In this episode, Dr. Hsu Li Yang chats with our host Maggie Fox about how Singapore managed the COVID-19 pandemic.

Singapore is a small country in Southeast Asia, but its experience with the first outbreak of Severe Acute Respiratory Syndrome virus – SARS – in 2003 and 2004 helped prepare leaders there for SARS-CoV-2, which causes COVID-19. Dr. Hsu Li Yang, Vice Dean for Global Health and program leader of infectious diseases at the National University of Singapore’s Saw Swee Hock School of Public Health, lived through the first SARS outbreak and helped fight COVID-19.

While restrictions were tight, Dr. Hsu says they worked – and people saw they worked. “Trust currently has never been higher because people could see the success of how the pandemic was managed,” he tells us. What else worked in Singapore?

View Transcript

Maggie Fox 

Hello and Welcome to One World, One Health, with the latest ideas to improve the health of our planet and its people. I’m Maggie Fox.

Planet Earth faces many challenges: pollution, climate change, and new wood reemerging infectious diseases. This podcast is brought to you by the One Health Trust with byte-sized insights into ways to help.

In this episode, we’re chatting with Dr. Hsu Li Yang. He’s vice dean for global health and program leader of infectious diseases at the Saw Swee Hock School of Public Health, National University of Singapore (NUS), he’ll tell us about Singapore’s battle with COVID-19.

Li Yang, by any measure, Singapore has weathered the pandemic better than many countries. I’ve got the data here from Johns Hopkins University. Singapore counted 27 deaths per 100,000, or a case fatality rate of 1/10 of 1% of the population. That compares to 316 deaths per 100,000 in the US. It’s a case fatality rate of more than 1% of the population, more than 10 times higher. How did Singapore do it?

Dr. Hsu Li Yang

Thanks for having me with you, Maggie. Let me start by acknowledging that we have been very lucky and things might have turned out quite differently. Having said that, I think my country made several difficult judgment calls correctly, and also implemented several policies well, for example, the initial decisions to minimize the importation and spread of COVID-19. And then to relax measures slowly rather than flip flop between lockdowns and full reopening.

This helped to reduce the caseload and deaths in the period before vaccines were available. And also when we were ramping up vaccinations. And talking about vaccines, the effort to secure sufficient vaccines early and to go to the last mile in terms of vaccinating the population was also important. And this allowed us to open up with a relatively smaller death toll compared to many other countries.

Maggie Fox 

You’ve hinted at this, but Singapore is a small country, and it’s easy to close borders. Was that one of the factors?

Dr. Hsu Li Yang

I think it is. It is physically easier to close borders in Singapore. But I think it’s also important to understand that Singapore is an international hub that’s highly dependent on external trade, air traffic, and tourism. So it was also a very costly exercise for us to do.

Maggie Fox 

How about the first outbreak of SARS in 2003-2004? Did people learn from that? And did they apply the lessons they learned?

Dr. Hsu Li Yang

Thanks for asking that question. SARS in 2003, I think was our defining outbreak, just like in several other places like Hong Kong and Vietnam. And thanks to the experience from SARS, which we never wanted to repeat again, we set up procedures and training and preparations for future pandemics that help to mitigate the current COVID-19 pandemic for us. So it was a xxxxxxxx Coronavirus, is related to our current COVID-19 virus. But it spread less easily. There were hardly any persons who were asymptomatic. And of course, the mortality rate was far higher at between 8% to 10%, depending on where you are around the world. In hindsight, SARS didn’t have that much of a health impact compared to COVID-19.

I think at the end of it, we had about 238 cases in Singapore and 33 deaths. But it resulted in our economy almost shutting down, one huge public sector hospital out of six being closed, which had tremendous impact and strain on all the other hospitals. I was working in the hospital that closed down at the time that I was in hospital. And I remember that when we left the hospital to go home, you could hardly get a taxi or a bus to pick us up and we had to walk some distance away from the hospital just to get public transport. I think there was a collective tremendous fear of SARS at that time that I don’t think we ever want to repeat again.

Maggie Fox 

That was a long time ago. But somehow everybody in the country managed to remember that I feel like in some countries people forgot some of those lessons.

Dr. Hsu Li Yang

That’s not really true. The older people like me remember when I was lecturing medical students recently, I asked them what they were doing during SARS and they said they were one year old. So we are coming into a generation that has forgotten SARS now.

Maggie Fox 

So was it public health officials? Was it the government? Who were the people who managed to remember what happened and apply it to maybe a naive population who didn’t have those memories?

Dr. Hsu Li Yang

That’s a great question. And I think SARS in 2003 for us was the defining outbreak.

