COVID-19 Lessons from China and Singapore

On December 31st, 2019, China informed the World Health Organization (WHO) that it had registered several cases of a respiratory virus, which originated in Wuhan, a port city of 11 million people in Hubei province. That was more than three weeks after the first cases were reported internally.

As a result of the SARS outbreak in 2003, China built a disease control and prevention system, which was supposed to be ready for a very rapid response. This system successfully detected H1N1 and Avian flu but failed to report the early cases of Covid-19. The first internal reporting appears to be on December 29, 2019. While investigating the failure of the early reporting, the National Health Commission kept the number of the infected patients artificially low to 27 sick patients of which 7 patients were critically ill while later, China's CDC acknowledged that by the end of December numbers were 104 cases of which 15 had died. During that time, the risk of human-to-human contagion was downplayed, whistleblowers were silenced and punished, celebrations connected with the Lunar New Year went on as usual. At least three crucial weeks in early detection, reporting and prevention were lost in reporting system failures and political cover-ups, mainly by the local Wuhan and Hubei authorities. The lost time, eventually led to the lock down of Wuhan on January 23, 2020 and of Hubei province on February 13, 2020.

China's chaotic, confused, uncoordinated mismanagement of the initial outbreak, which contributed to the spread of the virus not only in Hubei, but also outside China's borders, is strikingly different from the approach Singapore took to tackle the new virus.

Before the recent COVID-19 outbreak, Singapore already had a hospital, legal, and reporting system in place, which allowed for immediate response. When WHO announced COVID-19 as a public health emergency, Singapore was ready. It started doing extensive free testing, which due to the excellent and accessible healthcare system, was readily available. During the first week of January, only people arriving from Hubei province were tested. After that, everyone, who had been in China in the last 14 days, was tested. By the end of January, all public hospitals in Singapore were able to test, which allows for widespread testing even if there is a slight suspicion for COVID-19. Only 1% of the tested patients have been positive, showing how extensive the testing system is. All cases, even the mild ones, are isolated and treated in hospitals. The contacts of each infected person are tracked down with the help of tracking teams. These contacts are then tested and even without symptoms placed under a strict quarantine at home. Their location is monitored by phone several times a day. Those who don't obey are penalized. The communication to the public from day one has been very open, clear and consistent. Unlike in China, there has been much more transparency from the government of Singapore from the onset of the outbreak. Social distancing, early sickness symptoms, wearing a mask in public, "coughing" etiquette were all communicated via text messages to the general public early on. The government sends all citizens text messages via WhatsApp twice a day offering an update on the COVID-19 status in the state, including locations, which could have an outbreak. And on March 20, the authorities introduced the TraceTogether app. TraceTogether uses Bluetooth technology to identify people who have been in close proximity -- within 6 feet for at least 30 minutes -- to coronavirus patients. It is worth mentioning that in early February China also introduced Close Contact Detector phone app, offering citizens to see if they are at risk for novel coronavirus. This app is not as user friendly as the Trace Together app. The close contact detector requires access to apps like Alipay, WeChat or QQ, and the user's name, ID and phone number. Since then, the Chinese authorities have also developed another app called Color Code, which assigns a health color to each user according to his or her travel history and contacts.

As of March 23h, short-term visitors, tourists and transit passengers are not allowed in Singapore. Bars, movie theaters and other entertainment outlets are closed as of March 26th. However, schools, malls and restaurants remain open. People are not restricted to move. These actions were taken by the Singaporean government because the state experienced its first 2 deaths and is seeing an increase in the number of coronavirus cases.

As it stands, despite its proximity to China and interconnectedness between the two countries, Singapore has 432 COVID-19 cases and 2 deaths so far, comparing to China, with 81340 cases and 3292 deaths most of which occurred in Hubei province. China's higher mortality rate reflects higher number of fatalities in the early stages of the outbreak (17% of the cases between January 1-10, dropping to 0.7% after February 1), which also points to an early outbreak mismanagement. The exceptionally low fatality rate in Singapore attests for a successful early detection, prevention and preparedness to tackle and treat COVID-19.

The relative success of Singapore may not be possible to replicate. Singapore is a wealthy, relatively small city-state with an authoritarian government and accessible healthcare system. However, the contrast between the disorganized, chaotic and delayed response of China and the organized and efficient approach of Singapore can be of tremendous help for all other countries trying to contain COVID-19 pandemic.