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SINGAPORE was one of the first countries to report confirmed cases of COVID-19, on 23 January 2020. The Singaporean government’s model response to the COVID-19 outbreak successfully resulted in no evidence of community transmission by mid-February.
By 1 April, there were 1000 confirmed COVID-19 cases in Singapore, with small clusters reported in three dormitories of migrant workers. By 27 August, the number of COVID-19 cases in Singapore rose significantly to over 56 500, with 94.52% of these cases attributed to infections of migrant workers living in dormitories. According to Singapore’s Ministry of Health, there are 323 000 migrant workers living in dormitories, thus the prevalence of COVID-19 among this population is 16.55%. This is compared with a prevalence of 0.03% among the general Singaporean population, defined as the total population minus the number of migrant workers living in dormitories. This article provides an insight into factors, such as government policies, that may have contributed to the significant COVID-19 infection rates among migrant workers living in dormitories in Singapore.
Singapore’s migrant workers
Singapore has a population of 5.7 million people, which includes a migrant workforce of 1.4 million people, with almost 1 million migrant workers having a Work Permits. Work Permits are issued to low-skilled or unskilled migrant workers, mostly from Bangladesh, India, China and South-East Asia, who work in the domestic or construction sectors to be able to send money back to their families. They have been essential to the significant growth of Singapore in the past few decades by providing manual labour in the country’s construction industries.
Under the Employment of Foreign Manpower Act, migrant workers with Work Permits are ineligible for government health care subsidies, and employers are required to provide medical insurance of at least SGD$15 000 per year for each worker for any non-work-related inpatient care and day surgeries (here, and here). Employers are also required to provide accommodation for migrant workers, who mostly live in purpose-built dormitories, sharing rooms and bathroom facilities. As there is no minimum wage in Singapore, a migrant worker with a Work Permit may struggle financially, with substantial debt from visa-related agent fees in their home countries. They are also a vulnerable population who face multiple challenges, including language and cultural barriers, adverse working and living conditions, financial problems, and difficulties in accessing health care (here, and here). Many non-government organisations in Singapore provide subsidised medical services, legal aid, social work services and food support to migrant workers and advocacy for their rights.
Migrant health: Singapore’s response
Migrant populations are at increased risk of contracting infectious diseases due to travel, unfavourable working and living conditions, and difficulty in accessing health care services. The high number of COVID-19 cases among Singapore’s migrant workers highlights the vulnerabilities of migrants globally during this pandemic who are often excluded from their host country’s health programs, which may lead to delayed COVID-19 detection and care. This also increases the risk of outbreaks, as seen in the sudden surge of COVID-19 infections among migrant workers, which occurred after the peak of imported and community cases and could be attributed to Singapore’s initial policy response. This situation was further complicated by the restricted movement of doctors between workplaces in early February, which reduced the capacity of subsidised health clinics that migrant workers heavily relied upon for accessing outpatient health care not covered by their medical insurance. Subsequently, there were delays in COVID-19 testing, which was not free initially to migrant workers. Other measures such as the nationwide surgical mask distribution initially excluded dormitory residents, and the government’s 1 m safe distancing measures were unable to be followed by most migrant workers isolated in their overcrowded rooms.
In April, in accordance with the World Health Organization’s (WHO) recommendations, Singapore stepped up its detection, surveillance and management efforts in dormitories. The government mobilised medical and support teams, implemented thorough testing of symptomatic and asymptomatic residents, and enforced the isolation and monitoring of suspected and positive cases in designated facilities. Recommendations for occupational health and safety measures were implemented with the provision of sanitation products, increased waste removal and cleaning of dormitories, and through the protection of income, guaranteed by Singapore’s Ministry of Manpower.
Singapore had 27 deaths from COVID-19 by the end of August 2020, which equates to a 0.05% fatality rate. This low fatality rate could be attributed to these timely government efforts to enhance testing of dormitory residents and to the younger age of migrant workers who have recovered from COVID-19.
The COVID-19 pandemic is not the first infectious disease outbreak to disproportionately affect dormitory residents in Singapore, as there have been previous documented outbreaks of dengue, typhus and tuberculosis. To prevent future outbreaks among migrant workers, the Singaporean government should seek to reduce overcrowding in dormitories with further civil planning. The WHO advocates for governments to include and integrate migrant populations in their COVID-19 national emergency preparedness and response plans and into existing national health programs. Although this recommendation may have been overlooked initially, the Singaporean government should continue to implement inclusive response plans and health care to protect their whole population during the COVID-19 pandemic and beyond.
Conclusion
Migrants are a vulnerable population and are at increased risk of contracting infectious diseases, such as COVID-19. They also have more adverse health outcomes compared with the general population of their host country. Therefore, migrant populations should be included in their host countries’ government policies, national health care programs, and emergency response plans in accordance with WHO’s recommendations. The COVID-19 outbreak among Singapore’s migrant workers living in dormitories highlights these vulnerabilities and the factors that will need to be addressed going forward, not only during pandemics but also for the long term.
Melinda Sun is a 4th year medical student currently studying at Bond University on the Gold Coast.
Janie Dade Smith is Professor of Innovations in Medical Education at Bond University on the Gold Coast.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.