Singapore Perspectives 2004

13 Jan 2004

By Mr Khaw Boon Wan

Venue: The Island Ballroom, Shangri-La Hotel

"PI JI TAI LAI"

I have chosen a Chinese proverb to title my speech this morning: "pi ji tai lai". This is because I could not find an accurate English translation for this piece of ancient Chinese or more correctly Taoist wisdom.

One explanation for this proverb is this: "out of the depth of misfortune, comes bliss". I suppose the closest English expression is: "a blessing in disguise".

But this would not be right as how can one describe SARS as a "blessing", after it has sickened more than 8000 people world-wide, killed more than 700 and wiped out an economic fortune of at least US$30 billion, over a short span of 4 months? And it continues to haunt us.

I prefer the Chinese proverb as it more correctly described it as a great misfortune, something that nobody welcomes. However, in the course of fighting and overcoming this misfortune, something good does emerge, both globally as well as in Singapore.

Let me highlight 3 areas where I think something good has come out of this misfortune globally.

Global Cooperation is Enhanced

First, it strengthened the hand of the WHO in forging a global response to this first global epidemic of the century. WHO's authority and leadership in the fight against the SARS epidemic were accepted by all at an unprecedented level. Health authorities worldwide looked to WHO for information on the latest developments of the epidemic and the virus and for its advice on effective control measures. WHO's guidelines were regarded as authoritative and adopted by countries as national guidelines. Likewise, WHO?s travel advisories had impact on local stock markets and countries fought to stay out of WHO?s blacklist and to get out of it as quickly as possible.

WHO rapidly established a network of leading scientists and laboratories to work closely together to identify the causative virus, map its genome and develop diagnostic tests. WHO DG Dr Brundtland and ED Dr David Heymann became household names as they led a global coalition of public health agencies and research labs in the battle against SARS.

As a result, the SARS virus was identified and its genome mapped within one month of the outbreak. In contrast, the AIDS virus took three years to be identified.

Global cooperation has considerably shortened the process to understand the nature of this new disease, to produce an effective diagnostic kit and in the continuing search for a vaccine.

Many new cross-border relationships were forged, even as existing ones were further strengthened. ASEAN+3 and APEC member countries recognized the dire economic impact of SARS to countries and regions if nothing was done collectively to curtail it. Many international and regional meetings were organized at short notice to discuss collaborative measures to control SARS. Contact points were established for the rapid sharing of information between countries critical for the effective control of disease transmission. Collaboration and commitment were taken up at the highest levels of government among member countries.

At the height of the crisis, the annual World Health Assembly in Geneva adopted a resolution on the responsibility of all countries to ensure that adequate public health systems would be put in place to combat infectious diseases and to ensure prompt reporting. Member states also amended the outdated International Health Regulations and gave WHO new powers to enter countries to investigate infectious disease outbreaks with potential international impact.

This augurs well for the future, as WHO continues its fight against other global epidemic such as AIDS, obesity, smoking, etc

Transparency is Valued

Second, the world has now learnt that the instinctive approach to sweep bad medical news under the carpet so as to protect the economy was in fact the wrong approach. As SARS rapidly hit a number of countries and as different countries responded to the crisis differently, the world got an objective evaluation of what should be the right response. As the crisis unfolded, it became clear that under-reporting and covering up in order to protect local tourism was counter-productive.

At the start of the outbreak, Singapore took the unusual step of informing WHO and the international community of a Singaporean doctor suspected to have SARS onboard an SIA flight. We were not masochistic; neither were we naive about the potential negative impact of such a move. But such disclosure allowed prompt public health actions to be taken, including the identification and quarantine of contacts to prevent further spread of the disease. The responsibility for the protection of public health overrode all other considerations. This move led to the WHO issuing an emergency travel advisory on the same day; this was 15 Mar 03.

