A clinician-scientist’s journey through the pandemic.
“It was all about the exit strategy,” Professor Marcus Ong declares. How to prepare Singapore — and its healthcare system — for the transition to living with COVID-19.
Ong had his finger on the pulse of this pandemic and the public health measures necessary to tackle it since the start of 2020. And his estimates came backed by data — concrete figures extracted from the healthcare system. He would feed the data into simulations to predict the likely impact of different “what ifs”.
“So the idea of a simulation model is that you can play with things in the virtual world before you test them out in the real world,” explains Ong, who is the director of the Health Services and Systems Research (HSSR) Programme at Duke-NUS. “Ten years ago, we would not have been able to pull this off. During SARS, we were using Excel spreadsheets, best guesses and consensus by experts.”
This time round, the entire HSSR Programme came together, driving a four-pronged research approach called the COVID-19 Virtual Disease Health System Outbreak Model for Singapore, aptly abbreviated to CoViD-SOS. Through it, they addressed issues from the impact of the pandemic on vulnerable people and on mental health to the virus’ impact on hospital services and the effectiveness of different public health measures.
And right from the start, Ong’s models predicted three possible ways in which things could end. The virus could, as had happened during the first SARS outbreak, trigger one tidal wave of infections — “about fifty, sixty thousand cases” — before petering out. Or it could release repeated but progressively less intense waves over the next two to three years; where vaccines and new treatments coupled with safe distancing measures would be key.
“The last scenario was pandemic moving to endemic. Which was what we ended up in, where it becomes like tuberculosis or seasonal influenza and we have to live with it for a long time,” finishes Ong, who takes no satisfaction from having called the pandemic’s trajectory correctly from the outset.
“All the scenarios were quite grim and I would have been happy to be proven wrong. But we demonstrated that health services research can address an issue of national value and that helped bring this field into the realms of operations, decision-making, clinical policy and treatment,” he adds.
Ong and his team’s simulation results have helped — and continue to help — Singapore prepare for vastly different eventualities. They influenced the pandemic response strategies at the hospital and national level.
“I think I can help people more at a systems level, a population level,” says Ong, who also works regular shifts as a senior doctor in the emergency department of Singapore’s largest hospital, Singapore General Hospital. “Research, innovation and education are just as important as our clinical service.”
Why Singapore works
Ong’s concerns about the national healthcare system during the pandemic stem from personal experience. H1N1. SARS. And an understanding of the mechanics at work in a complex multi-factorial healthcare system.
“You can’t just leave the healthcare system to fight this battle alone,” he says, thinking about his fellow clinicians and frontline healthcare providers, many of whom worked extra shifts to keep services running. “They will get overwhelmed. That’s what happened in many other countries.
“In some countries, the rest of the population did their own thing and left the frontline healthcare system to carry on alone — that’s not sustainable.”
Indeed, the continuing overload of hospitals in the United States, the plea by the United Kingdom’s government to stay home to protect the National Health Service during the year-end holiday season and some contradictory public healthcare policy responses in other Asian countries, all bear out his warning.
“Singapore showed that it’s a combination of three things,” says Ong about the nation’s success in keeping people safe during the pandemic. “Healthcare system. Leadership. Social capital.”
He points to the fact that “if your government response and your social capital are poor, it’s still a disaster”.
And preparedness, especially, makes this combination work.
“All the hard work, preparation and planning,” Ong elaborates. “Having stockpiles of equipment, personal protective equipment and drugs. Having legislation in place that we can pull up to effect quarantine. All these have served Singapore well. If we had not had these, we wouldn’t have been able to have such a comprehensive response.”
He notes, too, that his colleagues from the Emerging Infectious Diseases Programme at Duke-NUS Jenny Low and Ooi Eng Eong along with many others were at the forefront of communicating science to the public and allaying their fears over vaccines. But Ong warns that nothing will ever convince everyone to take a SARS-CoV-2 vaccine.
So as the country eyed a future of living with SARS-CoV-2, a paradigm shift would be required; a balancing act, then, that would protect vulnerable groups while maintaining the capabilities of the healthcare system.
“In the emergency department, we already had a new paradigm for managing all our patients. Red, yellow, green,” details Ong about added triage protocols for the pandemic–endemic era. These new protocols run parallel to existing Priority I, II and III classifications that identify patients by the seriousness of their condition upon admittance at the emergency department and run all the way to general inpatient and isolation wards.
Red is for high-risk infected cases who need treatment in isolation-type facilities where air, for safety, flows in rather than out. Green is for low-risk patients and the newly introduced yellow lane is an intermediate risk rating.
“[It’s for] those with some kind of respiratory infection or contact history. Lower risk, but you still need some precautions,” Ong says.
And Ong sees some mitigation strategies as being extendable to social events in general — different measures for different immunity levels. It would help Singapore get back to life as normal while protecting the vulnerable.
“You may come to a point where you go to church and there’s one service for the vaccinated,” he muses. “And another for the unvaccinated.” His prediction would once again be spot on as Singapore would introduce vaccine-differentiated measures in early 2022.
A test of resilience
Reflecting on the first year of the pandemic, Ong calls it the toughest year of his life. No downtime. Additional shifts at the emergency department. Running and repeating simulations to predict the virus’ next move. And some challenges on the family front as his daughter, who has Tourette’s syndrome, was struggling to come to terms with the condition while preparing for the Primary School Leaving Examination (PSLE).
“She had lost interest in everything she used to enjoy. She would come home from school, head into her room and slam the door,” remembers Ong. “The last straw was when she developed selective mutism and didn’t utter a word to me for months because she couldn’t express herself.”
The Circuit Breaker saw Ong’s overseas work and conference travel grind to a halt and his two sons return home — the older one from law school in the UK and the younger one from the Singapore University of Technology and Design’s student dorms. This homecoming had a pleasantly unexpected impact on his daughter.
“She is very close to her older brothers, but both had been away at university,” recalls Ong. “So, when the Circuit Breaker came, they came back and she could talk and joke with them.”
“The other big benefit for her was that she didn’t have to spend hours travelling to school. She was happy to learn at home and by the end of the year, she exceeded all our expectations during PSLE,” adds Ong.
Family time also improved. Ong could regularly prepare lunch for his daughter and read the Bible with her at night.
But the biggest and most unexpected pay-off was that all these changes helped ease the pressures and stresses on Ong’s daughter and she could open up again.
“The Circuit Breaker gave me my daughter back, God works in mysterious ways!” says Ong.
He also drew support from the men’s cell group he leads at church, where he sees everyday examples of resilience and courage — from the retrenched regional manager who pedals through Grab deliveries in order to feed his three children to the university graduate clawing back his life after years of incapacitation with mental health issues.
“Resilience is knowing that you’ve been knocked down yet still having the courage to stand up,” says Ong. “You don’t give up. That is the quality of resilience, and I learned resilience from these guys.”
Public and political discussions are, as Ong noted, becoming all about the exit strategy from the pandemic, about Singaporeans picking themselves up, dusting themselves off, and getting back into the saddle.
“You can survive for 40 days without food, probably one or two days without water and about 10 minutes without oxygen,” says Ong. “But you can’t survive without hope. And we have hope by sharing a common purpose which is beyond just yourself.