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Commentary: "We do that to the migrant workers because, simply put, we can. We are inconsistent because they are migrant workers. But just because we can doesn't mean we should. It's bad public health."

Jeremy Lim is the director of global health at the Saw Swee Hock School of Public Health at the National University of Singapore, the chairman of the Medical Services Committee of HealthServe, a local NGO that offers medical and social assistance to migrant workers, and the co-founder of AMiLi, a gut microbiome startup. 

He also serves on the Ministry of Manpower's (MOM) taskforce to enhance mental health care support for migrant workers, Project Dawn. 

Lim shared his insights on the recent outbreak of Covid-19 cases at North Coast Lodge, his thoughts on what endemic Covid-19 could mean for Singapore, and why, despite the current dormitory clusters, he believes that Singapore should take the next steps toward allowing migrant workers back into the community.

By Jeremy Lim, as told to Jane Zhang

If we look back to when we spoke last year [in April], sadly, life has been very tough for the migrant workers in the dormitories — the outbreaks, the lockdowns, the suicides.

If we look at the recent Institute of Mental Health (IMH) survey on the mental anguish that Covid-19 has had on the average citizen who — let's face it — has had it much better than the average migrant worker, can you imagine how much worse the mental health impact has been on the migrant workers?

And now that things finally look like they are settling down, we have an outbreak in the dorms, which should not surprise anyone.

But — I think, reasonably — journalists and the general public are asking, "Okay, what now?"

We knew the dorms were high-risk. We learned a very painful lesson a year and a half ago. What now?

We need more clarity on what the threshold for "endemic" is

From a public health point of view, if we declare that the disease is endemic, it means that it will continue to circulate in the community and we accept it — so like chicken pox, or influenza. And we only get very concerned when it starts to put a strain on the health system.

For example, having 1,000 cases of influenza is no big deal, if 990 of them can be managed on an outpatient basis; you stay at home, you feel crappy for three or four days, but then you recover.

In this particular instance, I think we are in transition pains, meaning that we know what we did in pandemic times, but we don't know what we should do in endemic times.

The boundaries between what is pandemic and what is endemic have also not been articulated.

I would argue that the government needs to come out very, very quickly, to be emphatic and decisive in defining what it means to be Covid-endemic and to be resilient.

It's about the health system capacity, the number of ICU beds, the number of patients requiring oxygen, vaccination status?

But where are the numbers? Is it 85 per cent vaccination? Do we then segment them into the different populations by age, and so on?

This sort of clarity, I think, is crying out to be heard.

Because right now, the headline is still the number of cases every day. We’re still tracking wastewater. We are still doing Rostered Routine Testing. When we discover cases — whether it’s in a hostel or in a dormitory — we lock down.

And we scratch our heads and ask, "Is this what it means to be living in a Covid-endemic reality?" Because it certainly feels like we're still in pandemic times.

Reaching an endemic Covid-19 situation in dormitories

For the cluster at North Coast Lodge, we found the problem through wastewater surveillance. We then tested people and found a lot of cases.

I'm sure the numbers in the North Coast Lodge cluster will go up, because we are testing everybody.

We swabbed 5,300 dormitory occupants, and we got what? 86 cases (as of Aug. 25. The number has since increased to 130 on Aug. 27).

But, as MOM reports, everyone is asymptomatic or with very mild symptoms, and everybody is vaccinated.

Is it really worthwhile?

Especially given that as the world and Singapore try to get back to normal, we have a backlog of patients who have not been seen for their chronic conditions and other health concerns.

Might our healthcare workforce be better placed not swabbing and doing PCR tests, but instead be focusing on other much needed parts of the healthcare system?

All the migrant workers are well; they're all vaccinated, the vast majority are young and healthy. So vaccinated, young, healthy equals to extremely low-risk.

These guys have not actually imposed any strain on the health system. They were going about, doing their own thing.

We were the guys who came and said, "Excuse me, Mr. Migrant Worker, you have Covid. And now because you have Covid, we need to lock down the dormitory and all the workplaces that you have been in."

Understandably, the employers are frustrated, the workers are also frustrated.

We need to understand what [endemic] means specifically and why, because the rhetoric doesn’t match the actions.

We need to think of the impact of Covid measures beyond infection control

I think after a year-and-a-half, we should have a much more sophisticated, nuanced understanding that every intervention has some benefits and every intervention has some downsides. What are the trade-offs that we're very consciously making?

For example, in the dormitories [currently under Movement Restriction Orders (MROs)], we understand that the workers have been told that they cannot cook their own food anymore, during this MRO period.

And that sounds reasonable when you say, "Oh, we don't want people to mingle beyond what is necessary."

But they’re all sharing the same bathrooms. And the science has come out very compellingly that the Delta variant is much more infectious and can even be transmitted within seconds of interacting with each other.

