To understand the spread of COVID-19, the pandemic is more usefully viewed as a series of distinct local epidemics. The way the virus has spread in different countries, and even in particular states or regions within them, has been quite varied.
A New Zealand study has mapped the coronavirus epidemic curve for 25 countries and modelled how the spread of the virus has changed in response to the various lockdown measures.
The research, which is yet to be peer-reviewed, classifies each country’s public health response using New Zealand’s four-level alert system. Levels 1 and 2 represent relatively relaxed controls, whereas levels 3 and 4 are stricter.
By mapping the change in the effective reproduction number (Reff, an indicator of the actual spread of the virus in the community) against response measures, the research shows countries that implemented level 3 and 4 restrictions sooner had greater success in pushing Reff to below 1.
An Reff of less than 1 means each infected person spreads the virus to less than one other person, on average. By keeping Reff below 1, the number of new infections will fall and the virus will ultimately disappear from the community.
Conversely, the larger the Reff value, the more freely the virus is spreading in the community and thus the faster the number of new cases will rise. This means a higher number of cases at the peak of the epidemic, a greater risk of the health system becoming overwhelmed, and ultimately more deaths.
Here are some of study’s findings from states and nations around the world:
New South Wales, Australia
The effect of Australia’s strict border control measures, implemented relatively early in the pandemic, can clearly be seen in the graph below. Federal and state governments introduced strict social distancing rules; schools, pubs, churches, community centres, entertainment venues and even some beaches were closed.
This prompted the Reff value to drop below 1, where it has stayed for some time. Australia is rightly regarded as a success story in controlling the spread of COVID-19, and all states and territories are now mapping their paths towards relaxing restrictions in the coming weeks.
Italy was relatively slow to respond to the epidemic, and experienced a high Reff for many weeks. This led to an explosion of cases which overwhelmed the health system, particularly in the country’s north. This was followed by some of the strictest public health control measures in Europe, which has finally seen the Reff fall to below 1.
Unfortunately, the time lag has cost many lives. Italy’s death toll of over 27,000 serves as a warning of what can happen if the virus is allowed to spread unchecked, even if strict measures are brought in later.
The UK’s initial response to COVID-19 was characterised by a series of missteps. The government prevaricated while it considered pursuing a controversial “herd immunity” strategy, before finally ordering an Italy-style lockdown to regain control over the virus’s transmission.
As in Italy, the result was an initial surge in case numbers, a belatedly successful effort to bring Reff below 1, and a huge death toll of over 20,000 to date.
New York, USA
New York City, with its field hospital in Central Park resembling a scene from a disaster movie, is another testament to the power of uncontrolled virus spread to overwhelm the health system.
Its Reff peaked at a staggeringly high value of 8, before the city slammed on the brakes and went into complete lockdown. It took a protracted battle to finally bring the Reff below 1. Perhaps more than any other city, New York will feel the economic shock of this epidemic for many years to come.
Sweden has taken a markedly relaxed approach to its public health response. Barring a few minor restrictions, the country remains more or less open as usual, and the focus has been on individuals to take personal responsibility for controlling the virus through social distancing.
This is understandably contentious, and the number of cases and deaths in Sweden are far higher than its neighbouring countries. But Reff indicates that the curve is flattening.
Singapore is a lesson on why you can’t ever relax when it comes to coronavirus. It was hailed as an early success story in bringing the virus to heel, through extensive testing, effective contact tracing and strict quarantining, with no need for a full lockdown.
But the virus has bounced back. Infection clusters originating among migrant workers has prompted tighter restrictions. The Reff currently sits at around 2, and Singapore still has a lot of work to do to bring it down.
Individually, these graphs each tell their own story. Together, they have one clear message: places that moved quickly to implement strict interventions brought the coronavirus under control much more effectively, with less death and disease.
And our final example, Singapore, adds an important coda: the situation can change rapidly, and there is no room for complacency.
In recent weeks, Singapore went from global success story in its response to the coronavirus outbreak to having the largest number of cases in Southeast Asia.
There are some 15,000 confirmed cases in Singapore as of this week – more than Japan, South Korea and Indonesia.
Most startlingly, though, is the number of migrant worker infections in the country, which dwarfs that of the general population. For example, of the 528 new cases detected on Tuesday, 511 were foreign workers living in dormitories, while another seven were workers living outside the dormitories.
Singapore’s approach to disease mitigation, generally speaking, mirrors the country’s approach to just about everything – control, surveillance and containment.
But the increasing COVID-19 infection rates among migrant workers suggest there is another side to the tight regulation that governs nearly every aspect of life in Singapore – the institutionalised neglect of the country’s 300,000-plus migrant workers.
