The Meandering Undead

What Now:- The Undead Phase?

We are now in uncharted territory. We have gone where no human, hobbit, Klingon has gone before.

This hobbit is not even sure what phase we are in anymore. There were terms like Dorscon Orange, circuit breaker, phase 2 and 3, heightened alert, preparatory phase, transition phase etc that were invented by wordsmiths. Apparently, we may be now in the “stabilisation” phase.

I would like to think we may be in the necromantic “undead” phase. We will trudge on. Till when? To where? Nobody really knows.

I remember I had this discussion with a war historian many years back about why Germany lost World War 2. Man for man, equipment-wise, the German army was equal if not better than any other army at the beginning of the war. By 1941, Germany had conquered almost all of Western Europe. Those that were unconquered were allies of Germany or neutral. After the conquest of Western Europe, the Germans were mainly fighting the British (and later the Americans as well) in North Africa.

But they were defeated because they then chose to fight on two fronts in 1941 to 1942 when Hitler chose to invade Russia in the middle of 1941. Having failed to take Moscow in the winter of 1941, they decided to go for the oilfields in Caucasus in South Russia, which wasn’t a bad idea. The original plan was to just destroy the industrial capacity of Stalingrad and to capture the oilfields. But then Adolf Hitler decided that he wanted to occupy Stalingrad as well, which really was sort of a “vanity project”, as the city is named after his arch-nemesis Stalin.

As history showed, the main bulk of the German forces in the Battle of Stalingrad, the 6^th Army, was wiped out in an encirclement by the Russian Army in the winter of 1942.

The German Army never quite recovered from the disaster in Stalingrad and so lost the war in the Eastern front. In the end, they also lost the war in North Africa because too much resources had been devoted and lost in Russia and the African front was hopelessly under-resourced. This led to the allies invading Sicily in 1943 and Normandy in 1944 while the Russians continued to push westwards and recovering all its lost territory. The war in Europe ended in May 1945 when Germany was defeated by the allies sweeping eastwards and the Russians marching westwards into Berlin.

Fighting on two fronts

When it comes to resources, it is really quite a finite zero-sum game, at least in the short run. Testing of asymptomatic cases, even when self-conducted, is not resource-free on the healthcare system. Testing involves the redeployment of resources and which could have been utilised elsewhere.  

This hobbit is not so sure what we are trying to achieve here. We seem to be going to something akin to a heightened alert phase when the number of cases rise. Then when cases drop, we relax a bit. Which in turn will probably lead to a rise in cases again as social interaction increases, and then we reflexively clamp down again.

Two questions need to be asked:

• Are we in an interminable loop of relaxing/50% to work/5 to dine and restricting/WFH/HBL/2 to dine? Even though 82% have been fully vaccinated and another 3% more due to be fully vaccinated?

• What exactly is this country pursuing as an overarching strategy? Are we pursuing a zero-case strategy like China, Taiwan, New Zealand etc? Or are we going for endemicity, i.e. living with the virus exit strategy?

The answer proffered is that we need to stabilise the situation in the hospitals. For one thing, the situation for those in ICU and those that need oxygen seems rather stable. But there are actually more than 1000 patients admitted for Covid-19. Are our admission criteria too lax? By now we should have enough data to know what are the patient profile characteristics that will give a good prognosis and those that we know will not do well later on. This data should be carefully analysed and translated into better clinical practice so that we do not admit excessively and take up too many beds. At present, out of all patients diagnosed, 1.8% require oxygen, 0.2% are in ICU and the rest are either asymptomatic or mildly ill. Given our extensive experience in the last 20 months treating Covid-19 patients, can we extract more efficiency out of the system in terms of hospitalisations of asymptomatic and mildly ill patients?

On one hand, we say we are resolute on opening up and living with the virus. On the other hand, when we test almost everyone under the sun, we seem to be also going for a zero-case disease elimination strategy. As one public health expert put it, it is like asking each and every person caught in a downpour, “Are you wet?”

Another expert put it more starkly, “the pain of transition is made worse by being stuck in applying disease elimination measures to deal with an endemic disease. Much of what is being done in the name of disease prevention is counter-productive”.

Social media groups involving doctors are rife with comments questioning our strategy of testing asymptomatic folks. And many of these folks are respected experts in the medical community – public health physicians, infectious disease specialists etc.  

We may have some of the best healthcare workers (HCWs) in the world. But we are really tired of fighting on two fronts, supporting policies that apparently are aimed at moving towards endemicity and another set of practices that are aimed at disease elimination. Such a schizophrenic approach quickly tires out people both physically and mentally.

The Costs of Abundant Caution

It is easy to say we must do things “out of an abundance of caution”, which is probably one of the most overused phrases in recent times. But this hobbit feels these folks do not adequately address two important facets of a so-called cautious approach (even though 82% of population have been fully vaccinated):

• The economic cost and livelihoods lost, migrant workers’ well-being, children’s need for social interaction, mental health etc.

• While we say we want to protect healthcare and HCWs, some of these policies ignore the fact that many policies make provision of healthcare so much harder: the 2x weekly swabs, stay home orders for HCWs who are well and vaccinated, confusion among the public so that their only recourse are GPs (who are equally confused) and the already excessively crowded A&Es.