Sharing toilets is a risk we can live with, 20 people in a lorry is a risk we can live with, but no, you cannot cook because cooking is a risk?

And the downside to workers not being able to cook is very, very clear.

There’s the agency around being able to cook for themselves, that sense of autonomy and independence. That’s very important for mental health.

I would argue that these "partial" measures are of limited effectiveness, and really need to be weighed against their non-public health consequences.

And at some point, the measures — even if not counterproductive — have marginal benefits that are so small that it’s not worth it.

So in my mind, the most straightforward [thing] would be for the government to be decisive and say that at this number, we are endemic. And we have to declare this at some point. We cannot live in this kind of "neither here nor there" zone that we are in today.

Should be consistent between migrant workers and other higher-risk groups

We know that the risk of severe Covid-19 disease to the vaccinated, young, and healthy is very, very low. The bigger risk is that they transmit disease to others who may not be vaccinated, young, and healthy.

So, to me a different public health paradigm really should be about asking, how do we make sure that the at-risk groups don’t come into contact with potential Covid-19 cases given they may be asymptomatic or mildly symptomatic?

So long as there is Covid-19 here in Singapore, dormitories — and any place with high residential density — will always be higher-risk. Let's just accept it.

But the same is true with military camps, with university hostels; any place where there are concentrations of people living in close proximity, sharing common facilities, bathrooms, kitchens, and so on.

Migrant workers living in dormitories haven't been allowed to leave their dormitories to enter the community since March last year.

However, we don't tell university students: "You can only go to the university and home. You cannot hang out at your grandma's place, you cannot go to all these other places."

We don't do that.

We do that to the migrant workers because, simply put, we can. We are inconsistent because they are migrant workers. But just because we can doesn't mean we should. It's bad public health.

And in a Covid-endemic situation, the migrant worker should be treated no differently from any other person who is in a high-density residential setting. We should be consistent. And today, we are not.

Should let migrant workers back into the community

We want to enable vaccinated individuals — whether they are citizens, whether they are migrant workers — to live as normal a life as possible.

The more important thing is not to isolate the workers in some little corner of Singapore but to separate them from Singaporeans who are at high-risk for severe Covid disease.

Once we take into account all factors, the risk of disease and transmission, the damage to mental health and social fracturing, my bias — in the absence of further information from the government — is to enable the workers to return to the community.

Last year, fair enough — we didn't have the vaccine. We were thinking that the mortality from Covid may be 10 per cent — the lockdowns and all were very reasonable and correct things to do.

But fast forward to August 2021. I don't think it's the sensible or the prudent public health thing to do anymore.

I see this in three phases: First is the current reality, which in my mind is far from ideal.

Then there's the ramp up or transition period, which may mean limited time out in the community in measured ways.

We may need to split the workers into batches and stagger them in shifts, so that everyone can enjoy some time out and the risks of an uncontrollable outbreak are mitigated.

Finally there’s the full endemic phase, where the workers are treated exactly the same as every other resident on this island.

And I agree that we have to have a transition phase, because nobody can be 100 per cent certain either way that it’s safe, or it’s not safe. And therefore, rather than pour out the whole bottle of wine, you pour it bit by bit and pace it.

But it's very frustrating that the pace [currently] seems to be slow, and there is no clarity on what the timetable looks like.

It's very, very unfortunate.

What can we do?

Ultimately, it’s a question of leadership. When it comes to Covid, and how we treat the migrant workers in the dormitories, I would argue that we, first and foremost, have to be guided by the science.

We can tweak at the margins, based on political and other considerations, but if politics leads and then science follows, I think we are in a bad place.

I do think Singapore civil society can be more proactive also.

It brings to mind the Abilene paradox. Like, how no one really wants to eat at Restaurant A, but everybody says, “Oh, anything. You choose!” And finally you go to Restaurant A and the food seriously stinks.

And you say, “I thought you wanted to go!” “No, no, I was being polite," the next person says. And the third person says “I didn’t say anything because I didn’t want to upset anyone.”

Might we be in that same situation with the migrant workers, where the politicians think that the Singapore public is scared and do not want to see migrant workers out in the community at all?

We then might become populist, and ignore what the right thing to do is and say, “No, we need to listen to the people. We need to respect the views and concerns of the Singapore public.”

But the Singapore public might be thinking, “Wow, this is such a heartless government. These poor workers have been confined for over one and a half years. How can we not let them out?”

I think that civil society can have a louder and more organised voice in representing to policy makers what it feels is the right thing to do, and what is it that we as Singaporeans, we as very decent, rational human beings want for our fellow human beings.

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Top photo by ROSLAN RAHMAN/AFP via Getty Images. Some quotes have been edited for clarity and flow.

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