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FEATURE
A & pollo’s
rrows
Sun Tzu’s
Stratagem
Text by Dr Gan Wee Hoe | Photos by SingHealth and SGH
The culprit causing COVID-19 has been This is an infection where the fallout Another epochal event was the 1918
described as a “very smart virus [that] will – in terms of mortality, socio-economic influenza pandemic. It started at the tail
find ways to remain in the human pop- consequences and the profound impact end of World War I (WWI), when the four
ulation”.1 An infected patient recounted on the way of living as we know it – is years of war prior had already resulted
how battling the disease was akin to of monumental proportions. By many in insufferable hardship and depletion
“running a marathon on the bed”.2 accounts, we may only be at the end of of resources.
These are just two of the many the beginning.
The H1N1 virus infected one-third
crippling accounts of COVID-19 that of the world’s population and was
have emerged since the tentacles of this Pandemics in human history associated with at least 50 million
pandemic first surfaced at the turn of The bubonic plague in the 14th century deaths. The epidemiological observation
the decade. wiped out almost a third of Europe’s of the high mortality in the 20- to
On 31 December 2019, the Wuhan population. Caused by Yersinia pestis 40-year-old age group (apart from the
Municipal Health Commission reported and spread by infected fleas carried by young and the elderly) was surprising
to the World Health Organization (WHO) rodents to humans, the disease was so to many. During WWI, the US had joined
China Country Office on a cluster of pneu- contagious that it has been described to aid the Allies’ eventual victory against
monia cases occurring in the capital city by the Italian poet Giovanni Boccaccio Germany. Of the US fatalities on the war
of Hubei province. Subsequent reports that “the mere touching of the clothes front, half were due to influenza and not
suggest that the first case could be traced appeared to itself to communicate the attributed to direct enemy action.6
back to as early as 17 November 2019.3 malady to the toucher”.4 Ironically, WWI also shaped the social
Much has been postulated, re- Ships were sailing into ports with attitudes among the citizenry in many
searched and written about COVID-19. crew either severely ill or dead. To countries, who were by then used to
At the time of writing, global case count stem the spread of infection, officials restrictions in their daily lives. This,
has crossed the five-million mark with kept sailors in isolation on their ships together with the advent of science
the infection claiming more than 331,000 for 30 days (trentino), which was later and technology propelled by the war,
lives. As countries gradually ease lock- lengthened to 40 days (quarantino).5 ensured equanimity and acceptance as
down restrictions, reports of second and This public health concept has proven its public health measures were applied on
third waves are already surfacing. effectiveness even up to the present day. a large scale.
06 JUN 2020 SMA News
Rain of Apollo’s arrows The Art of War by Sun Tzu is one of of large-scale swab and serological
the most well-known guides on military testing to ascertain their COVID-19
Even with humankind’s experience
warfare. A general from the 5th century BC, status, and the setting up of community
with past pandemics, it remains almost
Sun Tzu has been widely acknowledged as care and recovery facilities to allow the
unfathomable how a contagion such as
a master strategist. The Art of War is said to recuperation of those infected.
a virus, measured only in nanometres,
have shaped Mao Zedong’s thinking and One may question the political
has thrown the order of life of almost the Chinese communists’ actions against
everyone topsy-turvy. wisdom of the State taking the lead
the Japanese.9 at great cost, given that the majority
With COVID-19, WFH and HBL (which of migrant workers come under the
stands for work from home and home- The art of war is of vital importance
to the State. It is a matter of life and employment of private companies.
based learning, respectively) are now
instantly recognisable acronyms with death, a road either to safety or to ruin. The political will for Singapore to take
thematic associations with Singapore’s The contemporaneous application these extraordinary measures is because
circuit breaker measures. Global losses of Sun Tzu’s teaching on battle first and foremost, it is the right thing to
are estimated at up to USD 8.8 trillion7 preparation is to recognise that political do. Migrant workers have contributed to
(SGD 12.5 trillion) and economic considerations, policy decisions and our nation building and development.
ground actions are inextricably linked Until recently, they belonged to a
repercussions have become a leitmotif
and deterministic to success or failure. segment of the workforce in Singapore’s
of a COVID-19 Black Swan event.
society that was not often talked about.
In modern day Singapore and much Singapore has long relied on migrant
workers for infrastructure building and Our Government is also keenly
of the developed world, our usually very
other essential services. Today, we have aware of the policy consideration
low mortality rates from communicable
about 200,000 of them housed in 43 that without addressing the problem
diseases threw the hard truth of
purpose-built dormitories, 95,000 in 1,200 of infection in the migrant worker
COVID-19 deaths into sharp relief. The
factory-converted dormitories, 20,000 population, we cannot win the war
five countries with the highest number against COVID-19. Many of them work
of fatalities are all in North America and in construction temporary quarters and
85,000 in Housing and Development in the community and share the same
Europe, with the US leading the pack. It social and recreational spaces as fellow
is a surreal situation. Board flats and other private residential
premises across the country.10 Singaporeans. The position statement
Apollo, a god in the ancient Greek that Singapore has “a responsibility to
pantheon, shot arrows of plague at the While much has been debated on our migrant workers”12 dictated the
Greek army for nine continuous days whether we can afford to reduce our decisive actions that unfolded over the
because King Agamemnon captured dependence on migrant workers, last couple of months.
and refused to release the daughter of what is clear and present today is the
disproportionate impact of COVID-19 In many aspects, the “dormitory
Chryses, who was Apollo’s priest. operation” is not only a whole-of-
on this group of residents in Singapore.
