Singapore's coronavirus playbook: How it fought back against the COVID-19 pandemic

Italy reported its 3,405th coronavirus death on Thursday, officially overtaking China as the nation with the most coronavirus fatalities. Not long ago, it looked as though that grim distinction could have gone to Singapore.

The city-state was just the third country to report cases of COVID-19, and by mid-February, two months after the disease originated in Wuhan, China, Singapore had reported 80 cases. It was the worst-hit country outside mainland China at the time. Since then, however, it's emerged as a model for how to curb the virus' spread, along with Hong Kong and Taiwan, earning praise from the World Health Organization for its defense strategy.

Fast-forward to the present day. Singapore has reported fewer than 390 cases and had zero deaths until Saturday when it confirmed its first two fatalities since the outbreak began there in late January. While new coronavirus cases have clearly increased there, it's far less compared to countries like Italy that saw a spike in cases to the thousands. New York City, which has a similar population size and density to Singapore, has nearly 4,000 cases, despite confirming its first case on March 1, more than a month after Singapore, which confirmed its first case on Jan. 23.

The contrast is staggering and comes at a time when the world is grappling with the rapid spread of the coronavirus. Across the world, cities have gone into lockdown, closing schools and nonessential businesses like movie theaters and urging residents to stay home. Italy has closed itself off, followed by several other European countries, while the US and Canada in recent days restricted nonessential travel across their borders.

Singapore's relatively low rate of infection came through a potent combination of early and intensive policy intervention, including shutting its borders to Chinese travelers on Feb. 1 -- roughly a week after China announced it would lock down the city of Wuhan. The government also set up a virus-fighting task force, promptly imposed strict hospital and home quarantine measures, and banned large-scale gatherings. It did stop short of shutting down schools and fully closing its borders. 

"We want to stay one or two steps ahead of the virus," Vernon Lee, director of the communicable diseases division at Singapore's Ministry of Health, is reported to have said. "If you chase the virus, you will always be behind the curve."

Proactive, not reactive

Within 24 hours of a new infection, Singapore races to stitch together a holistic picture of an infected person's movements. It does this, in part, through an exhaustive process known as contact tracing, which involves mobilizing a team of more than a hundred dedicated contact tracers who work around the clock.

"Once a case is confirmed, within 2 hours  [contact tracers] create a detailed activity log of the patient's movements and interactions in the 14 days before admission," Singapore's Prime Minister Lee Hsien Loong said in a Facebook post. 

In order to help build the log, contact tracers conduct thorough phone interviews with infected patients, asking them questions like what meals they ate and who they'd met over the past 14 days. Based on information extracted from those interviews, authorities can identify and quickly isolate those who've been in close contact with a given patient.

"Fortunately COVID-19 patients have been generally cooperative in sharing information. This enables healthcare workers, public officers, and the Singapore Police Force to map out the history and contacts quickly," said the Singaporean leader.

Singapore's band of contact tracers has been so effective in their work that approximately 40% of people first found out they might have been infected only when the country's health ministry phoned up to say they needed to be tested and isolated, according to the BBC.

Aside from conducting extensive interviews with patients, contact tracers also lean on the police to play back surveillance footage from private venues or businesses that the patient may have visited, or they might track them down via digital signatures left by ATM card withdrawals or credit card payments.

On Friday, Singapore took a step further with its contact tracing process, rolling out a smartphone app called TraceTogether, which it has encouraged Singaporeans to download. Using Bluetooth signals, the app enables authorities to identify people who've been exposed to patients infected with the coronavirus. Phones within two meters of each other exchange Bluetooth signals, allowing the app to make a record of the encounter. The app is expected to help fill in the blanks during contact tracing when a patient doesn't have the contact details of person he or she had come into contact with or when a patient simply cannot remember an encounter from the two weeks prior to their infection.

Singapore's government has been criticized for having autocratic tendencies that bypass legislation or engage in types of surveillance that would almost certainly face pushback in more democratic countries. But some experts say the public's loss of some degree of privacy is a worthwhile compromise to mitigate the spread of COVID-19.

"The government has a great track record of looking out for its residents," said Oly Fernando, a Filipino professional who's been living in Singapore for two years. "The response to COVID-19 has been calm and methodical, and I feel safe and privileged to be here."

Lessons learned from SARS 

Singapore, along with Hong Kong, was heavily affected by the SARS (severe acute respiratory syndrome) epidemic back in 2003, and has institutionalized the lessons it learned. That pandemic took five months to eradicate, but not before claiming 33 lives in Singapore, one of the worst-hit countries outside China.

 "Singapore invested heavily in developing capacity and an infrastructure to deal with these types of outbreaks over the past 10 to 15 years, including increasing capacity for intensive care and patient isolation facilities, building expertise in infectious disease," said Clarence Tam, an assistant professor at the Saw Swee Hock School of Public Health at the National University of Singapore.

Tam says the measures implemented by Singapore are "not particularly novel or unique -- they've been used repeatedly to deal with infectious disease outbreaks."

Fears of a second wave

Although Singapore -- along with Hong Kong, South Korea, and Taiwan -- has found comparative success in containing the spread of the novel coronavirus, fears are growing that a second wave of cases may hit as the pandemic escalates in the US and Europe.

On Sunday, Singapore expanded its travel restrictions shutting down its borders to all short-term visitors entering or transiting through the city-state after witnessing a surge in imported cases. In recent days, about 70 percent of Singapore's new COVID-19 cases came from people who had returned to the city-state after exposure to the virus while overseas. Most of them were Singapore residents and long-term pass holders returning to Singapore after travel abroad, Singapore's Ministry of Health said Wednesday. 

Still, officials have warned that the number of cases is expected to rise and that deaths are "inevitable" as cases spike in other parts of the world.  

Singapore may implement additional extensive social distancing measures if local transmission increases, but it'll need to be weighed against the social and economic harm that they bring, according to Tam.

"Governments and health authorities worldwide will be facing some difficult choices regarding how best to control the epidemic over the coming months."