How did COVID-19 affect Singapore’s national mood?
“The one thing that I’m qualified and interested in is the mental health aspect of COVID-19,” says Professor Eric Finkelstein.
“So, I did a study to get at the incidence of depression and anxiety during the pandemic,” he continues, referring to a study whose findings were published in the International Journal of Health Policy and Management today.
As a professor with the Health Services and Systems Research Programme at Duke-NUS, Finkelstein was uniquely placed to analyse the impact of COVID-19 on Singapore’s population, from both economic and behavioural perspectives.
“The idea was to generate data to develop interventions aimed at addressing mental health needs in Singapore,” says Finkelstein, who is also the executive director of the Lien Centre for Palliative Care.
“I wanted to find the unmet need for people who have these mental health conditions, but who are not accessing the health system,” expands Finkelstein. “To see if there might be opportunities to follow up and provide access to care.”
But mental health had not been his initial research focus.
Finkelstein was conducting an unrelated survey in 2020 when, out of interest, he decided to add some questions about the impact of COVID-19.
The responses were varied but had one thing in common — more and more, people were experiencing mental health issues.
“That’s a hidden problem in Singapore,” says Finkelstein.
Indeed, the Singapore Association for Mental Health reported a 50 per cent increase in calls made to its helpline in February and March 2020 compared with the average it received between April 2019 and January 2020.
He adds, “Now is that because of this pandemic? Or because of the interventions that have been put in place? It’s hard to know.”
Nonetheless, between lockdowns, lost work opportunities and the devastating effects of social isolation, it was clear COVID-19 was taking its toll.
Exposing Singapore’s ‘hidden problem’
Unlike tallying COVID-19 case numbers, exposing the damage to a nation’s collective mental health was a trickier task.
Finkelstein’s expertise in surveying public health behaviours came into play here.
He and his team adapted quickly to online surveying. Where they used to interview patients in clinics or their homes, they were now speaking with people over the phone.
“It’s not as good,” Finkelstein admits. “I mean you can’t read body language or facial expressions, and we survey a lot of patients, so we look for signs of fatigue or distress.”
“When you’re on the phone you just don’t have that same ability.”
Despite the challenges of online work, the results were clear. Out of 897 participants, 23 per cent reported moderate to severe anxiety, significantly higher than previous mental health surveys.
Younger people, people with chronic conditions, children or those with a lower trust in government were found to have higher levels of anxiety about COVID-19 and a higher perceived risk of being infected.
However, the risk perception of these participants was also skewed. Nearly half feared they would be admitted to the Intensive Care Unit if they were to contract COVID-19; just under a third believed they would die.
The study also found that 40 per cent of people with chronic conditions had missed a healthcare appointment for fear of contracting COVID-19.
“I think COVID-19 has shed some light on the high rates of undiagnosed mental health problems in the region,” says Finkelstein. “But this problem existed before COVID-19 and will exist after COVID-19.”
But the health economist in him still wanted to quantify the total economic burden and he would go on to field a study to do just that. Between reduced productivity, lost work opportunities and unemployment, what exactly was the financial aspect of this shadow pandemic?
He’s determined to investigate this issue, and his hunches are usually spot on. You don’t become one of the world’s most highly cited researchers three years running without a finely tuned research intuition.
Needles or needless
Finkelstein already had a catalogue of studies on incentivising people to act on public health measures.
In the past, he researched how financial and behavioural incentives impact obesity, weight loss and palliative care.
This area of expertise translates directly to the issue of vaccination.
“The willingness or unwillingness of people to vaccinate is definitely an interesting topic,” muses Finkelstein.
In an online poll on vaccination, 22 per cent of respondents answered that they would never get vaccinated.
Most countries were finding a stubborn percentage of the population who were refusing to budge on this issue. So, what held those people back?
“It’s what economists call ‘elasticity’ — their willingness to vaccinate and to what extent we need to ‘bribe’ our population,” explains Finkelstein, adding that if the vaccine is free, people don’t rush to get it because they know they can get it later.
In the end, it would take a mandate and vaccination-differentiated measures as well as a new variant that causes more severe disease to achieve the vaccination rates necessary for re-opening.
Calculating the costs
As an economist, the price of the pandemic has been a consistent theme in Finkelstein’s research. The price of vaccines, the price of testing, and of course, the price of lockdowns.
Interestingly, in 2017, before SARS-CoV-2 had entered the lexicons of everyday language, Finkelstein had already been analysing Singapore’s responsiveness to lockdowns.
His research was based on previous pandemics in Asia such as H1N1 in 2009, and SARS-CoV-1in 2003.
What he and his colleagues found in this 2017 study, published in BMJ Open in early 2018, was that Singapore residents willingly supported government restrictions if these restrictions reduced transmission.
The respondents were split into two key groups: the mortality-averse and the tax-averse. To gain support from both groups, public health measures need to stress the necessity of lockdowns to reduce mortality, while minimising the economic impact on society.
Overall, Finkelstein’s 2017 findings on Singapore’s receptiveness to lockdowns rang true in 2020, when he focused his research on the cost of lockdowns on mental health.
“I think by the end of 2020, we’d done a great job in arresting the spread of the pandemic, but I think it came at a pretty high cost,” says Finkelstein of Singapore’s first brush with the virus.
“If you look at mental health services in Singapore, certainly, you can see that rates of depression or mental illness are way up.”
He wrote — and would continue to write — commentaries highlighting that circuit breaker measures were delaying tactics.
As Finkelstein sees it, this globalised world means that SARS-CoV-2 will always be lurking.
So, while public health measures would always be necessary, it was similarly important to prioritise individual mental health measures.
Finkelstein says it is about how we learn to live with COVID-19. It is how governments and communities improve treatment options, reduce mortality rates and encourage vaccination.
“You can’t live your life in your basement forever,” Finkelstein says.
“Once you realise that these variants will be around indefinitely, at some point you’re going to…realise that and recognise that you can mitigate those risks, but you can’t reduce them to zero.”