Some scholars in Greek mythology Since the first cases were diagnosed in Government endeavour, but a whole-
have drawn a link between plagues migrant workers in early February 2020, of-society effort. Ultimately, Singapore
and leadership. King Agememnon’s dormitory residents now (as at 24 May is aware that we can overcome our
ill-considered decision resulted in 2020) account for 29,363 of 31,616 cases current public health crisis only if our
devastating losses in his army. It was of COVID-19 infections in Singapore.11 migrant workers, too, win the fight
said that “…he [King Agememnon] rages against COVID-19.
Close, communal living and the
with baneful mind, and knows not at all
pattern of life are probably significant If you know the enemy and know
to look both before and after…”. 8 The yourself, you need not fear the result
factors in disease propagation. There
ability to understand cause and effect of a hundred battles.
are countries facing the same issues
unpins the ability for effective prevention, which compartmentalise them away and
preparation and prosecution of an Shortly after their report of atypical
choose to do nothing, but Singapore is pneumonia cases to the WHO China
operation. This is manifestly projected in one of the few governments in the world
the management of a public health crisis. Country Office, Chinese scientists
which has arguably done the most to isolated and fully sequenced the virus in
contain COVID-19 in migrant workers. early January 2020. The gene sequencing
Sun Tzu’s stratagem
Additional housing arrangements data was submitted to Virological.org,
Most people will agree that handling were onboarded to de-densify living a forum for analysis and interpretation
a public health crisis is akin to waging quarters. Significant resources were of virus molecular evolution and
a war against an invisible enemy. deployed from the public and private epidemiology. This early access was
Strategies and tactics therefore need to healthcare sectors to ensure timely pivotal in allowing scientists around the
be employed, overlaid by political will access to healthcare for every migrant world to kickstart research in diagnostics
and underpinned by unity of the people. worker. These also include the conduct and therapeutics.
JUN 2020 SMA News 07
from COVID-19 can be
avoided if there were
timely access to intensive
care resources to support
those with severe disease
through their most critical
periods of illness.
Hospitals have
concurrently been ramping
2
1
up their intensive care
capacities. Refresher
training for healthcare
workers with previous experience in
WHO also activated its R&D scientists from the National University critical care has been conducted to
Blueprint soon after. The Blueprint of Singapore’s School of Public Health scale up more teams. Ventilators, other
improves coordination among has enabled us to better understand the life support equipment and medications
scientists, clinicians and public health transmission dynamics and apply the are stockpiled to enable hospitals to
professionals in research priorities right interventional strategies. go into surge capacity when infections
and the development of public health To leverage our strengths and exploit peak nationally.
response standards – absolutely vital as the enemy’s vulnerabilities is a time- To date, Singapore’s fatality rate
the world comes to grips with a highly tested stratagem that applies to both from COVID-19 stands at 0.1%, among
infectious novel pathogen. conventional warfare and the non- the lowest in the world. In comparison,
It is estimated that from January to conventional battleground, such as the countries such as the UK, Italy and
April, more than 23,000 scientific papers COVID-19 pandemic. Belgium have fatality rates in excess
on COVID-19 have been published of 13%.16
The good fighters of old first put
at a doubling time of 20 days!13 This
themselves beyond the possibility Even for our migrant worker
is an astounding pace that left many
of defeat, and then waited for an population, generally of the young-
“drowning in COVID-19 papers”.
opportunity of defeating the enemy. to-middle age groups and largely free
While Singapore may be a small nation, of serious chronic diseases, additional
Merely five months into the pandemic,
we punch above our weight and are an we are still a distance away from measures have been put in place
undisputed powerhouse for translational developing an effective cure or vaccine. to reduce morbidity and prevent
research in biomedical sciences. While the “enemy” is holding the mortality. They are equipped with
From the early days of the pandemic, higher ground, one should bid for time, health monitoring devices, such as
our hospitals and research agencies minimise unnecessary confrontations thermometers and pulse oximeters;
actively participated in multi-centre and losses, and await the right they also have round-the-clock access
clinical trials on different modalities of opportunity for a decisive strike. to medical care, including after-hours
COVID-19 treatment. We also made major telemedicine services.
Primary prevention has been the
breakthroughs in developing the first- mainstay of public health strategy In the absence of effective
in-the-world rapid COVID-19 detection against COVID-19. Whether it is safe therapeutics or vaccines, COVID-19
system employing the surrogate virus distancing, the wearing of masks or remains a significant threat to public
neutralisation test,14 and using serological the practice of hand hygiene, these health. We need to buy time for scientists
testing to establish a link between two measures seek to minimise infections in to do their work. Before we reach there,
local COVID-19 clusters.15 the general populace, especially those the preventive strategy is the best we
from the vulnerable groups. have in our limited armamentarium.
