CCB – The Good, The Bad And The Mysterious

We have been in Circuit Breaker (CB) mode for about four weeks. The original CB period was supposed to end on 4 May. But this mode is going to continue for another 4 weeks, until 1 June. We are therefore now in CCB mode – Continued Circuit Breaker Mode. Hopefully it will not be extended or tightened again. Somehow only my gynae classmates find tightening of CB measures amusing.

There are encouraging signs on the data front. While Covid-19 rages on in the dormitories, such that 500 cases a day is now considered not bad news, numbers in the community have been coming down. These can be seen in the daily Situation Reports put out by MOH. This hobbit finds these Reports interesting and informative. There is a mountain of data in the Reports but let us just concentrate on two aspects – Unlinked Community Cases and Unlinked Work Permit (WP) Holders Not Residing in Dorms. These two sets of numbers are found in Table 1.1 of the daily Situation Reports.

We concentrate on unlinked cases because these are the cases that present the greatest threat to us. With all the dorms under lockdown, new cases found there do not present a significant threat to us in the community. That is not to say we should adopt an indifferent and callous attitude to these poor folks stuck in the dorms, but these do pose a different level of threat to the rest of us. The same goes for linked cases in the community, because containment measures such as contact tracing and quarantine would have kicked in quickly once they are linked, so as to lessen the threat of transmission.

That leaves us with the unlinked community cases and the unlinked work permit holders NOT residing in dorms. To this hobbit, it is the same whether a person has a work permit, an employment pass or even a pink IC – if they do not live in the dorms, they should be considered a community Covid-19 case. Because the virus doesn’t care if you hold a certain type of identity document or not.

In the MOH Press Release dated 1 May, it was said,

“The number of unlinked cases in the community has also decreased, from an average of 16 cases per day in the week before, to an average of 6 per day in the past week. We will continue to closely monitor these numbers, as well as the cases detected through our surveillance programme”.

and

“The number of new cases amongst Work Permit holders residing outside dormitories has decreased, from an average of 27 cases per day in the week before, to an average of 14 per day in the past week”.

This hobbit (like most hobbits) is a lazy fella. Instead of using a 7-day moving average like what MOH has implied above, we can derive a 14-day moving average simply by subtracting the top row from the bottom row of Table 1.1 in the two relevant columns to get the total number of cases in the 14 days up till the day of each situation report. Divide that number by 14 and you get the daily average over 14 days for each day. So here is what the figures look like: (this format of reporting by MOH first started on 17 April):

 

Date	Total Cases over 14 days for Unlinked Community Cases	Average Per Day for 14-day period	Total Cases over 14 days for Unlinked WP holders NOT in dorms	Average Per Day for 14-day period	Total Unlinked Cases	Average Per Day for 14-day period
17 Apr	291	20.8	97	6.9	388	27.8
18 Apr	285	20.4	95	6.8	380	27.1
19 Apr	281	20.1	96	6.9	377	26.9
20 Apr	276	19.7	103	7.4	379	27.1
21 Apr	284	20.3	116	8.3	400	28.6
22 Apr	266	19.0	121	8.6	387	27.6
23 Apr	264	18.9	121	8.6	385	27.5
24 Apr	258	18.4	115	8.2	373	26.6
25 Apr	248	17.7	108	7.7	356	25.4
26 Apr	242	17.3	116	8.3	358	25.6
27 Apr	219	15.6	122	8.7	341	24.4
28 Apr	200	14.3	112	8.0	312	22.3
29 Apr	180	12.9	103	7.4	283	20.2
30 Apr	168	12.0	97	6.9	265	18.9
1 May	157	11.2	83	5.9	240	17.1
2 May	138	9.9	79	5.6	217	15.5

Conclusions:

• The trends looks promising
• Unlinked cases peaked on 21 April, which was exactly the day the Prime Minister addressed Singapore which was followed by policies that furthered tightened the CB with barbers and bubble tea establishments closing
• While unlinked community cases have more than halved since 17 April, the unlinked cases involving WP holders NOT residing in dorms have proved to be a tougher nut to crack, the downward trend in this category is not as pronounced as the unlinked community cases. This is very worthy of our concern.

