that Singapore maintains an optimistic and supportive society in order to overcome such upcoming challenges.

 

Conclusion

 

At first glance, this essay recognizes that the situation appears bleak for Singapore’s public health situation, as no country can be completely prepared for an epidemic, and Singapore is uniquely susceptible to such epidemics due to its geography. However, this essay argues that there is reason for optimism, due to Singapore’s substantial resources, efficient governance, and psychological resilience. For example, it should be comforting that the World Health Organization has labeled Singapore’s response to the Zika outbreak as a ‘role model’, instructing other countries to do the same in responding quickly and transparently. Finally, in light of the socio-economic costs of implementing such measures, this essay submits that it is crucial that Singaporeans adopt an optimistic outlook on its ability to handle this situation, simply because we have to, and not let such epidemics disrupt our way of life.