Asia policymaker perspectives: covid-19 and a Singaporean response

In a new series of interviews, members of Global Counsel's Asia team will interview thought-leaders in policy and business from across the region, focusing on key themes for Global Counsel including geopolitics, trade and technological developments and the impact on business and politics.

In this edition of the series, Global Counsel’s Senior Associate Andrew Yeo speaks with Dr. Ben Rolfe, CEO of the Communicable Disease Threats Initiative (Asia Pacific Leaders Malaria Alliance), about how Singapore – which at one time had one of the highest number of covid-19 cases outside of China – has responded to the ongoing pandemic so far.

Governments in Asia have since late 2019 rolled out a series of measures to contain the spread of the covid-19 virus. What is the logic behind these measures?

The origins of public health systems stem from preventing and managing disease outbreaks and the strategies – both containment and mitigation – we see governments employing today have historical precedence. Shakespeare was in quarantine when he wrote King Lear, and the Australians were known for managing the third wave of the bubonic plague at the turn of the last century in 1900 by reducing travel between the states and out to the Pacific. For the Spanish Influenza in 1918, which reached Australia in 1919, Australia again reduced railroad traffic, travel between states, and managed that outbreak through distancing measures.

At its core, all these measures are about reducing the reproductive rate of the disease, and we measure that as the number of new infections that one infection causes. By basic mathematics, if that number of infections is below one, your outbreak will get smaller and eventually disappear. And if that number is above one, it will increase. Singapore is bumping along around 1.1 and just about under control. In Italy, we’re running at 2.5 to 3, and it has been really out of control. These measures are about reducing that rate down to below one in order to get on top of this.

The 1918/19 Spanish flu was devastating, but the critical difference today resides in how we now live in a hyperconnected world which has profound implications not only for the spread of diseases, but also the economic impact of our efforts to stop it. On one hand, we have the potential of ecommerce and its mitigating role during difficult times like these while on the other, global supply chains mean economies are intertwined more than ever before.

How would you describe containment efforts so far?

The bottom line is that we have both a highly communicable disease with no foreseeable cure, and an intuitive understanding that when there is no contact between humans and everyone is locked down, the reproductive rate will go down drastically. But we cannot easily eradicate covid-19 in the way we did with SARS. In the case of SARS, we were able to see cases very quickly. There was less asymptomatic transmission and cases were very severe. Covid-19 has a long incubation period, is highly infectious, and it seems we have quite a lot of asymptomatic transmission, making it much harder to contain. We have come to an infection point where we cannot really contain it and have to strategise measures to slow it down.

The experience of SARS has massively informed both governments’ and citizens’ responses in Asia. In Singapore, the government was able to immediately mobilise the new National Centre for Infectious Diseases and all the mechanisms of the public health system. There was also an intuitive understanding in the population around using sanitizers and distancing. Singapore is the best-case scenario, but other countries like China also mobilised very quickly using what they learned from SARS, both in the population and the government.

The characteristic most particular to this virus is not so much the mortality - which is relatively high, ten times higher than influenza - but the morbidity, the hospitalisation and the demands it creates on the health system. That is the key fact, because that is what is most debilitating. And the elderly are particularly at risk because of high mortality rates, around 15% in the over 80s.

Singapore has adopted a strong containment strategy from the start, but the narrative has changed somewhat. How do you see Singapore’s approach evolving?

Singapore started with a containment strategy and are now mixing a containment with a mitigation strategy, which is exactly right. Shops are open, kids are still going to school, normal life is pretty much proceeding compared with Europe, and we have a very small number of cases to the point where the individual risk of catching the disease is close to zero in Singapore. There are not many, or any countries elsewhere that you could say that for.

In the early days, there was the potential to contain this, and the Singapore government’s response was textbook containment. Had other countries performed with similar aggression and competence, this could have been put back in the box. It however became very clear to the Singapore government within a few weeks that this was unlikely. The government is expert at messaging and immediately hinted that things were going to change and has since been communicating that this as a long game. They have been very good at bringing the public along with them, while the UK in comparison have just failed to do that.