In foreign worker accommodation,
the pattern of disease spread differs Flattening the curve is what we seek
depending on local ecological, to achieve epidemiologically, which will
Concluding thoughts
environmental and social factors translate into lower peaks of infected A Gallup poll of the most important
specific to each dormitory. Working cases that could otherwise overwhelm events in the 20th century featured,
with infectious disease modelling our healthcare system. Many fatalities among others, the World Wars and Neil
08 JUN 2020 SMA News
Armstrong’s 1969 historic landing on
the moon.17 Pandemics did not make Dr Gan is Head and Senior References
Consultant, Department of
it to the list. COVID-19 may just be the 1. Tan A. Covid-19 caused by a ‘smart virus’ that
Occupational and Environmental
historic event to tilt the equation. can find blind spots, crucial for system to be
Medicine at the Singapore General
flexible to overcome challenges: experts. Available
The auntie from the nasi padang Hospital. He was seconded to the at: https://bit.ly/3d161H3.
Ministry of Health (MOH) from April
store which I frequent predicted that 2. Lee LY. ‘Running a marathon on the bed’:
to June 2020 and served as the MOH
it would take “at least three years” for policy member in the interagency COVID-19 survivors describe their struggles with the
Singapore’s economy to turnaround to task force to manage and contain coronavirus. Available at: https://bit.ly/3d7IS5L.
the pre-COVID-19 state. A friend, who is the spread of COVID-19 in foreign 3. Ma J. Coronavirus: China’s first confirmed
a freelance sports coach, has not been worker dormitories. The opinions in COVID-19 case traced back to November 17.
working since the shutters came down this paper are those of the author’s Available at: https://bit.ly/2LZNTkO.
and do not reflect the positions or
on sports halls throughout the country. views of MOH or SingHealth. 4. Mark JJ. Boccaccio on the black death: Text and
commentary. Available at: https://bit.ly/2LXx9Lg.
Yet, there are positives out of this.
COVID-19 has accelerated revolutionary 5. History.com Editors. Black death. Available at:
https://bit.ly/2X2gf4l.
disruptive technology. My neighbour,
a lawyer, shared with me how he has 6. Billings M. The influenza pandemic of 1918.
Available at: https://stanford.io/2TEzfE8
adapted to working from home using
different platforms for teleconferences 7. Asian Development Bank. COVID-19 economic
impact could reach $8.8 trillion globally – new
and virtual meetings. Instead of meaning
ADB report. Available at: https://bit.ly/36ydmeJ.
to go speedily, “Zoom” has taken on a
whole new dimension. 8. Homer. The Iliad. Available at: https://bit.
ly/2M2nEKE.
We need to get ahead of the curve in Legend 9. Kuiper K. Sunzi: Chinese strategist. Available at:
order to secure order back to our lives. 1. Providing primary care medical services to https://bit.ly/2Xz3hu4.
Sure, there will be new norms to adapt migrant workers at their place of residence
10. Ng JS, Ong J. The Big Read: Solving Singapore’s
to. Old habits like queuing for bak kwa 2. SingHealth deployed medical and dental foreign workers problem requires serious soul
at People’s Park will have to change. teams to swab migrant workers in dormitories searching, from top to bottom. Available at:
to ascertain their COVID-19 status
Employment landscapes will evolve. https://bit.ly/2XsfsJ2.
However, what is immutable is the 3. Donning personal protective equipment
11. Ministry of Health, Singapore. 24 May 2020
(PPE) before commencing clinical duties
resilience of the human spirit and our daily report on COVID-19. Available at: https://bit.
4. Extracorporeal membrane oxygenation ly/2ZDIAzB.
fortitude in the face of adversity. simulation training with full PPE
12. Ministry of Manpower. Ministerial statement
We will overcome.
by Mrs Josephine Teo, Minister for Manpower.
Available at: https://bit.ly/3c5Yzcq.
Information is accurate as at time of writing. 4 13. Brainard J. Scientists are drowning in COVID-19
papers. Can new tools keep them afloat? Available
at: https://bit.ly/36wbZgC.
14. Duke-NUS Medical School. Duke-NUS,
3 GenScript and A*STAR launch first-in-the-world
SARS-CoV-2 serology test to detect neutralising
antibodies without need of containment facility or
specimen. Available at: https://nus.edu/2LXFOx8.
15. Channel NewsAsia. Duke-NUS used COVID-19
antibody tests to establish link between church
clusters in a world-first. Available at: https://bit.
ly/3c7cbUC.
16. Rajendran S. Singapore’s COVID-19 death rate
low, but seniors vulnerable. Available at: https://
bit.ly/2ZEQoRL.
17. Newport F, Moore DW, Saad L. The most
important events of the century from the
viewpoint of the people. Available at: https://bit.
ly/36v0XbA.
JUN 2020 SMA News 09You can also read