Home Recovery: Policy is Implementation

The next issue that has caught the attention of the medical profession is that of our Home Recovery strategy, which has been declared as the “default care management model” for Covid-19 patients. In itself, this strategy is absolutely correct and in-line with our stated strategy of living with the virus. But the implementation was (out of an abundance of euphemism) in a word – suboptimal. Which is rather interesting, because our transiting into endemicity was not a sudden thing. It has been discussed publicly for months. Other countries have also done it; there are both positive and negative examples of this that we can learn from. Yes when the rubber eventually did meet the road, we were found wanting.

The famous World War 2 American general, George S Patton said “Good tactics can save even the worst strategy. Bad tactics will destroy the best strategy”.

Surely, if this was intended to be a “default” model, then small-scale trials could have been run earlier to spot potential problems in communication and implementation? For example, when a new and important software system is introduced in a big company, there is always User-Acceptance Testing (UAT) performed before the system is rolled out, so that teething problems can be identified and ironed-out. Was there any trial or UAT done before our Home Recovery care management model was implemented? A past Head of Civil Service once said “Policy is implementation”. Unfortunately, some folks obviously didn’t read his memo.

New NS Vocation: Patient Buddy

That leads us to the issue of operations planning and implementation. We are now 20 months into having Covid-19 infections on our shores. If there is one thing that appears to be obviously lacking, it is our capability to plan and implement operations on a large scale quickly and well. And each time, the SAF is called in to save our butts. This is troubling to this hobbit. In many other countries, the armed forces are called in to help out in sudden emergencies and disasters, such as earthquakes and typhoons. In Singapore, they are now called in to answer phone calls and be patient buddies after the country has battled the same Covid-19 virus for 20 months. Chew on that.

An insider commented to this hobbit, “It really goes back to the reward system. If the system rewards those that can best write beautiful policy papers, then the system will produce the best policy paper writers and presenters. If the system rewards those that can do the “sai-kang” (literal Hokkien translation – faecal work; i.e. grunt work) best, then the system will produce the best operators”.

As Mr Brown, the “blogfather” recently inferred in a post (“Kim Huat and the somewhat endemic phase”)  – stop dishing out all these complicated flowcharts that most people have difficulty understanding. In fact, this hobbit has some advice for these flowchart exponents – send your beautiful flowcharts to the most junior person in your department, such as the administrative assistant or receptionist. If they understand it, then it is a good flowchart. If these junior or lesser educated folks don’t understand it, it’s a lousy flowchart. Go back and redesign the workflow and flowchart until it is understood by junior staff before it can be allowed to be circulated. Because if they don’t understand it, chances are not many people out there will.

The Magic Number of 143

Going on to the subject of boosters. On 14 Sep 21, GPs were informed by AIC that boosters can be given for those 60 and above if they had received their two doses at least 6 months (or 180 days) ago. On 17 Sep 21, this was revised to 5 months (or 150 days). That’s fine. Then on 24 Sep 21, another (third) email was sent by AIC (on behalf of MOH) to yet again change the criteria to 143 days and if the person had received an SMS from MOH to take their booster shot.

Do the folks who craft and send out such emails in rapid succession think GPs have nothing to do but read their emails and circulars? Why 143 days? Why not 144 or 142? And why must it be accompanied by the SMS invitation? A nice number like 150 days or 5 months is very good. Thank you. Please don’t load us with more bureaucratic instructions that consumes more memory space. I have a small brain with limited memory space. This hobbit would like to suggest that bureaucrats should be given a KPI that states “Have you made HCWs’ life easier with less bureaucracy?” in their annual performance assessments. I think many will fail this KPI miserably.

So very, very sick of it

A GP working in the Queenstown area said it well in his FB post dated 20 Sep 21,

“Every day MOH sends us a bunch of new directives; there’s so much that my free 5gb mailbox is actually almost full! One day they say one thing, one day we read it in the papers before we get informed.

It’s now 5pm and I wanted to go home at 2 and have a nap, instead I’m clearing all the *@# from just now. And I might as well just stay here since we start again at 6 anyway. I am sooooo sick of having to rush to see and jump queue for pts with a cold, and doing all the paperwork involved in swabbing them. I am so sick of having to trace results every night and calling the pts to tell them that it’s negative. Am so sick of having to learn one new thing after another, and reading about new policies which are not clearly thought out, in the newspaper… quarantine yourself, and then after 3 days gradual return to activities. What the heck is a “gradual return”?

So very, very sick of it”.

It is apparent that to this GP, all the many and periodic expressions of appreciation and gratitude by politicians mean little to frontline HCWs like him when the bureaucrats just insensitively shovel out loads of instructions that make no sense or make life unnecessarily complicated. Pleasantries unsupported by action can only do so much.

What We Need Now

What we need now is hope, not the dreary prospect of interminably oscillating between opening up and shutting down activities, when we already have one of the highest vaccination rates in the world.

What we also need now is unity of purpose to rally the people and the HCWs. This in turn requires clarity of thought.

Hope, clarity of thought and unity of purpose. To achieve these three, we have to first settle on a communications message that is consistent, cogent and concise. This message must then be delivered with great conviction. We then have to develop and implement operations that cohere with this message.

If not, we will just be meandering around like undead zombies in search of both disease elimination and endemicity and finding neither.