What are the trade-offs that governments face as they decide on measures to deal with the outbreak?

The policy ‘trilemma’ is underpinned by the national economy, health system and mortality risks to the elderly. If we lock the economy down, we reduce the risk to the health system of overcrowding, and we reduce the risk of the elderly, but we have no economy. The more we take off the brakes and allow social interaction, the greater the demands we place on the health system, and the greater the risk to our elderly population. The policy challenge with this virus is that once we have lost the initiative, like Italy and now likely the USA, the social distancing required to keep it under any level of control appears to be economically devastating.

However, this is just the first painful phase. As countries learn through practical experience about the impacts of different social distancing measures, they will identify what the optimum level of ongoing mitigation measures and social distancing will be so that health services can cope.

My fear is that the economic consequences are going to be very severe, because it will take 18 months to two years to get a vaccine. Even in Hubei, 99% of the population remain unexposed to this infection. The extent to which we can sustain control measures and the economic impacts of sustaining that are policy considerations governments are grappling with.

The ongoing pandemic shows that a public health crisis requires not just a medical response, but a broad range of crisis response measures. Singapore’s Foreign Minister Balakrishnan called the crisis an “acid test of every single country's quality of healthcare, standard of governance and social capital”. What is your view on this?

The pandemic is a test of both the health capacity and forward planning capability of any government, and the compact between citizens and state. People expect their leaders to take care of them, and the notion of protection is core to that. People do not merely look to the ministries of health for medical advice in a crisis like this, but also at prime ministers for leadership, and the financial responsibility that resides with central agencies of government. 

The capital that you build up with your population – underpinned by trust and legitimacy – is directly proportional to your ability to bring them along with you as you initiate control measures. Vienna, for example, has been able to put the city on lockdown, massively reducing the risk of the virus spreading, in large because the compact between government and citizen is robust enough.

Do all communities have sufficient social capital, cohesion, trust and respect in the compact between government and citizens for that to work? It may prove very difficult for the government in some parts of the United States to enforce strict mitigation measures. Were those measures to become necessary in Singapore, it will be relatively easy for the government to enact them.

What are some of things Singapore has done which can be modelled by others?

Singapore has been exceptional in that they have not only mobilized the public health infrastructure, but they have done two other things very well.

They’ve looked at the economy, worked out who is most vulnerable, and mobilized incredibly quickly. For example, during the first wave of cases from Wuhan, the government was immediately offering by late January S$100 ($73) per day to quarantined self-employed people. When a Malaysian two-week lockdown on March 18 left 300,000 Malaysian commuting workers unable to travel to Singapore for work, the government quickly mobilised to provide affected companies with S$50 ($37) per worker per day to cover the costs of housing each worker, and negotiated with hotels to lower their rates for companies. The Singapore government also worked with banks to provide relief for small businesses, such as moratorium for loans and extended loan facilities and risk-sharing. Governments all over the world are now following Singapore’s lead.

The Singapore government also mobilised their communications very rapidly and effectively. They’ve been convincing by being frank, but messages were also drip-fed to people, so the public have been primed. Before a major announcement arrives, the ground has always been softened a few days before with press releases and with junior government ministers issuing statements. They have this extremely well-orchestrated but in a way that doesn’t feel contrived. People rightly have trust in the daily social media updates, and a strong identification with the prime minister. In this way people have been brought along on this difficult journey. Many countries can learn from that, particularly if you contrast it with the US and the UK, which have both failed spectacularly.

It’s early days but what are some of the lessons we can learn from the outbreak?

Many countries are going to struggle from their lack of universal health coverage and social safety nets. In the US, where many people are on zero-hour contracts, it’s very difficult for people to take time off work if they are feeling sick. And if people feel it is going to cost them money to get a test, or if they’re going to be liable for the charges if they’re sick, they will not get tested.

