Zero tolerance warfare against COVID19: how far can we go, for how long, at what cost？

我們想讓你知道…To what cost of humanity the society is willing to make to achieve water-tight containment?

Chinese Version（中文版）：新加坡經驗：春節大量國民返台　邊境管制「放寬」可行嗎？

By Ruby Huang, Dale Fisher, Violet Cheng and Allen Lai

Living with the virus: water-tight containment with nimble adaptation

On January 01, 2021, the tossing year is over, and a brand new year just begins.

On December 31, 2020, the Taiwanese Band “MayDay” and the famous singer “A-Mei” held New Year’s Eve concerts in Taiwan, which might be the few mass-scale gatherings in the world to celebrate the New Year. While the rest of the world is facing another round of lockdown and harsher pandemic control measures, Taiwan indeed stands out as a parallel society. Taiwan’s Central Epidemic Command Center (CECC) adopted a digital geofencing monitoring scheme for these mass gatherings and reinforced personal registration admission. These advanced deployment schemes have proven to be effective and identified enthusiastic fans who violated the self-health management regulation [1].

▲ “A-Mei” held New Year’s Eve concert in Taiwan. (Photo Credit: Taitung County Government)

The COVID-19 pandemic has entered the second year. The community COVID-19 cases in Taiwan have continued to remain extremely low. New York Times published “How Taiwan Plans to Stay (Mostly) Covid-free” [2] through the interview with Health Minister Chen Shi-Zhong, the commander of the CECC, to reflect the sustainability of Taiwan’s stringent border control policy. Additional comments from Associate Professor Jason Wang in Stanford University and Professor Dale Fisher in National University of Singapore (NUS) further stirred up extensive public discussion.

In this commentary, we teamed up with Professor Dale Fisher from NUS to provide alternative perspectives on how “living with the virus” in a controlled way could be achieved. Is there a possibility to have water-tight containment measures with nimble adaptation that could sustain any society to the end of this pandemic? We will address this from the three pillars of pandemic preparedness: adaptive governance, network partnership, moral suasion that we have introduced in the previous 2 commentaries [3 - 5].

▲ Flight travellers are welcomed, guided and streamlined clearly by airport staff and signposts according to countries of embarkation (Singapore Changi Airport, Jan 6, 2021, provided by Dr. Lai)

Adaptive governance against a protracted battle

Admittedly, the COVID-19 pandemic is often times likened to warfare for state heads to rally support [6]. It indeed is a protracted battle, dragging much longer than any major outbreaks, such as SARS and H1N1 pandemic. At its core, the pandemic attests any government to its sustainable policy formulation, implementation, and adaptation.

Yet, the pandemic fatigue, associated with prolonged precautionary measures against the protracted health crisis, undoubtedly has a far-reaching impact on all walks of lives [7].

For individuals, one may be demotivated after having followed public health control measures for an unprecedentedly long time, just to keep the society safe from the virus. The general public may feel complacent and let their guard down if epidemic policy remains unchanged as stringent regardless of low imported cases. As a result, the virus may re-emerge (stronger) through the slack off.

For organizations, the pandemic fatigue is doomed to dampen the early high-energy spirits when the crisis kicks in, and has become a marathon with no clear end in sight [8]. Morale gets compromised, along with ailing efficiency and performance. In a similar vein, public servants are not immuned from this pandemic fatigue.

At the national level, governance structures such as Taiwan’s CECC or Singapore’s Inter-Ministerial Committee have entered an unchartered territory: how long shall the state keep this scaled-up centralized command and control structure in place, at what cost? Or more specifically, when will this governance structure scale down and move towards decentralization or decomposition? This is particularly true when other health priorities are competing for finite resources on the national health agenda.

▲ Photo Credit: Reuters

This is where the concept of adaptive governance shall play to its significance amid protracted warfare of COVID-19 battle. What it literally means is both governance structure and decision power need to scale up or decentralize (or empower) subject to evidence-based risk assessment of the evolving pandemic. This helps ensure strategies and decisions are properly implemented, the requisite resources allocated, and policies and procedures are rapidly adapted according to the need [9].

Keeping up with adaptive governance against this protracted battle is crucial for every national government. At some point in time, such transition shall take shape, integrating with local jurisdictions and stakeholders. This brings us to the next pillar of water-tight containment - network partnership.

▲ Photo Credit: Reuters

Mission-oriented network partnership

Countries that keep the pandemic under control tend to be more risk-averse, knowing that one index case with super spreading potential could lead them into havoc. Hence, many stick to zero-tolerance principle to avoid any possible risk of community case. As a result, border lockdown prevails.

One may argue: is it possible to fine-tune the control measures based on risk so as to maintain water-tight containment?