And it is this neglect that, my research suggests, lies at the heart of explanations for Singapore’s COVID-19 crisis.
Cramped rooms with one toilet for 80 men
In 2014-15, I carried out a large study of transient migrant workmen from India and Bangladesh in Singapore, interviewing close to 200 men over 18 months. Most worked in the construction and shipping industries, and some in the landscaping and cleaning sectors.
As well as uncovering stories of routine labour exploitation and debt bondage among the workers, I also found most workers’ living conditions were shockingly substandard.
Employers are supposed to provide meals for migrant workers, for example, but workers complained the food was often no more than soggy rice and gravy. Often, it was spoiled and inedible.
My research also found substandard accommodation greatly compounded the difficulties these workers faced.
Many migrant workers live in the cramped, purpose-built dormitories (PBDs) shown in media reports in recent days.
These dormitories only became common a couple of years ago when migrant-rights organisations began focusing on housing conditions of workers. The government’s response was to build large dormitories in remote, outlying areas.
This enabled the government to claim it had addressed criticisms of poor worker housing. At the same time, it ensured these workers were further separated spatially and socially from the rest of Singapore’s population.
This separation has been an ongoing concern of the government since the so-called “Little India riots” of 2013, which broke out after a migrant worker was knocked down and killed by a bus. More than 50 police officers and eight civilians were hurt, and dozens of Indian workers were either charged with offences or sent home.
But not all, or even the majority, of workers live in dormitories. Many live on the upper floors of small construction subcontracting firms, or in shipping containers and other temporary housing on work sites.
The conditions are abhorrent: cramped rooms housing up to 30 men apiece, no air-conditioning or appropriate ventilation, bed bugs and cockroaches, and often just one filthy toilet shared by more than 80 people.
In both dormitories and these accommodations, two men often rotate on one bed. When the day-shift worker returns to the room to sleep, he takes the place of the night-shift worker using the same bed.
In these conditions, dengue and other waterborne diseases thrive. A few weeks before I arrived in Singapore in 2012, there was a massive outbreak of dengue among migrant workers in the industrial northwest. Many men were infected, and most swiftly deported.
In 2015, I visited a factory where five Bangladeshi men were pursuing a case for unpaid salary against their employer. They told me previous workers had contracted dengue and were deported while they were still sick. As a result, they were pushed by their boss to work longer hours, despite not being paid. The deportation of injured and sick workers is a common occurrence in Singapore.
These living and working conditions explain why we are seeing such high rates of COVID-19 infections now. The government’s main response has been the construction of several large dormitories for workers, but beyond that, it has yet to take comprehensive steps to improve conditions.
The government does have a salary and injury claims system for migrant workers, but NGOs in the country claim it – like policies to improve workers’ living conditions – is woefully inadequate.
Workers now very afraid of COVID-19
Last week, one of the participants in my research, a 32-year-old Bangladeshi man named Monir, sent me an email saying:
We are in lockdown for two months. Can’t go out. Singapore very danger now. But we are lucky we not stay worker’s dormitory. We sleep Geylang [a district of Singapore] company store.
During the current crisis, the workers in the dormitories are currently only allowed outside their rooms at certain times to reduce contact with others. Some have been relocated to offshore, floating accommodations where they are similarly confined.
Debbie Fordyce, a longtime migrant worker rights advocate, told me,
When returning Singapore students were give a two-week holiday in five-star hotels rather than be a potential source of infection to their family, these men are being bunched together with a far higher vulnerability than if they were in a space alone or with fewer people.
The government should have been better prepared for a possible outbreak among these workers. Instead, it turned a blind eye to their needs.
When the government issued face masks to all Singaporeans at the fist sign of COVID-19 in early February, migrant workers were excluded. (The philanthropic arm of a state investor later distributed more than 1 million masks to migrant workers and domestic helpers.)
Last week, the government imposed a stay-at-home order for 180,000 migrant workers in the construction industry until May 4, confining them to their dormitories. Advocacy groups have warned about quarantining large groups of people together like this, comparing it to cruise ships.
While recent media coverage on the COVID-19 crisis in Singapore has exposed the substandard conditions of migrant workers, my study shows there is a longer history of institutionalised neglect of these men.
This is not an exceptional time for these workers – their rights have long been ignored because they are transient and, for the most part, deemed disposable.
Papua New Guinea
Singapore’s response to the coronavirus has been held up by many around the world as a model. As of this week, the country has had 266 total cases (with zero deaths), and its infection rate is much slower than the rest of the world.
The first thing that helped with its response was it was ready before the outbreak even occurred because of the SARS outbreak of 2002-03.
It was aware then that its infrastructure wasn’t ready for an outbreak of this kind. So, in the years since, isolation hospitals were built, more negative pressure rooms were created and legislation was put in place.