If you keep significant proportions of your population uninsured, it will come back to bite you, because it is in everyone’s interest that you have a healthy population, both in terms of your day-to-day economic productivity, and also in your ability to manage a crisis. The US will suffer dearly because the sheer number of uninsured people there means the population is behaviourally incentivised towards not reporting or getting tested. 

These safeguards are a critical part of the social infrastructure that keeps communities safe, and countries that have all of that – strong safeguards, robust health systems, universal access to health, strong social capital, healthy compact between citizen and state – are going to fare best. I think we are going to find that the US is lacking in all of those aspects, and the UK as well, in some respects.

We also need to consider low- and middle-income nations. In an interconnected world where travel is the norm and not the exception, new clusters will be seeded until we have a vaccine. You simply cannot keep four billion of the world’s population without access to basic health services and expect to be safe, no matter the wealth of your country. People move across borders, diseases don’t have passports, and diseases like this where people transmit asymptomatically are now going to be a major problem for the next two years.

How would you assess the response of the World Health Organisation (WHO) to the virus, and what reforms would you like to see?

I think the WHO has acted very responsibly within their constraints. It is critical to understand the WHO’s constraints because you can’t expect it to behave in ways it is structurally incapable of doing.

First, the WHO’s total global funding is about the same as a referral hospital in the U.S. for one year. This is a massively underfunded organisation, given that the cost of getting it wrong is the entire global economy almost coming to a halt. When the history of this is written, we will be kicking ourselves that we allowed the agency looking after the health and well-being of all global economies and their populations to be so drastically underfunded.

WHO has some outstanding people, but it’s of course a large bureaucracy and it’s important to understand the nature of the beast. A way of understanding the WHO is to think of it as a trade organization for national ministries of health. Trade organisations do not criticise their own members vociferously, and to paraphrase your previous interview, multilateral institutions like the WHO work best when they don’t work too well, because if they work too well they impinge on the sovereignty of nation states. This means that the WHO is structurally unable to ask hard questions of ministries of health. When you create an organisation with those institutional constraints, it is unrealistic to expect it to criticise China or any other country.

Flowing from this logic, it is unrealistic to expect the WHO to engage deeply with heads of government, because they report to ministries of health. If WHO were to criticise the response of President X, just imagine the impossible position that creates for that nation’s ministry of health. It’s not going to happen. So, if you are expecting a multisectoral response that is focused on prime ministers and ministers of finance – which is what you need for a crisis of this magnitude – but you have an organisation that only involves ministries of health, you can get a sense of what the constraints are. The private sector, for example, has almost no engagement with the WHO, the same is true for treasuries, foreign ministers and prime ministers.

What is the trajectory of the disease going forward?

We are in a very difficult situation, because if you look at 1918 influenza or the H1N1 Swine Flu, it affected 30-40% of the global population. Harvard’s Centre for Communicable Disease Dynamics is looking at between 20-60% of the global population getting infected with covid-19 within a year. There is no easy way out of this and most of the world’s population could well get the disease. We are trying to manage it in as responsible a way as possible, but there is not much of a sweet spot between effective mitigation measures and keeping the global economy moving. That will be our challenge going forward – to find a very uneasy confluence between the two.

Dr Ben Rolfe is a public health expert based in Singapore with more than 20 years of experience in infectious disease, government relations and communication. CEO of the Communicable Disease Threats Initiative (Asia Pacific Leaders Malaria Alliance) for six years, Ben now advises full time on covid-19. Ben has previously provided advisory support in over 30 countries, including at the Asian Development Bank and as a Lead Specialist for the Australian Department of Foreign Affairs and Trade. Prior to Singapore, Ben has been based in Manila, Canberra, New Delhi, Asmara, Vienna, Phnom Penh, Dar Es Salaam and London.

Opinions expressed by interviewees in this interview series are solely theirs and do not necessarily reflect that of Global Counsel.