One caveat is that you have to use the individual daily reports and not rely on just the report of the current (latest) day because figures change for a certain day when cases become linked after several days of investigations.  For example for the Situation Report dated 18 April, the number of unlinked cases for WP holders NOT in dorms was 13 for 18 April. But this same statistic for 18 Apr dropped to 5 by the time the Situation Report for 23 April was published.

The average total unlinked cases for both categories is now 15.5 for a 14-day period. Hopefully, by the end of CCB, this will drop to <5. In places like Taiwan and HK, the total number of cases (whether linked or unlinked) is in the single-digits, so aiming for the same number for us just for unlinked cases alone is not a tall order. For example, since 15 April, HK has not had more than 5 cases a day, linked and unlinked. The same goes for Taiwan, which other than for 22 cases reported on 19 April due to cases found on a warship, they too haven’t had more than 5 cases a day either. In South Korea, new cases a day are now in the single digits, and the highest number they have had since 15 April was 22 cases. But Korea is a country with 51 million people, about nine times the size of Singapore.

There are policies, and then there are policies. As we are now into the 5^th month of our struggle with Covid-19, let’s look at some of them. This hobbit thinks policies can be roughly grouped into the good, the bad, and the mysterious.

 

The Good

Recently, the SMC has just modified the requirements for CME in this current cycle in response to a request from the SMA. All Covid-19 related CME activities are now considered Core points for all doctors. Also, the cap for self-reading of journals (Category 3A) has been raised from 10 to 20 points. This is very good.

The locum rates for doctors who work at Community Isolation Facilities (CIF) is $130 per hour. This is a very fair deal. Good too.

In a Webinar, the DMS said MOH was committed to support all PHPC clinics with free PPEs beyond the initially stated 12 weeks. This is to be welcomed too.

 

The Bad

Let’s imagine this – you are one of the squad leaders on top of Helm’s Deep in Part 2, Twin Towers of The Lord of the Rings Trilogy. You are put in a charge of a squad of 10 elven archers and you and your squad face this sea of orcs, trolls and Uruk-hais marching towards you. You are scared shitless. But you swallow your fear in spades and await the onslaught from these beasts with your small squad of elves as well as the rest of the Elven and Human Army. Suddenly, this guy comes up behind you and says in an authoritative tone, “Dude, I am cutting your squad strength by half. You now only have 5 archers left. Good luck”.

“Whaaaaaat?!?!?” you scream out in anger, fear and frustration. Meanwhile, the orc and trolls army has multiplied further and are marching closer and closer to Helm’s Deep.

Sounds crazy? But this is exactly what is happening in the trenches today with our medical clinics.

To be fair, there are medical services that are obviously non-essential and should be closed, such as aesthetics and health screening. There are even some specialist services that are probably non-essential and should be limited as well, such as stable cataract surgery or joint replacements.

But GP services, especially Public Health Preparedness Clinics (PHPC)?

This hobbit has seen numerous GP and PHPC clinics’ requests for full manpower denied. This whole process of registering your essential staff is so illogically painful it is shameful. The IT system itself is a basket case – it hangs frequently. There is also no clarity and transparency in how decisions are arrived at. Some clinics were given a total of two workers while there is another that is given five. How are these numbers arrived at? What is the criteria? Yet another clinic was given 400+ workers (probably a mistake, but still…)

There is no consensus amongst doctors whether number of employees/workers includes or excludes doctors. Some doctors take it to only include non-doctor workers. Some doctors think it excludes cleaners who come by for an hour a day to do cleaning.

The number of staff allowed – are they for one shift, or for the whole clinic per day? Nobody really knows. What if you have different staff for different shifts? Can you have six workers in a clinic working three shifts? i.e. two workers per shift or must it be the same two workers in all 3 shifts?

