Zika erupts in Singapore: how we made it worse than it might otherwise have been

‘Cover up!’ screamed the immediate reaction I noticed on social media. The Health ministry had just announced that they have found 41 cases of Zika infection, barely 24 hours after they said that there was one confirmed case (on Saturday 27 August 2016). How can the number jump so fast without them knowing about these other cases earlier — was the implication behind the shouting headlines. They must be hiding facts from the public!

The accusation is not fair. The bits and pieces of information released thus far indicate a somewhat flat-footed ministry, but not one that is consciously withholding important information from the public. It is not at all like the Transport ministry concealing for several years the fact that about 35 train sets had dangerous defects, and that 26 of them needed to be sent back to China for overhaul. Unfortunately, this is how impressions are formed. All it takes is for a few government departments to be caught redhanded for trust in government as a whole to suffer.

In this essay, I hope to show why I think the ministry was flat-footed. But in the course of examining the details, the practices of the construction industry come into view too, and with them come larger questions as to the cost to society that flows from our being too lenient, perhaps even supportive, of this industry’s labour practices.

The cost is going to be significant. Overnight, Singapore has become the Asia hotspot for Zika, with more reported cases than any neighbouring country barring perhaps Thailand. Travel advisories have been issued against us. No doubt we all knew that sooner or later Zika would arrive, but to arrive in this big-bang way, making headlines, was something that was entirely avoidable.

The timeline

Zika is not a new disease. Wikipedia has a timeline showing how the virus was first isolated in Uganda in 1947, and over the years appeared on and off in Pacific islands. On 29 April 2015, the first confirmed case was reported in Brazil. By the middle of the year, cases of microcephaly were giving cause for great concern, having been linked to Zika. Other neurological symptoms might also be related to this infection, but it’s still too early to be sure. In other words, it is not just a threat to unborn babies in pregnant women, but there could be longer-term effects we don’t yet know on adults who have been infected.

Perhaps because microcephaly was so attention-grabbing, and so much of the reporting centred on Brazil and its neighbours, most people might not have noticed a small article dated 30 January 2016 in the Straits Times. The report (Straits Times, 30 Jan 2016, Thailand has most Zika cases in region) said that between 2012 and 2014, there were seven Zika cases in Thailand in various provinces. The Philippines, Cambodia, Indonesia and Malaysia each have had one Zika-related case since 2010. The short report added that the World Health Organisation was of the view that the confirmed reports vastly under-represented the real situation. The disease was likely to have spread far more widely in South-east Asia than the number of confirmed cases suggested.

In other words, the disease was already endemic in our region — makes sense, since we’re not that far from the Pacific islands — except that we weren’t alert to it. That said, by July 2016, people were beginning to take notice. “Thailand wary as Zika cases soar close to 100” was the headline of a Nikkei story dated 5 July 2016.

By then, Singapore already had its first case. A male permanent resident, aged 48, went to see a doctor on 12 May 2016. He mentioned to the doctor that he had been in Sao Paolo, Brazil, five days earlier. He was quickly hospitalised and tested for Zika. The tests came back positive and he was transferred to the Communicable Diseases Centre at Tan Tock Seng Hospital. The Ministry of Health announced it on 13 May 2016. The patient recovered and no follow-on cases were found.

In early and mid-August 2016, three doctors at Sims Drive Medical Clinic noticed a spike in the number of patients complaining of fever, rash and joint pain. Yet, tests for dengue, chikungunya, measles and rubella came back negative. Today newspaper reported that “The possibility of them contracting Zika was not raised, as most of these patients — a bulk of whom are foreign workers who worked at a construction sites in the vicinity — had not travelled to countries with ongoing Zika outbreaks.”

Nonetheless, the doctors decided to inform the Ministry of Health on 22 August 2016 of what they had noticed. It is not clear what the ministry did on receipt of this information, at least not in the immediate days that followed, though there are clues that they did little, as I will share with you below. No public announcement was made.

