Workers wearing face masks as a preventive measure against the spread of the Covid-19 coronavirus wait for transport to their job sites in Singapore on April 15, 2020. Photo: AFP/Roslan Rahman

SINGAPORE – Singapore’s low-wage foreign laborers are falling ill with the coronavirus in their thousands after being quarantined en masse, a development that experts say could put unprecedented strain on the wealthy city-state’s healthcare services as its Covid-19 case numbers surge.

What began as a success story for Singapore owing to its early containment of the disease through quarantines and contact tracing has since turned into a cautionary tale on the public health risks of overlooking swathes of marginalized workers that have now become the Achilles’ heel of the city-state’s coronavirus response.

Not unlike the two economic realities inhabited by Singapore’s transient workers and its citizens and permanent residents, the outbreak itself has been likened to a tale of two infections. When a record 1,426 new cases were reported on April 20, only 16 cases involved Singaporeans and residents with the vast majority of the infections occurring in foreign worker dormitories.

“Singapore is running two epidemic curves at the moment, there’s outside the dorms and inside the dorms,” said Dale Fisher, a senior infectious diseases consultant at the National University Hospital. “One is skyrocketing up just like New York and Italy did, and the other one is plateauing down in low double-figures.”

The island-nation of 5.7 million now has the highest number of officially confirmed Covid-19 cases in Southeast Asia with a total tally of 9,125 infections and 11 fatalities. Singapore is, however, one of the top testers globally with 16,600 tests per million people in a region where testing capacity varies widely from country-to-country.

The comparatively lower rate of infection in Singapore’s wider community has been attributed to the success of restrictive “circuit breaker” measures that took force on April 7, putting Singapore on a partial lockdown with social gatherings of any size banned and all schools and non-essential workplaces closed.

The central business district of Singapore on April 7, 2020. Photo: AFP / Roslan Rahman

Lee Hsien Loong, Singapore’s long-serving premier, said in a televised address today (April 21) that while Covid-19’s spread in the local community has leveled off to below 30 new cases daily, infections continue to rise sharply in dormitories since authorities recently began aggressive testing of both symptomatic and asymptomatic individuals.  

“To our migrant workers let me emphasize again, we will care for you just like we care for Singaporeans,” said the premier, adding that none of the new cases of migrant workers have required supplemental oxygen or intensive care and almost all of those infected have only mild symptoms.

In his speech, Lee said circuit breaker measures – which were due to expire on May 4 – would be extended another four weeks until June 1 in an effort to “bring down daily infections more sharply to a single digit, or even zero, and to reduce the number of unlinked cases.”

Lee lamented that unlinked cases – “cases where we do not know how they got infected, or from whom” – have persisted. “This suggests that there is a larger hidden reservoir of Covid-19 cases in the community,” he said.  

Singapore’s daily caseload exceeded 1,000 for the second day in a row on April 21, with 1,111 new cases confirmed. Twenty cases involved Singaporeans and permanent residents of the city-state, according to the Ministry of Health (MoH).

Total cases have risen more than nine-fold since April 1, prompting concerns that Singapore’s health care system is coming under pressure as a rising number of patients are hospitalized. The city-state has so far not suffered from the shortages of personal protective equipment (PPE), ventilators and critical care beds seen elsewhere.

“Everyone is at risk of being overstretched, that’s the big fear,” said Fisher. “The practice of isolating patients in hospital has obviously overflowed, which is why we have community isolation facilities now. ICUs (intensive care units) haven’t been pushed yet but, certainly, the hospitals are quite full of positive patients that are being monitored.”

Foreign workers look out from the balcony of a dormitory at Cochrane Lodge 2 in Singapore, April 15, 2020. Photo: AFP/Roslan Rahman

Community isolation facilities have been opened at the Singapore Expo and MAX Atria, the city-state’s largest convention and exhibition venue, and elsewhere to relieve pressure on hospitals. Recovering patients and those with mild symptoms who do not need extensive medical treatment have been sent there for recovery.  

Paul Tambyah, president of the Asia-Pacific Society of Clinical Microbiology and Infection, told Asia Times there is a “definite risk” of the health service becoming overwhelmed. “There is quite a bit of buffer in the system…but I don’t think we can cope with 500 to 900 people being infected every day for a very long time.”

Though transmissions among foreign workers are quickly multiplying, the vast majority of the cases are said to be mild because those infected are younger men without underlying conditions. Tambyah, however, estimates that if just 1% of infected workers require long ICU stays, “the strain on the system will be considerable.”

At a press conference on April 14, Health Minister Gan Kim Yong reportedly said that the recent rise in infections had “stretched” health care resources but that the system has so far been able to cope. The minister earlier this month offered reassurances that Singapore has the capacity to handle an anticipated rise in cases.

