Coronavirus: Why did Singapore have more cases than Hong Kong - until now?
At least in layman eyes, Hong Kong looks like it should be far more vulnerable than Singapore to the spread of the coronavirus.
After all, it has 13 border crossings with mainland China, where the disease is thought to have originated in a market in Wuhan, Hubei province, while Singapore is more than 3,500km away.
So why is it then that the two places have such a similar number of infections, with Hong Kong only surpassing Singapore's count on Tuesday, when figures as of 8pm showed 49 confirmed cases (and one death) in Hong Kong and 47 confirmed cases in Singapore?
Some experts suggest the answer is, at least in part, due to standards of detection.
Health care experts say the Singapore government's approach of actively weeding out those affected could explain its relatively high number of cases, while Hong Kong's relatively low number might mean there could be silent carriers within the community.
Leong Hoe Nam, an infectious disease expert at Mount Elizabeth Novena Hospital, suggested Singapore was detecting more cases because it gave an incentive for citizens to come forward when they were unwell, and citizens in general trusted the government.
For example, the health ministry is providing financial help to Singaporeans, permanent residents and work pass holders who are quarantined, such as giving $100 to the self-employed, and to employers of those who are in isolation.
He added that if Singaporeans were sick with the coronavirus, they could get free medical treatment.
"You are not short changed at all so there is no reason to stay away and hide," said Leong. "Essentially, it is a get-out-of-jail-free card, and the idea is to draw every [potential] case out into the open and get tested."
By doing so, officials hope to ring fence clusters of local transmission through identification of those who have come in to contact with the confirmed cases and having them quarantined and tested, to prevent the virus from spreading.
Singapore authorities have identified three possible clusters: a health products shop that catered primarily to Chinese tourists; a church; and a business event at Grand Hyatt Singapore, at which a Malaysian, two South Koreans and a Briton are thought to have been infected.
"We are looking very hard for cases, and the harder you look, the more cases you'll find. The upturn [in cases] will come down later because we are actively quarantining," said Leong.
He said Singapore's neighbouring countries were likely to have a lot more cases but they were not "looking hard enough".
There have been fears that Indonesia, which has close links with China, was under-reporting cases, with officials saying that Indonesian nationals evacuated from Wuhan, the epicentre of the virus outbreak, would not need to be tested for the virus.
Jeremy Lim, a partner at global consultancy firm Oliver Wyman's health and life sciences practice, said more developed nations tended to have better detection - and reporting - of cases, more "sophisticated" contact tracing, and a wider availability of test kits.
"Better hospitals tend to have higher rates, at least initially, of medication errors and other avoidable events," he said.
"It is not just because the culture of transparency is stronger and motivation for learning higher, but the resources that can be invested in tracking events."
On test kits, he said that Singapore's research institutes had developed their own test kits and had sent 10,000 of them to aid virus-hit communities in Wuhan.
"More testing means more cases," said Lim.
Leong said Singaporeans also had a high level of trust in their government.
The emptier-than-usual streets, he said, showed citizens were heeding authorities' advice to avoid crowded places.
Singapore's health ministry has advised against large social events and gatherings after it raised its outbreak alert level on Friday to orange - the same that would have been used for the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003, had the framework existed then.
The alert level indicates that while the nature of the disease is severe and can spread easily from person to person, it is being contained and has not spread widely.
After the alert level was raised, droves of citizens flocked to supermarkets to hoard essential supplies. This prompted Prime Minister Lee Hsien Loong to make a national address on Saturday, stressing that the country was well-prepared to face the outbreak and had sufficient food supplies.
Some measure of calm returned on Sunday, with Claire Hooker, a senior lecturer at the University of Sydney's Centre for Values, Ethics and the Law in Medicine, describing Lee's speech as a good example of risk communications.
"It gave people very concrete actions" that "handed back a measure of control to people whose sense of control will feel threatened", she told Bloomberg.
Singaporeans also trusted that the government would provide quality health care, said Lim.
"If people trust that quarantine facilities are decent and that they will receive proper care, they will be more likely to come forward," he said.
Singapore is using its universities and chalets to house its suspected cases, which initially drew flak from undergraduates who were made to evacuate within a day.
The national development ministry said about 370 people were currently at government quarantine facilities, well within its capacity of 1,000 people.
Meanwhile, in Hong Kong, authorities are scrambling to ensure there are adequate quarantine sites, while Chief Executive Carrie Lam Cheng Yuet-ngor - in the face of public anger - backed down from a plan to offer free treatment in the city to mainlanders and anyone else needing hospitalisation due to the coronavirus, saying public hospitals would charge all non-residents full medical costs.
