News analysis

The cautious, uneasy easing of Covid-19 restrictions

As more countries relax their lockdown measures, the pressure mounts on others to follow suit as their citizens grumble and businesses suffer, but experts caution that a hasty approach may lead to waves of new infections

Globally, more than 100,000 new Covid-19 infections were reported in just 24 hours on Wednesday, according to the World Health Organisation (WHO). More than 5.1 million people worldwide have been infected.

Yet there are moves around the world to ease lockdown restrictions, allow businesses to resume and for life to return to normal.

After weeks of being confined to their homes, with businesses and livelihoods affected, it is hardly surprising that most people are keen to return to life as it was before Covid-19.

They cannot bear the thought of being cooped up indoors until a viable vaccine becomes available - which experts say is unlikely to happen until next year.

Italy, one of the worst-hit countries in the world with more than 227,000 people infected and more than 32,000 deaths, has already started easing its strict lockdown.

It is opening shops and restaurants - with certain precautions. These include limiting the number of people in a shop and keeping clothes tried on by customers off the shelves for 24 hours. In restaurants, only family members may sit together at the same table.

Nearer to home, Vietnam, which has had fewer than 350 infections and no deaths, has allowed non-essential businesses to open. But it too has continued to take precautions, such as limiting the number of passengers on public transport and enforcing social distancing on beaches.

South Korea, which saw an early explosion of cases, has also been easing lockdown measures. In spite of a small outbreak linked to some clubs, the country said it will not re-impose a stringent lockdown if the number of new cases remains below 50 a day.

As more countries relax their lockdown measures, the pressure mounts on others to follow suit as their citizens grumble and businesses suffer. No country wants to be left behind economically.

Singapore, too, plans to further ease circuit breaker curbs next month, and has started testing pre-school teachers for the infection as a precaution.

Here, restrictions will be eased in three phases - months apart - causing some unhappiness among those who will still not be allowed to restart their businesses or resume the lifestyle they crave.


People getting their hair cut at an express salon in Waterway Point, in Punggol, yesterday. ST PHOTO: KEVIN LIM

The new normal will not be like the old one. Some measures, such as wearing a mask when in public and social distancing, will remain in force for a very long time.

WHY EASE NOW?

If anything, the more pertinent question is why some countries are starting to relax the strict - and effective - measures that they had implemented only recently, at a time when the infection is still spreading fairly rapidly across the world.

Each country has its own reasons but, broadly speaking, it is because:

  • These countries have brought the spread within their borders down to what they consider an acceptable level;
  • The cost to the economy of continued lockdown is higher than most are willing to bear;
  • The cost to people in terms of mental, social and physical isolation could have long-term repercussions.

Another factor is that much more is now known about the disease which appears likely to become endemic.

 
 

When countries went into lockdown - starting with China's Hubei province in January - the spread of the infection was increasing exponentially within their borders in spite of travel restrictions.

Many healthcare systems were overwhelmed. In some countries, hospitals ran out of beds; there was not enough personal protective gear for healthcare workers and not enough ventilators for patients.

Today, while the pandemic is still raging globally, the healthcare systems in the countries opening up are better able to cope with new Covid-19 patients, giving them the best chance at life.


A waiter in a mask serving diners at a reopened restaurant yesterday on the waterfront in Naples, as Italy eased some of the lockdown measures put in place during the coronavirus outbreak. PHOTO: REUTERS

While there is no clear treatment or cure, some drugs like remdesivir which was developed to treat hepatitis C, have been shown to reduce the period of illness.

It is also clear now that age plays a major part in determining how seriously one falls ill and whether one lives or dies. Most countries opening up are trying to protect seniors.

This is harder to do in Asia, where extended families live together and younger members can infect older ones.

So countries must open up differently, depending on their cultural and social patterns.

HOW MUCH TO EASE?

Professor Euston Quah, head of economics at the Nanyang Technological University, suggested a simple way to figure out which activities should be eased and by how much - see which areas of the economy are suffering the most.

Compare that cost of lost income, business closures and job losses against the cost of a second wave of infections and the toll it would take in terms of medical costs, suffering and deaths.

"As long as the cost of the former is greater than the latter, it makes sense to ease more, but not otherwise," he said.

In the case of Singapore, Prof Quah would personally like to see most activities resumed - except those with large crowds including parties or clubbing. To him, education remains a challenge as it brings together a large number of people, but he added: "Having all classes online and through webinars and other platforms to me is not effective learning."

RISKS ABOUND

Professor Alex Cook of the National University of Singapore's Saw Swee Hock School of Public Health has warned that countries must be prepared to re-institute measures should the number of infections rise exponentially following an easing of measures.

Since people may be infected without symptoms and still pass the disease on to others, there is a high chance of rising infections once countries relax their restrictions.