Five days later, on Saturday 27 August, the Ministry of Health and the National Environment Agency released the news that they had

“been informed of a case of Zika virus infection. The patient is a 47-year-old female Malaysian who resides at Block 102 Aljunied Crescent and works in Singapore. As she had not travelled to Zika-affected areas recently, she was likely to have been infected in Singapore.”

The Straits Times reported (28 August 2016, Aljunied woman is first case of local Zika infection) that “She started to have a rash, fever and conjunctivitis on Thursday and saw a doctor on Friday before being sent to the Communicable Diseases Centre at Tan Tock Seng Hospital.” It is not clear which GP or clinic she went to. Upon admission to the CDC, the diagnosis was confirmed.

By around Sunday night, the ministry announced that they had identified a total of 41 cases (including the Malaysian woman). It said in its press release early on 29 August 2016 that it had “confirmed 41 cases of locally transmitted Zika virus infection in Singapore. Of these cases, 36 were identified through active testing of potentially infected persons.”

This, alas, is where the gobbledegook begins, giving people reason to accuse them of being parsimonious with the truth.

Meaning-deficient sentences and gap-ridden statements

Firstly, what does “active testing of potentially infected persons” mean? Isn’t that what should always be done? How is it that something so routine is worth mentioning as if it were a highly creditable effort? Secondly, if 36 of 41 were identified though active testing, what about the other five positive-tested persons? No mention at all in the ministry’s statement. In its present form, the press release indicates that the ministry is poor at public communication in a crisis situation. The officials don’t review what they are about to say to (a) purge their sentences of banal claims, and (b) spot gaps in information before they say it. Meaning-deficient sentences and gap-ridden statements give the public reason to wonder if an attempt is being made to obscure important facts. They naturally invite a negative impression.

A closer reading of the statement tells us a bit more about the five cases.

As you can see, the 47-year-old Malaysian woman that triggered this announcement was actually the last of the five to develop symptoms. Four others had been ill for several days before. At least three of them were not warded at the CDC till 27 August, which suggests that they were not tested for Zika until the woman proved positive.

Epicentre went undetected for weeks

You may recall however, that the Sims Drive Medical Clinic informed the ministry on 22 August 2016 of its unusual cluster of fever cases. The ministry did not seem to have acted on this information. Mr Koh Peng Keng, Ministry of Health Group Director, Operations, in response to questions by Today newspaper (28 Aug 2016, Why the MOH did not announce the Zika cases earlier) said, “The first case we knew of was patient A (the 47-year-old Malaysian woman whose case was reported on Saturday). The rest of it we had to work with the GPs, to do a lot of tracking to try and look back.”

“The GP alerted us of this unusual cluster of cases with mild symptoms, it’s only (then) we went back to check….most of them had already recovered.”

The way he phrased his reply appears to confirm my suspicion that they scrambled to test the cluster only after they realised (through the case of the Malaysian woman) they had Zika on their hands.

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Addendum, 30 Aug 2016:

I see a news story from Channel NewsAsia that confirms my suspicion even more directly.

Health Minister Gan Kim Yong confirmed on Sunday (Aug 28) that it was the report of the first locally transmitted case that prompted the Ministry of Health (MOH) to look back into past cases “where people were seen by doctors but were not suspected to have Zika”. In a press briefing, officials from MOH and the National Environment Agency (NEA) said that fresh blood and urine tests conducted on some of these individuals picked up the Zika virus, which can be detected “up to a month” after recovery. Based on these tests, the earliest case of locally transmitted Zika infection is likely to have occurred on Jul 31, according to MOH. — Channel NewsAsia, 29 August 2016, Locally transmitted Zika cases: A timeline. Link.

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The ministry’s statement said that they tested 118 persons working at a construction site at 60 Sims Drive. Of these, 36 tested positive, 78 tested negative and as at the date of the statement, 4 still had results pending. Of the 36 who tested positive, 29 “have fully recovered” with seven warded at the CDC.