In contrast, the initial response by some local officials in China led not only to the unnecessary escalation of the crisis but also to their personal downfall. But as soon as the Chinese leadership understood the nature of the phenomenon, they quickly took charge and managed the crisis with sound judgement and remarkable wisdom. Some foreign commentators unfairly focussed on the extent of the initial outbreak in Guangdong and criticised China for mismanagement. But for many of us, we knew that if not for the able management by the Chinese leadership, the world would have experienced a larger crisis. What if they did not freeze inter-city movement? What if they did not cancel the golden week holidays? What if the local epidemic were to spin out of control and become a national pandemic? That might have been the outcome, if the crisis were managed by a less able team.

The choice is now clear. Promptly reporting of the full facts so that others are forewarned and can take preventive measure is now the standard operating procedure.

So when we had the EHI Lab SARS-infected incident, we let the whole world know. Our Straits Times Index suffered a drop, but recovered almost immediately once the investors got over the knee-jerk reaction.

We assembled an international team of experts to audit our BSL3 laboratories and publish their full report. We wanted to know how the lab incident happened and how to prevent it. If it could happen here, it could happen elsewhere too and the world should not have to repeat the tuition fees already paid by us.

Unfortunately, a Taiwan lab did repeat the tuition fee. But when it happened, there was immediate full transparency in its response. Likewise, in China during the current Guangdong incidents where we saw swift and prompt reporting with full involvement of the WHO. This stood in sharp contrast to what was seen in early Feb/Mar of last year.

Good Public Health is Better Appreciated

Third, the role of an effective public health surveillance and enforcement system is now fully acknowledged. It is no longer Cinderella taken for granted and unappreciated.

The world has now recognized the strong link between economic growth and public health. Investment in public health infrastructure is not merely for public good, but an essential pillar on which economic progress is built.

There is under-investment both in developed and developing countries in this area. Hopefully the SARS crisis would now lead to serious action, especially in our region. Much needs to be done. Countries need to ensure that their public health systems are able to respond rapidly and effectively to contain disease outbreaks. The crucial elements include good surveillance, epidemiological investigations, rapid and thorough contact tracing, isolation of cases and their contacts, and clinical treatment of the infected.

Both hardware and software are needed. There is need for adequate isolation facilities to manage patients with highly infectious diseases and well-equipped laboratories to help diagnose the cause of infections. There is need to train manpower to build up capability especially in areas such as public health, epidemiology, infectious disease and microbiology. IT systems need to be developed or strengthened to capture, analyse and disseminate crucial disease information in a timely fashion. Further down the road, there will also be need to enhance the capability to research, develop and produce diagnostic tests and vaccines.

Countries seem to be moving in this direction and if it leads to effective action and not mere rhetoric, the world will be a safer place for all.

Singapore's Bliss

Because Singapore was on ground zero of the crisis, we too derived benefits out of this crisis.

Bonding Singaporeans as One People

First, the crisis has bonded Singaporeans as one people, much more effectively as no other previous crisis has achieved in the past.

As SM Lee put it, this is one crisis where all Singaporeans, regardless of race, language or religion, have been equally fearful at the same time. The Japanese occupation struck fear in all races, but to different degree. Ditto the subsequent fight against communists and communalists.

But SARS was non-discriminatory. It is colour blind.

For 4 months, all 4 million Singaporeans faced one common enemy. As we shelved all other work to fight this one common enemy, we experienced strongly a bond as one united people. Everyone played their part, from hand-washing to helping neighbours on HQO.

At MOH Command Centre, we received so many phone calls, so many emails, offering to help. It was so heart-warming. Most did not really know what they could do but they wanted to do something. They wanted to be useful and helpful in the fight.

It is like the home front during a war. The soldiers are risking their lives in the trenches. The elders and the women at home help out in the hospitals, clear the debris, rebuild the homes struck down by air raids.

Others contribute money, food, gifts to lift the morale of those in the trenches. There was full cooperation and collaboration among the public, private and people sectors.