This is one big royal mess. A GP running a PHPC Clinic is very clear in his mind – He says  “I have four clinic assistants. If they give me only two, then I will reduce my clinic opening hours by 50%”. I know a few senior GPs who told me they will close their clinics altogether because they can’t take this anymore. If all these GPs cut their opening hours by half, then the combined effect would be a significantly diminished PHPC capacity. Is this really the policy intent of enforcing worker limitations in GP and PHPC Clinics? To cut capacity in the PHPC system? Instead of mustering all the elves and humans to fight the orcs, you tell your frontline warriors to stay at home? How does this gel with the Health Ministers saying “healthcare workers are our most important resource?”. Clinic assistants are also healthcare workers, aren’t they? And yet we want them to stay home….

The usual answer one gets is “you can appeal”. But to appeal is unnecessary work at best and demeaning at worst. If I am truly frontline GP battling Covid-19, why should I have to appeal? Why don’t you reduce the opacity and tell me what is your criteria for deciding on how many workers a clinic may have?

One wonders, is there any other country in the world that wants to decrease service capacity in the primary care system during this Covid-19 pandemic? We may be the only one.

My clinic’s workload has come down by at least 50%. Most GP clinics I know have seen their workload cut by between 50% to 75%. So on one hand, it is true you may not need so many staff from this perspective. But due to current infection control measures, efficiency and productivity also drops significantly, so less patient volume may not correspond to a tandem reduction in manpower needs.

In any case, pre-Covid, GP clinics running out of 600 to 700 square feet shop-lots are already some of the most efficient healthcare providers on this island. How much more productivity do you want out of each of them? Do the authorities actually think GPs hire more workers than they need in peacetime? Especially when they are paying each and every of these clinic assistants out of their own clinic takings?

But moving beyond numbers, we need to have more empathy with what the GP is going through while fighting two fronts:

• The GP is risking life and limb with his clinic team to continuing serving his patients amid the Covid-19 pandemic (Physical Threat and the Disease Front)
• He is very stressed by the loss of patient load which translates to very diminished income. (Financial Damage and the Economic Front)

He doesn’t really need to have a third front, which is to contend with the authorities on justifying why a clinic assistant is needed on the Regulatory Front. As one PHPC family physician said, “You are supposed to help me make my life easier as a frontline healthcare provider, not add onto the stress and psychological trauma by cutting down my staffing and threatening to fine me or put me in jail, especially when I am supposed to be helping the country battle Covid-19”. He followed through with a string of expletives which this hobbit has censored. (Sorry, bro, cannot post lah).

Interestingly, this same doctor told me he has seen his clinic staffing cut to 2 but he knows a lawyer has been given a quota of 5 essential workers. He rationalises that maybe there are many people who want to have their wills written in a hurry.

So what is going on with the GP is that he has to fight the virus, stave off economic ruin and contend with the most unfriendly GoBusiness IT system and live in fear of the threat of being punished under the ID Act should he offer some service that is deemed non-essential.

But that is not all. We also now have additional interpretations of what is essential medical services and what is not.

For example, in a directive dated 30 April, it was said some of the non-essential services that were discovered in medical clinics included:

• Consultation for skin and hair conditions which are stable and on long-term follow up;
• Provision of botox, fillers and chemical peels for aesthetic purposes; and
• Supply of facial cleanser, lotion and cream refills over the counter.

As previously said, banning of provision of aesthetic service is straightforward enough. But the other two points are not so simple. The main issue for GPs is that we really do not know who walks into my clinic beforehand every day and what are their reasons for seeing me. I do not have a triage to sieve cases out, and even if I had, it is gone now, thanks to GoBusiness who just halved my number of clinic assistants.

A patient who comes into my clinic say for diarrhoea may at the end of the consultation ask me for another tube of steroid cream for her stable eczema. Do I give it to her or not? And why would any patient pay for delivery charge for medicines when he walks into my clinic to refill his acne medicine after buying takeaway food from the hawker centre which is located 30 metres from my clinic? Do I deny the patient his bottle of cleanser for acne or the diarrhoea patient her tube of steroid cream?

Many non-essential services are offered opportunistically together with essential medical services given in the same sitting, and often so at the patient’s request.