Singapore’s first dormitory cluster was identified on March 30, with four infections at the S11 Dormitory in Punggol, which houses some 13,000 workers. Cases rose dramatically in the dormitory after authorities gazetted the site as an “isolation area” subject to a total lockdown with occupants expected to remain in their shared living quarters.  

The dormitory has since become Singapore’s largest cluster with at least 1,977 cases, while a total of 19 foreign worker dormitories have similarly been gazetted as isolation areas. Health experts and rights groups attribute the soaring rate of transmissions to high-density conditions in the dormitories, where rooms are typically shared by 12 to 20 occupants.   

Authorities have attempted to reduce population density in the dormitories, with priority given to some 7,000 workers employed in essential services such as logistics, transportation and construction, who have been housed in temporary lodgings.

Testing among migrant workers has been aggressively ramped up since the dormitory lockdowns began with positive patients placed either in hospital or in isolation facilities. But it’s not clear yet according to observers and analysts that the number of new cases has peaked.

Foreign workers wearing face masks as a preventive measure against the spread of the Covid-19 novel coronavirus look out from a fence of a workers’ dormitory in Singapore, April 9, 2020. Photo: AFP/Roslan Rahman

“There’s a whole lot of people out there that are positive that we haven’t found yet. Even if transmission stopped today, we’d still be finding 1,000 cases a day,” Fisher of National University Hospital told Asia Times, adding that authorities are working to establish on-site medical centers at all foreign worker dormitories island-wide.

Health experts and rights groups had highlighted the vulnerability of Singapore’s migrant workers to infectious diseases prior to the surge in dormitory cases.

Some of the city-state’s initial policy responses, however, overlooked migrant workers, who are mostly from South Asian countries and employed predominantly on construction sites, assembly lines and shipyards.

While free surgical masks were distributed to households nationwide in February, the initiative did not include migrant workers living in dormitories. Mask-wearing has since become compulsory in Singapore for all those who leave home after research confirmed that asymptomatic patients could spread the pneumonia-like illness.

Sealing off crowded dormitories, which are usually privately operated, rather than lodging the workers in more-distanced temporary lodgings from the start has worsened the outbreak, analysts and observers say. 

“When there are 10 to 20 people living in the same room, it is impossible to ensure safe distancing or prevent infectious diseases from spreading,” said Tambyah.

Some 323,000 foreign workers live in 43 mega-dormitories across the city-state, but others live in rented apartments and worksites. Authorities recently announced that all construction workers holding work permits living outside such dormitories would be placed on mandatory stay-home notices (SHNs) in effect from April 20 to May 4.

Singapore’s Ministry of Manpower (MoM) described the move as “precautionary” in response to contact tracing that pointed to transmissions occurring on construction worksites, which it said “may have contributed to the increase in numbers.”

The highest number of infected cases have come from the construction sector, the ministry said.

Migrant foreign workers at a construction site in Singapore. Photo: Twitter

“This suggests that workers are going out to work while infectious. Some may be asymptomatic, but others may be mildly symptomatic,” said Alex Au, vice president of advocacy group Transient Workers Count Too (TWC2), in reference to segments of the foreign workforce who continue to carry out essential services.

Some employers in Singapore are known to institute penalties of up to S$50 (US$35) per day and deduct wages when foreign workers take leave on medical grounds, said Au, an employment practice he described as “abusive” and “a very plausible explanation for the exponential growth of Covid-19 cases.”

The manpower ministry’s SHN order, moreover, obliges employers to monitor their workers’ health, ensure they have adequate food and “take care of their well-being.”

Rights groups and observers have voiced objections to such measures over concerns that workers would be entirely dependent on employers for their most basic needs.

“Dorm operators who work on a profit-driven model don’t always have public health interests as a central concern,” said Laavanya Kathiravelu, an assistant professor at Singapore’s Nanyang Technological University who studies migrant labor.

“Placing almost complete responsibility on employers means that information is often transmitted ineffectively and inaccurately. Language and cultural barriers contribute to this,” she added.

MoM has said it would take strict enforcement measures against errant employers who do not comply with SHN requirements.

The surge in foreign worker infections has also given rise to xenophobia. A reader letter published in the Chinese daily Lianhe Zaobao on April 13 stoked controversy when its author said among other claims that workers themselves were ultimately responsible for the outbreak due to their “bad personal hygiene habits.”

“Singaporeans should take collective responsibility not just in terms of flattening the curve or stopping the spread of the virus, but also in ensuring that we band together to call out and correct racist and prejudiced views,” said Kathiravelu, “especially when they are directed at marginalized and vulnerable populations like low-wage migrants.”