The answer is surely affirmative.

▲ Photo Credit: Reuters

Take border control for example. There is an opportunity to kick off safe travel between countries that share similar transmission incidence. And this risk can be even further reduced with a strong public health system capable of: early disease detection, testing, contact tracing, quarantining of contacts and isolation of contacts.

To win over the long-haul battle against COVID-19 pandemic, each national government shall catalyze network partnerships built upon a clear mission.

The mission is to achieve efficient and effective public service delivery based on risk stratification, whereas the network partnership refers to a design of seamless workflow catered to each risk group.

During the current phase of COVID-19 pandemic, both Taiwan and Singapore have the luxury and capacity to do so.

▲ A pavilion is set up for swab test outside Terminal 3 of Changi Airport (Singapore Changi Airport, Jan 6, 2021, provided by Dr. Lai)

Singapore has a series of restrictions whereby travellers from select countries with negligible local transmission can enter singapore with a test only. At the other extreme is those from high prevalence areas who require the usual 2 weeks in supervised hotel quarantine. Some middle ground allows travellers to go to one address for a shorter period of quarantine and testing. According to Health Minister Gan Kim Yong’s response to the parliamentary question, up until Dec 26 last year, only 2 foreigners tested positive for COVID-19 among close to 2,500 passengers who entered Singapore via seven reciprocal green lane arrangements [10].

▲ Flight travellers queue up to register for swab tests upon arrival in Singapore’s Changi Airport (Singapore Changi Airport, Jan 6, 2021, provided by Dr. Lai)

Taiwan has been very successful in implementing similar restrictions to travellers from high prevalence areas. But the relaxation to travellers from low-risk regions hasn’t been much implemented. This risk aversion in the setting of a long-haul battle could cause much strain to the public resources. This has been reflected in the recent shortage of quarantine facilities which ultimately requires centralized coordination and allocation from Taiwan CECC.

This risk stratification concept is similar to the triage principle adopted in the emergency department where the resources should be first allocated to those of higher risks. In fact, the controlled entry of foreign workers into Taiwan based on the capacity of the centralized quarantine facility is already aligning with the principle.

With the influx of returning citizens and residents for the upcoming Lunar New Year holiday, the implementation of risk stratification could greatly enhance the efficiency in public service delivery without compromising the water-tight containment goal given that the existing public health system in Taiwan is very robust. This will not only divert public resources to mitigate risks of other high-prevalence areas but also gradually revitalize the economic activities of certain sectors such as the aviation and tourism industry.

▲ Photo Credit: Reuters

The best design board can be drawn from Singapore’s latest border entry workflow for travellers from Taiwan. The adoption of public-private partnership (PPP) in the operation workflow greatly enhances the service efficiency and quality. Travellers from Taiwan with valid Air Travel Pass (ATP) could fill in the pre-departure health declaration forms via the government online immigration portal. After landing, the entire service is delivered through the privatized Changi Airport Group which commissions a private healthcare system to run the screening, swabbing, and testing station. After clearing immigration, travellers will be guided to the medical station. After testing, the traveller must take the designated taxis to the destination (home or hotel) and wait for the testing results. The testing result will be emailed by the healthcare provider to the traveller within 5 hours’ turnaround time. Upon getting a negative swab test result, the traveller can resume normal activities in the community without further restrictions.

Taiwan has adopted public-private partnership (PPP) in rationalizing face mask production and distribution. In fact, the infrastructure and workflow for the pre-departure health declaration and post-landing medical station at Taoyuan International Airport have also been optimized for symptomatic travellers and travellers from high-risk areas.

It is therefore up to the political will to make the call whether to open this door for travellers from low-risk areas.

▲ A designated well- ventilated area inside the Swab Test Pavilion jointly operated by Raffles Medical and Changi Airport Group (Singapore Changi Airport, Jan 6, 2021, provided by Dr. Lai)

Community empathy in collective altruism

During the long-haul battle against COVID-19, containment measures such as rigid borders and mandatory quarantine are not without a cost.

While they are critical, in our view, one should take a moment to consider the social and economic impact to support a country’s efforts.

Is it possible to nuance the border restrictions to ease that economic and social pain felt by a small number of people?

Families are separated, missing weddings, births, and funerals which are not just casual interactions. Businesses fail, dreams and efforts are destroyed, and retirement plans ruined. While the pandemic calls for personal sacrifices in the name of collective altruism, we must not forget the pain and anxiety experienced by those individuals.

▲ Photo Credit: Reuters

Compared to Singapore, the societal composition of Taiwan is less diverse in terms of having immediate or extended families with cross-border origins. The dependence on international business in Taiwan and Singapore also differs at the macroeconomic scale. However, this doesn’t mean that we don’t share the common denominator during this fight against COVID-19, which is compassionate empathy towards one another.