Dr Derrick Heng, Ministry of Health Group Director for Public Health revealed in the Today story that “The (earliest) case that we know of was July 31.” I believe he meant to say that the first construction worker to experience symptoms did so on 31 July 2016. Very likely, many of his fellow workers fell ill in the days following (since by the ministry’s 29 August statement, twenty-nine of them were said to have “fully recovered”). This means that the Malaysian woman was not actually the fifth person to have symptoms, despite my table above. She might have been the 40th!

In short, we didn’t discover the disease until around 40 cases had occurred. Flat-footed, I’d say.

Following the discovery of so many cases, a Stop Work Order was issued to the construction site on 27 August, as the housekeeping of the construction site was found to be unsatisfactory with potential mosquito breeding habitats. The construction site was required to rectify these conditions before the order could be lifted.

As at noon on Tuesday, 30 August 2016, the number of cases had ballooned to 82. In addition to the 41 cases mentioned above, fifteen more were reported by noon, 29 August and another twenty-six persons by noon, 30 August. Five persons lived or worked a little distance from the epicentre at Sims Drive and Aljunied Crescent, but not more than 1 km away.

Australia, Taiwan and South Korea had issued travel advisories against Singapore. More countries may soon follow.

What stands out from the narrative so far

Two things struck me as I researched through the details of this developing story.

No real preparations

Firstly, while it had been stated that sooner or later Zika would come to Singapore, no real preparations seem to have been made. General practitioners on the frontline didn’t seem to have been fully alerted to the disease by public health authorities. Undoubtedly, in its mild form, Zika may present in ways that resemble many viral fevers, but as the doctors at Sims Drive Medical Clinic admitted, even when they saw a rising trend in fever and rash, they still didn’t think of Zika. They checked off dengue, chikungunya, measles and rubella, but not Zika.

The most likely reason was because they were probably placing too much importance on travel history. Perhaps everyone was thinking ‘Brazil’ for Zika, not realising that the disease was already in Southeast Asia. Our authorities might not have done enough to inform doctors of this. In fact, ministry doctors and officials themselves were probably of the same mindset, which may explain why it took about 40 cases before the ministry discovered it.

When we treat foreign workers badly, we pay

Secondly, we should read significance into the fact that a big majority of the initial cases came from among foreign workers at a construction site at 60 Sims Drive. Indeed, it is true that mosquito breeding is a continuing problem at construction sites. Contractors simply don’t have enough civic-consciousness to pay attention to this. The 36 cases from the construction site constituted roughly one in three of the workers tested. That’s a very high proportion.

How many of these 36 had earlier sought treatment at clinics is not known, but I would hazard a guess that even if they did, it was only after they had been ill for at least a few days. My volunteering with the charity Transient Workers Count Too has taught me that employers in this industry are always quick to penalise foreign workers for seeing doctors and taking sick leave. Workers fear they might lose their jobs. This punitive attitude on the part of bosses then means that an ill and infectious worker remains at work or in the dormitory for as long as he can. Only when he gets intolerably sick does he go to a doctor. But, in the meantime, how many mosquitoes has he fed? How many other workers has he infected?

The moral of the story is this: we cannot treat an underclass shabbily without a cost boomeranging upon society as whole. In this case, a node of infection developed within a construction site, a node we didn’t pick up on until the numbers had incubated and climbed and begun to affect the residents around. So instead of Zika cases appearing in Singapore one or two or three at a time, we get this blast. One or two or three cases would not have led to travel advisories and consequential impact on the tourism industry. A long-incubated blast on the other hand makes for stunning headlines.

I would hasten to add, though, that Singapore’s numbers are high because we have the means to test and discover cases. It may well be that the cases in surrounding countries are higher, except that there are no statistics. This shows that we are good are reacting to a problem. If only we were as good at anticipating problems, including the kind of anticipation that includes a wholistic understanding that shabby treatment of foreign workers will have public health consequences for all of us.