It showed us how much we needed to do in order to prepare for the next pandemic. And we have managed to keep those lessons with us. We have been planning and training for the past few decades. And I think it’s quite fortunate that the COVID-19 pandemic, if it had to happen, happened when it did, when the people in the government’s and our ministries still remembered SARS, and still could apply some of the lessons that we learned very early.

Maggie Fox 

People in many countries in Asia see mask use as a civic duty to protect others as well as themselves. Was that a factor in controlling COVID in Singapore?

Dr. Hsu Li Yang

Actually, we do not have the mask-wearing culture of Japan. But both the government and local experts repeatedly explained the importance of wearing masks after initially going wrong during the early part of the pandemic. And then people could also see the effects which included fewer cases of COVID-19 for long periods of time, in 2020, and 2021. So in fact, many people are still wearing masks out in the public open spaces now, even though it has become optional since almost half a year ago.

Maggie Fox 

And I believe there’s been another recent loosening of mask requirements, right? Do you think that’ll lead to another bump in cases? Or are people wearing them when it’s appropriate?

Dr. Hsu Li Yang

Well, that hasn’t quite happened yet. But the prime minister in this National Day Rally promised that it would. So we are just kind of coming down from the Omicron BA-4 and BA-5 with now. And that became kind of extended because it melded with the BA-2.75 wave as well. So I think once the mask requirements in schools and indoor public spaces are loosened, we should expect a small bump in COVID-19 cases, but it’s quite likely we will also have a bump in other respiratory and childhood infections as well.

Maggie Fox 

How important were mandatory restrictions? Is there anything unique about Singapore’s population or culture that makes restrictions more acceptable?

Dr. Hsu Li Yang

I think virtually every country had some sorts of mandatory restrictions. I think Singapore being small and being willing to spend great efforts in policing and enforcing these restrictions were important initially, and that kind of helped set the tone for the subsequent prolonged period of the pandemic.

Maggie Fox 

How’s the populations trust in what the government and public health officials tell them?

Dr. Hsu Li Yang

I think that trust currently has never been higher, because people could see the success of how the pandemic was managed. But initially, there was always high trust in the government and different civil service public health officials and that helped in mitigating the worst of the outbreak at the start.

Maggie Fox 

Even in Singapore, I can see reports of fears about vaccinating children. Can you talk about how the country has handled that?

Dr. Hsu Li Yang

I think that’s a little bit inflated by the news because I don’t think we are afraid of vaccinating children per se. Our measles vaccination rates are 95%. So that’s really high. And I think many parents were concerned about the implications of vaccinating children with new mRNA vaccines that don’t have a long history of follow up. So there’s this concern about potentially unknown long term side effects. But we made a huge effort at communicating with the parents through multiple media sources, including schools, social media platforms. And it also helped that by then virtually all the parents have already been vaccinated for months before the children’s vaccinations started.

Maggie Fox 

So they felt a little bit more confident about vaccinating children?

Dr. Hsu Li Yang

That’s right. In fact, we projected our projection so off the mark, that there were more parents bringing their children for vaccination than we had expected at the start.

Maggie Fox 

And now after years of fighting COVID, there’s the risk that other public health battles like the control of drug-resistant microbes have lost ground. How do you get back on track?

Dr. Hsu Li Yang

That’s a great question. And I think we are finding our way just like everyone else in the world. Certain things are in our face. So the pandemic is something people remember and there’s a lot of pandemic preparedness activity going on. Other things like antimicrobial resistance control of noncommunicable diseases, that’s starting to pick up from where we left off. I think we are in good stand, though, because we spoke about the high trust that people have in the public service here. And that’s been useful, I think, for translating into action against all these other various conditions.

Maggie Fox 

Li Yang, thanks so much for spending time with us!

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Guest

Dr. Hsu Li Yang is an infectious diseases physician who is currently Vice Dean of Global Health at Saw Swee Hock School of Public Health, National University of Singapore (NUS). He is also Associate Director of the Singapore Centre for Environmental Life Sciences Engineering, a Research Centre of Excellence on biofilms and microbial communities based jointly at Nanyang Technological University and NUS. Although he has been involved in COVID-19 research and education, his primary academic focus is in the area of antimicrobial resistance. He has worked with famed comic book artist Sonny Liew to publish educational comics on both COVID-19 and antimicrobial resistance.

Credits

Hosted and written by Maggie Fox
Special guest: Hsu Li Yang

Produced and edited by Samantha Serrano
Music composed and sound edited by Raquel Krügel
Transcript created by Harsh Pingle