Experts globally are predicting multiple waves of infections as countries ease their measures.

 
 
 
 

Said Prof Cook: "If we went back to life as normal in June, I'm pretty sure the cases would start popping up. Phase one (of Singapore's cautious reopening) is designed to limit this risk."

The fear is that people will get overconfident or suffer from control fatigue and start taking risks.

"If enough people do this, then contact tracing might not be enough of a brake to stop the epidemic growing.

"The lower the number of cases, the more attention each case can be given, and the reduced risk of transmission each case has. Let it grow and it becomes harder to stop growth," he said.

The black swan, said Prof Cook, is infection in a new group of closely connected people - and the epidemic balloons, like it did among the foreign workers.

The group could be servicemen, prisoners, students in a school or seniors in elderly daycare centres. If that happens, "the spread could be rapid and the impact horrendous", he said.


Boats carrying Vietnamese tourists in Ha Long Bay, in Quang Ninh province, on Tuesday after the government eased a lockdown to curb the coronavirus outbreak. PHOTO: REUTERS

This is a possibility since the vast majority of people in the community remain susceptible.

Britain, with more than 248,000 cases, giving it an infection rate of 3,660 per million population, found that fewer than 1 per cent of people in the community had been infected but undiagnosed, according to an article published in the British Medical Journal on Monday.

This is far lower than the 4 to 5 per cent of the community in Spain and France unknowingly infected. Even there, 95 per cent of the population remains at risk.

 

So the major consideration for countries in deciding what measures to relax and how fast this should be done must be focused on keeping new infections down - and preventing healthcare systems from being overwhelmed as that could result in needless deaths - to delay the second wave for as long as possible.

Countries should not bow before pressure to ease measures too rapidly. This could undo the achievements of months of lockdown.

There must be precautions in place to reduce the spread of the virus such as using the self-disinfecting coating on more high-touch surfaces, keeping the number of people sharing public transport low (according to the Google mobility report, there has been a 64 per cent drop in people at bus and MRT stations), no large gatherings, continued use of masks, social distancing and frequent cleaning of hands.

The number of infections in Singapore - aside from the high numbers that still emerge daily from the foreign worker dormitories - has been brought down to low numbers daily.

Singaporeans will be able to enjoy greater freedom if the population continues to stay vigilant, maintain social distancing and keep infection levels under control.

MORTALITY FACTOR

Meanwhile, the calibrated moves over the past few months - isolating returning citizens and workers, ringfencing foreign workers living in dormitories and setting up parallel healthcare facilities for them, and imposing circuit breaker measures on April 7 - have one primary objective: to make sure that Singapore's healthcare system is able to cope so that every patient gets the best chance of surviving.

This, in turn, has kept the mortality rate remarkably low, compared with the global average.

 

Even if the 27,000 dormitory cases were excluded because those infected were generally younger and healthier; and only the slightly more than 2,200 community and imported cases are counted, the 23 deaths would constitute about 1 per cent of those infected - far lower than the 6.5 per cent globally.

Sweden, which imposed minimal restrictions, has had more than 3,800 deaths out of over 31,500 cases - or a mortality rate of more than 12 per cent.

Some people say the Swedish infection figures should be higher as it does not test as rigorously as most other countries.


Workers disinfecting the premises and placing stickers on seats to ensure safe distancing at the Mapo Art Centre in Seoul yesterday, ahead of its reopening on Monday. PHOTO: EPA-EFE

So let us look instead at deaths per million population. In Sweden, it is 380 per million population. In Singapore, it is four.

It is higher in countries like Spain, Italy and Britain where the sudden surge had overwhelmed their healthcare systems, resulting in less than ideal medical care for patients.

Rushing to revert to life as normal could change those figures here. Easing measures slowly, a step at a time, will be in everyone's interest.

 
 
 

And the first step is to relax certain activities within the country, but not to open up for travel, given the more than 100,000 daily new cases reported to the WHO.

When travel restrictions are eased, they should be with places that have Covid-19 well controlled. Among those in the region, they would include places like Vietnam, Cambodia, Thailand, Taiwan, Hong Kong and Australia.

The question is: Will these places allow travel with Singapore, which is still reporting hundreds of new cases a day.

No one needs to be reminded that it was international travel that spread Covid-19 in the first place.

So for the time being, holidays must stay on the backburner and the tourism sector may need to continue to bleed for a while longer.

But it is better to endure short-term pain for long-term gain.

If all restrictions were simply lifted, Prof Cook said there will not just be a second, but even third or fourth wave "that would be much worse than what we've seen to date".

 
A version of this article appeared in the print edition of The Straits Times on May 22, 2020, with the headline 'The cautious, uneasy easing of restrictions'. Print Edition | Subscribe