SARS bonded us. Our social capital was boosted several folds.

Strengthening Public Health Defence Capacity

Second, SARS exposed our gaps in public health defence capacity more effectively than any previous scenario planning exercises have achieved.

After 50 years of modern medical practices and antibiotics, we thought we had seen the end of history for infectious diseases. SARS woke us up to the harsh reality that we have not seen the end of infection.

MOS Dr Balaji made an observation that the outbreak caused the worst damage in cities with the most sophisticated health care facilities like Singapore, Toronto and HK. In cities with less developed tertiary facilities like Hanoi, the outbreak was relatively less severe. The big fear that SARS would spread to the inland provinces of China and caused big havoc there as they had poorer healthcare system never materialized.

Dr Balaji reasoned that the concentration of severely ill patients in one setting, with multiple disciplines and heavy inter-specialty referrals of patients, facilitated the spread of the virus. The concentration of tertiary disciplines in one setting created the conditions for the SARS virus to spread quickly.

But this is not a call to go back to primitive healthcare. But it is a call to re-emphasise the virtues of simple infection control measures, like cleaning hands properly, more disciplined barrier nursing, besides recognizing the need for more isolation facilities.

But more worrying, we have now a small demonstration of what bio-terrorism may be like in the future.

We were lucky that SARS was not as infectious and required close physical contact to spread. If SARS was airborne, the damage would have been many-fold more serious. Imagine if SARS could spread like flu.

The crisis has jolted us into action, into enhancing our capacity in infection control, in bio-safety in laboratories, and in our bio-defence.

Differentiating Singapore as a Competitive Node

Third, our successful response to the crisis has differentiated us from the other countries. It reaffirmed our unique strengths of being better organized with greater social discipline.

Because the outbreak affected several countries at the same time, others could see for themselves the different characters of these societies.

Investors have especially taken note. They know that this would not be the last crisis. Even if there were no more SARS outbreak, there would be other viral outbreaks. Investment decisions will have to take into account the host countries? ability to respond to such crisis in the future. An inadequate response will mean disrupted economic activities and damages to assets and employees.

I believe the need for diversification, putting investments in alternative locations for better risk management, is now given greater consideration. One local CEO of a major US MNC told me that pre-SARS, all talks in their US corporate HQ were about expansion in China. Post-SARS, she began to hear of talks about putting some eggs in the SE Asian market.

This enhances our value for foreign investments. It enhances our competitiveness as a useful investment site. That besides putting eggs in China, it makes good sense to also put some eggs elsewhere, like in SE Asia, and especially Singapore.

One tangible outcome of the crisis was the setting up of the REDI (Regional Emerging Disease Intervention Centre) at Biopolis. This is an idea discussed between PM Goh and President Bush which rapidly led to a commitment to set up such a project in Singapore, under the APEC framework. REDI will serve as a regional resource for training and research and help us build our individual and collective capacity to monitor, respond to, and prevent critical infectious disease threats in the Asia Pacific region. We are working with our US partner towards its launching in a few weeks? time.

Singaporean creativity was also noted internationally as our scientists and engineers put on their thinking caps and rapidly came out with innovative products like thermal scanners to check temperature of masses in a non-intrusive way, RFID gadgets and contact bowls to register contacts in public places.

Conclusion

We scored well in the fight against SARS. It reinforced our key strengths: we are better organized as a society; we have better discipline. This has been the unique characteristic of the Singapore society. It has led to our economic transformation.

It is a trait not easy to replicate elsewhere. It gives hope that Singapore can continue to flourish despite tough competition from larger countries with cheaper land and labour.

But meanwhile, with global travel and the threat of bio-terrorism, let me take this opportunity to remind everyone that we all need to change our daily habits. We need to have a standard of public hygiene like the Japanese. As organisms survive on wet surfaces, our toilets particularly need to improve. Wearing masks when unwell to prevent spreading infection to others must become our norm.