Then, on December 31, when the world first became aware of coronavirus in China, Singapore started to get prepared. By the time the World Health Organisation declared a public health emergency at the end of January, it was ready.
In February, Singapore made it clear again this virus had the potential to have major health, social and economic consequences. We knew that because we saw what happened in China. The virus brought a country of 1.4 billion people basically to its knees.
The rest of Asia was clearly frightened and scampering to get ready, too – Taiwan, Hong Kong, South Korea. There was no confusion in the minds of these countries what this virus could do.
Yet, still other parts of the world weren’t preparing.
Keeping people who test positive in hospitals
Looking at what we do differently today, I think the biggest one is Singapore didn’t let positive patients back into the community.
China also didn’t do that. Wuhan created 50,000 hospital beds in two big temporary hospitals. These weren’t hospitals for sick people, these were all the mild cases that Australia, Europe and US sends home.
Home quarantine is not easy. You’re not supposed to mix with your family, you’re supposed to have your own toilet, you’re not supposed to have visitors. If you’re going to keep people at home, you need to be really sure they’re not transmitting it.
In Singapore, we think it’s better to hive those people off and look after them elsewhere until the virus is clear. People with mild cases are kept in hospitals – we have enough space to put all the positives together.
If you’re going to look after people at home, how do you know they are complying with self-isolation rules? Are you doing phone tracking? Are you doing random checks regularly enough? Are there harsh enough penalties to frighten people from disobeying?
Singapore has contact tracing teams, who identify all the contacts of an infected person and ring them up. Often these people have early symptoms and we’ll arrange for them to be picked up and tested.
Singapore is very liberal with our testing. Less than 1% of our tests are positive, so that reflects just how many tests we are doing.
If people don’t have symptoms, they’re put in home quarantine. And home quarantine is very strict. A couple times a day, you’ll get an SMS and you have to click on a link that will show where your phone is.
In case you cheat and leave your phone at home with someone else, the government has people knocking on doors now and then. The penalties are pretty harsh.
Consistent, regular communication
We have been very strong on community engagement. The messages we send are: if you are sick, stay home. If you are sick and have had contact with a COVID-19 patient, come in for a test. If you can’t stay home and you have to go out, wear a mask. If you cough, cough into your elbow. Avoid crowds, particularly indoors.
To everyone else, we say social distancing. For restaurant and bar owners, try and reduce the number of people in your businesses. People know what to do and they know if there’s a lockdown, they’re going to be closed. There’s a lot of business and revenue to be lost.
Everyone understands and adapts. You know what happens when people don’t adapt – we end up closing things down.
The messaging has also been very strategic. There’s a cross-ministerial task force – we regard this as a whole of government issue, not just a health issue. The prime minister comes on television every couple weeks, the chair of the task force is now a well-known face. Messaging is generally limited to a small number of authoritative people
There’s great transparency. There’s already great faith in government, so that helps quite a bit.
The messaging from the government is also consistent – they provide the latest numbers and say what’s happening in other countries and what might need to be done in Singapore.
We also created a public awareness campaign with cartoons. This is an alternative medium people might connect with. They are very popular, with over 1 million viewings online. The World Health Organisation is now translating them into other languages.
Why Singapore isn’t in lockdown
It’s pretty well-known that children are asymptomatic or only have mild disease, so there was no real reason to close schools. If you close schools, what’s the trigger to reopen them?
In Singapore, we want life to go on as normal. We want businesses, churches, restaurants and schools to stay open. This is what success looks like. Everything goes forward with modifications as needed, and you keep doing this until there’s a vaccine or a treatment.
On testing, the threshold for getting a test is pretty low. For the first week, we tested only people from Wuhan or Hubei province, then we tested anyone who had been in China within the last 14 days.
By the end of January, all of our public hospitals could do tests. Then we moved to enhanced screening – we tested anyone coming to a hospital with a respiratory illness, anyone who had been in contact with a COVID-19 patient.
Now, it’s even become more liberal. If you’re a hospital staff member with a mild cold, we’ll give you a test.
But if you’re a normal person with no contacts with anybody and mild symptoms, we’d just send them home. You can get a medical certificate that allows you to stay home from work for five days. If you are a casual worker, there’s financial help with that, too.
Leadership needs to be organised
It’s nothing really fancy. We don’t have the magic answer here, we just do it well and efficiently.
It’s certainly more challenging to put these things in place in bigger countries with different political systems, but it just means people need to know their roles.
For instance, communicating to the nation should come from the national government, but the state level should talk about state-relevant things.
It’s really about leadership being organised enough to get the messaging right as a team. Then people will feel more comfortable and are much more likely to follow the rules.