Somehow I think all these directives are written by people who do not understand GP practice and have not practised as a GP in the heartlands. This hobbit suggests that these powerful directive folks read up on Stott Davis Model and Pendleton Model of Family Medicine consultation models in addition to their usual work of writing and issuing directives. Or as suggested by a general surgeon – perhaps talk to a real doctor.

 

The Mysterious

Immunisations. MOH considers adult immunisations as non-essential and that influenza and pneumococcal vaccinations can be given only if the patient is also “being seen for essential routine chronic care”.

WHO does not make a difference between adult or childhood immunisations. Here is what the WHO says in its website:

One of the “Guiding Principles” states…

“Immunization is a core health service that should be prioritized for the prevention of communicable diseases and safeguarded for continuity during the COVID-19 pandemic, where feasible. Immunization delivery strategies may need to be adapted and should be conducted under safe conditions, without undue harm to health workers, caregivers and the community”.

One of the “Considerations” for routine immunisations:

“Where health system capacity is intact and essential health services are operational (e.g., adequate human resources, adequate vaccine supply), fixed site immunization services and Vaccination-Preventable Disease (VPD) surveillance should be executed while maintaining physical distancing measures and appropriate infection control precautions, equipped with the necessary supplies for those precautions”

I guess either our health system is not intact or our MOH is not taking guidance from WHO on this.

Another great mystery is of course our Dorscon system. In the beginning, I guess most of us didn’t really understand it. Then many started making jokes about it. Now, nobody even bothers to refer to it except in the most perfunctory way. When it gets to this level of irrelevance and irreverence, it is perhaps time to bury it.

Next we move on this ban on walking pets and exercising in the private estate grounds. The ban was first announced on 28 April by the Building and Construction Authority (BCA) before the decision to reverse it was made on 2 May and the reversal will be implemented with effect on 5 May. It took all of four days to reverse a decision and another 3 days to implement the reversal. Mysterious isn’t it?

To be absolutely clear, this hobbit thinks the original decision didn’t make much sense and caused a lot of grief. Some condo estates may be very big, and a resident needs to walk 100 to 200 metres to the main gate and enter public areas where the dog can walk. So what must the resident do to abide with this directive? A dog lover friend of mine contemplated carrying her dog for 200 metres to the main gate, or putting the dog in a baby stroller and pushing the dog in the stroller to the main gate. Luckily, she owns a poodle which is small. But what if you own a golden retriever or a Doberman? Lug the mutt like an army full-pack for 200 metres?

Next we move on the ban on home-based food businesses such as baking, which was announced on 26 April. You can order fast food delivery to your home but you cannot perform home-based food businesses and get the goods delivered elsewhere by similar professional delivery services. The decision to reverse this was made yesterday (6 days from announcement) and the implementation of this reversal decision will be made on 12 May (16 days from 26 April). Frankly, my public health and epidemiology knowledge is limited at best (I slept through most of COFM class, like many other people), but this hobbit thinks really the additional epidemiological risk posed by home-based food businesses baking is quite limited if you already allow deliveries of goods and cooked food from establishments, restaurants and hawker centres to homes. So why this sudden albeit transient attention on home-based food businesses? Another mystery.

 

The Biggest Mystery of All

And now we will move on to the really important news in our  nation’s mighty battle with the Covid-19 – The Virus Vanguard.

The Virus Vanguard must be the shortest-lived superhero grouping in the history of the galaxy. It survived for as long as SARS-CoV-2 did in my 70% alcohol sanitizer. Which is really a pity.

Anyway, this hobbit has to go. I have an important date with my fellow mythological character, Care-leh Dee, the Virus Vanguard trillionaire philanthropist superhero who can hopefully give me some financial assistance for my loss of income. And I will also ask her to use her empathy to remove all the negativity I have about GoBusiness and my inability to give a tube of steroid cream to my diarrhoea patient with stable eczema.

I also hope to get MAWA Man’s autograph through her. Wish me luck.

 

Gentle Reminder – Do remember to vote in next week’s SMC elections.