With pandemic fatigue creeping into our society in face of the new surge of infection, there seems to be a loss of mutual understandings and considerations in our daily lives. Emotional and confrontational responses in the social media outlets are getting frequent; personal sacrifices are taken for granted; irrational discrimination or even bully becomes justifiable. The entire community has been on tight leash with frictions that are easily sparked.

To what cost of humanity the society is willing to make to achieve water-tight containment?

As we have survived the one-year mark of harsh containment, are we really ready for more? Physically, mentally, spiritually?

▲ Photo Credit: Reuters

Conclusion

Taiwan was affected early in this outbreak and there is no doubt that the health outcomes are among the best in the world. Other countries likewise doing well include Singapore, Vietnam, Cambodia plus Australia and New Zealand.

The secret is not really a secret. It is the strong implementation of the public health measures applied variably in each country as well as strict border measures. An occasional feature among these has been a breach of border restrictions that has led to limited community transmission but without widespread outbreak.

Malaysia and Thailand likewise had good control however their border breeches have led to much more challenging outbreaks which are still evident now. Their border breaches were from illegal travellers from high prevalence countries, not organised tested business people, family members and tourists from low prevalence countries. [11]

Every country has a story and has worked tirelessly figuring out what is best for their specific circumstance. That sovereign right is not for dispute and is indeed the government’s responsibility.

▲ Photo Credit: Reuters

The global rollout of vaccines will not bring an abrupt end to the threat from COVID-19, potentially for another year or more.

So to any country we urge that the social and economic impact on individuals, families and businesses can’t be forgotten. Policy design with these individual sacrifices and sufferings in mind is particularly precious during this testing time of our lives. Nimble adaptation of governance and responsive network partnership during pandemic control are to serve the purpose of keeping individuals, families and businesses afloat.

During combat, no one is left behind. So if we can help ease the pain and impact of one more individual, one more family and one more business during this pandemic, the essence of us being one Homo sapiens species would thus be exemplified.

Till we see the light.

Team Info:

Professor Ruby Huang, MD, PhD; National Taiwan University School of Medicine & National Taiwan University Research Center for Epidemic Prevention Science (NTU ReCEPS)

Dr. Ju Yun Cheng, DVM; National Taiwan University Research Center for Epidemic Prevention Science (NTU ReCEPS)

Dr. Allen Lai, MD, MSc, MPA & PhD (Lee Kuan Yew School of Public Policy)
Professor Dale Fisher, MBBS, FRACP, DTM&H; National University of Singapore Yong Loo Lin School of Medicine

Reference:

[1] 東森新聞（2021 年 1 月 3 日）。電子圍籬2.0侵害民眾隱私? 監委籲指揮中心說清楚 ，東森新聞。
[2] Zhong, R. (2021, January 02). How Taiwan Plans to Stay (Mostly) Covid-Free.
[3] Lai, A.Y., and T.B., Tan, “Combating SARS and H1N1: Lessons and Insights from the Singapore Experience”, Austrian Journal of South-East Asian Studies, 2012, 5(1), 74-101.
[4] 黃韻如、鄭如韻、賴育宏（2020 年 12 月 8 日）。新加坡經驗：長期忽略移工　防疫跌大跤，雲論：ETtoday 新聞雲。
[5] 黃韻如、鄭如韻、賴育宏（2020 年 12 月 8 日）。新加坡也有機師趴趴走　他們如何堵住防疫破口？，雲論：ETtoday 新聞雲。
[6] Meichtry, S., Sugden, J., & Barnett, A. (2020, October 26). Pandemic Fatigue Is Real-And It's Spreading.
[7] World Health Organization. (2020, October 7). WHO/Europe discusses how to deal with pandemic fatigue.
[8] Smet, A., Tegelberg, L., Theunissen, R., & Vogel, T. (2020, December 03). Overcoming pandemic fatigue: How to reenergize organizations for the long run.
[9] Lai, A.Y., Kamradt-Scott, A., and R., Coker, “Next Pandemic: Transnational Health Challenges in East and Southeast Asia”, in Tan, A.T.H. (Ed.) East and Southeast Asia: International Relations and Security Perspective (N.Y.: Routledge), 2013
[10]Today (2021, January 05).2 foreigners tested positive for Covid-19 since green lane arrangements began: Gan Kim Yong, Today.
[11] Immigration & Checkpoints Authority, SG Arrival Card.
[12] 桃園機場 1 日電（2020 年 9 月 1 日）。桃園機場新冠肺炎採檢改用深喉唾液減輕醫護人力，聯合新聞網。
[13] Chong, C. (2020, September 25). How can S'pore reopen its borders and keep people safe?