Thousands of medical workers in Hong Kong went on strike last week to demand a complete ban on entries from mainland China, worried that hospitals would be overwhelmed by new cases as mainland Chinese sought to use Hong Kong's health care system.
There have also been protests against the use of certain housing estates as potential quarantine facilities.
Hong Kong Doctors Union President Henry Yeung Chiu-fat said Hongkongers had lost trust in the Carrie Lam administration.
This stemmed from the anti-government protests against the now-withdrawn extradition bill that began in June last year, and various moves by the government regarding the coronavirus had exacerbated the situation, he said.
One example was Hong Kong's ongoing clamour for surgical masks.
Lam said on Saturday that the Hong Kong government was running low on masks, and that her administration was left with 12 million, or one months' supply.
Private companies have stepped in and are handing out free masks to the public, drawing crowds of people desperate to protect themselves.
The Singapore government has been keen to assure its citizens it has enough masks to go around; authorities have distributed four masks for each of Singapore's 1.3 million households.
"It goes all the way to when the people were shouting for the closing of the borders [with China] before the Lunar New Year, and the government turned a deaf ear to them," said Yeung.
Hong Kong leader Lam shut 10 of the 13 borders with mainland China on February 3, but only after intense pressure from the public.
Singapore, on the other hand, on January 31 became one of the first countries to ban the entry of foreigners arriving from mainland China.
Even now, Yeung said that there were deliverymen ferrying food supplies from mainland China to Hong Kong - something he said posed a "danger".
David Hui Shu-cheong, a respiratory medicine expert from Hong Kong's Chinese University, said another issue was the large number of Hong Kong citizens that had until recently been crossing the border on a daily basis, either to live, work or study.
Though Lam's restrictions last weekend cut down on this practice, many critics said the move had been too little, too late.
Among Hong Kong's new measures to tackle the coronavirus is implementing a two-week quarantine for all travellers entering from mainland China, including Hong Kong residents.
Yeung said Hong Kong's relatively low number of infections may be because the punishment for flouting quarantine orders was "weak".
Hong Kong officials yesterday said nine people had breached such orders so far, and two were on the run.
"The first time they give such an order, there is just a soft reminder or warning," said Yeung.
In Singapore, people who flout quarantine orders can be fined up to $10,000 and jailed for up to six months.
On Sunday, Singapore's manpower ministry revoked the work passes of four people who were caught working while they were supposed to be in isolation.
JUST NOT AS BADLY HIT?
Experts also suggested Hong Kong might genuinely have fewer cases.
Hui pointed out that arrivals from mainland China had fallen sharply over the past eight months.
"Very few mainland Chinese tourists have come to Hong Kong for holiday because of the social unrest," said Hui, referring to the anti-government protests.
Rising anti-mainland sentiments among Hong Kong's protesters have occasionally spilled over into violence and the vandalism of businesses perceived as having links to the mainland, prompting many would-be tourists to reconsider visiting Hong Kong.
"Thus, more mainland Chinese would [have gone] to Southeast Asian countries for holiday," he said.
Mainland Chinese arrivals in Hong Kong in December fell more than 50 per cent year on year, to about 2.4 million.
Even so, that is far more than the 300,000 mainland Chinese who visit Singapore in an average month.
Ivy Teh, global managing director of The Economist Unit's health care arm, said the slowdown in tourism from mainland China "could have reduced Hong Kong's exposure to Chinese visitors from [the] Hubei region".
She said that during the same period, Singapore had gained a reputation as a "safer alternative" for mainland Chinese.
Even so, Teh praised the Singapore government's "extremely quick proactive actions".
"A multi-ministerial task force was set up quickly involving health, education, transport [ministries] even before any case was confirmed," she said. "The efforts have so far been highly coordinated, which is why we see the faster identification and ring fencing of close contacts of suspected cases."
The Singapore government says it has tested 665 people. Of these, 581 tested negative, 39 are awaiting results and the rest - 45 - were positive.
Teh said Hong Kong hospitals had already been struggling with the winter flu season before the spread of the coronavirus, which would further stretch health care institutions.
Leong, the infectious diseases expert, said the relatively low number of infections in Hong Kong was worrying, and showed the need for more testing.
Yeung expected cases of "silent carriers" to emerge in Hong Kong in the coming weeks, and that when this happened the city would overtake Singapore.
He said Hong Kong families were sending elderly parents and children abroad because they were afraid of the coronavirus spreading, and hoped the Lam administration would completely close the borders to stem the spread.
"At this stage, Singapore and Hong Kong have the luxury of trying to control the epidemic by identifying and quarantining," added Leong.
"If we don't do this aggressively now, once it goes out fully in public, we will have lost."
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This article was first published in the South China Morning Post.