The 2003 epidemic Severe Acute Respiratory Syndrome (SARS) tested the ability of several states in East Asia to keep it under control; this essay chronicles the steps taken by the Singapore government. Once the epidemic broke through confinement in hospitals into the community at large, efforts to keep it under control became discursively a “war against SARS”; epidemic is a “disease” that invades potentially all the bodies of the entire nation and the state is the only organization that is capable of defeating it. Strategically, the government placed exposed individuals under strict quarantine and introduced new regulations for personal hygiene for all. The public had to be mobilized to assist in tracing the exposed, help the quarantined, and to observe the personal hygiene procedures voluntarily. Success of the government's strategies was absolutely dependent on the voluntrism of the entire population. In this sense, during its course, the epidemic produced a “national” community that the long-ruling single-party state government had been skeptical to affirm. The end of the epidemic became a moment of affirmation of the nation as community.
The 2003 global epidemic of Severe Acute Respiratory Syndrome (SARS) was an unplanned occurrence, an accident. The time and place of its initiation and thus first target, denoted the “index” case, could not be fixed with accuracy, but was perhaps, sometime in November somewhere in southern rural China. The first victim of the disease, its random target, was innocent of intention to cause harm to others. This victim in turn inducted randomly unknown and unwilling individuals as co-victims, who then doubled as agents of infection in chains of expanding contamination; its human targets were thus diffused and random, a chaotic order, potentially unlimited. Everybody was at risk. Although the epidemic was global in its reach, it was particularly devastating in East Asia, where it originated. Among the countries most invaded by the disease was Singapore. I will argue in this essay that amid the devastation of the economy and loss of lives, ironically, the SARS epidemic may be said to be a “crisis that the single-party dominant government in Singapore has been waiting for,” but first, a brief account of the epidemic.
SARS – Epidemiology
According to the World Health Organization, SARS is the first seriously transmissible new disease to emerge in the twenty-first century (WHO 2003). The outbreak of SARS – as an atypical severe pneumonia – was subsequently identified as having begun in Foshan City, Guangdong Province, southern People's Republic of China (PRC), sometime in November 2002. This was not reported until early February 2003 after more than 100 people had died from a “strange contagious disease.” It was not until mid-April that the PRC government finally agreed to deal with the disease in an open manner. Meanwhile, a PRC doctor who was visiting Hong Kong checked into the Metropole Hotel, Waterloo Street, on February 21, 2003. The next day he was hospitalized and later died in the Prince of Wales Hospital (PWH) with “atypical pneumonia”; ignorance at the time led to an outbreak of contagion among the hospital staff, making the hospital the first site of epidemic. Three Singaporean women who were vacationing in Hong Kong stayed on the same floor and used the same hotel elevator as the doctor before he was hospitalized. Upon their return to Singapore, all three fell ill with the same “atypical pneumonia.” The doctor had similarly infected others from elsewhere in the world, such as Toronto (Canada) and Vietnam. In retrospective construction, the doctor who died in PWH was the index case who brought the epidemic outside the PRC. Each of the individuals infected in Hong Kong was to carry the disease to his or her respective cities. Attesting to the greatly enhanced multidimensional global integration, the epidemic was brought under control in a short three months after the outbreak. In all, at the end of July 31, 2003, 8,009 individuals were infected in seven sites (in descending order of cases PRC, Hong Kong, Taiwan, Canada, Singapore, Vietnam, and United States).1 The speed with which the epidemic was brought under control and the relatively small number of infected individuals may be said to be miraculous, when compared with pandemics of the past such as the Spanish flu which killed millions worldwide in one year, 1918–1919 (Hung 2004).
As mentioned above, the epidemic was brought to Singapore by three women vacationing in Hong Kong who fell ill upon returning home. Two recovered quickly. The third, Esther Mok (real name), was to be the index carrier of the epidemic to the island. She infected several members of her immediate family – father, mother, grandmother, uncle, and a pastor who visited her. In addition, she also infected other patients who shared the same ward with her, before her isolation: “In the same ward was a middle-aged woman, Madam P, who would later spark a mini-outbreak at the cardiac ICU (Intensive Care Unit); Madam L who later passed the virus to her friend, visitor Mrs Gladys Lim; and Miss A, a nurse who had tended to Miss Mok's mother and fallen ill. Miss A, in turn, passed the virus to another cluster of patients, healthcare workers and visitors at the TTSH (Tan Tock Seng Hospital)” (Chua 2004: 28). From the day of admission to the TTSH, on March 1, till her isolation in the hospital on March 6, she had infected a total of twenty-two people. All her infected relatives perished; Mok alone recovered.
In the same ward as Miss Mok was Mr K.C. Tan, who suffered from chronic kidney disease and diabetes. After a fifteen-day stay at the TTSH, he was discharged but was back in the Singapore General Hospital (SGH) after a few days. In spite of having developed a fever beyond 38 degrees celsius, he was treated in an open ward (from March 24 till April 2), until it was discovered “that he had been warded in TTSH's ‘hot ward’, the Sars-infected Ward 5A” (Chua 2004: 57). He was then isolated. By then (April 5) he had already infected healthcare workers who attended to him and those who carried out diagnostic tests on him in different parts of the SGH. The healthcare workers passed the virus on to others and the number of healthcare workers affected began to rise very rapidly. All the patients and healthcare workers of the two affected wards were moved to and isolated in TTSH. The areas where Mr Tan had been treated had to be closed also, such as the Urology Centre, diagnostic radiation centre, and National Cancer Centre, because of mini-outbreaks in these areas. “In all, 62 people were linked to the outbreak – 25 healthcare workers, 20 patients and 17 family and social contacts” (Chua 2004: 57).
One of Mr Tan's visitors at the SGH was his brother, who subsequently fell ill and was hospitalized at the National University Hospital, where he was treated for heart failure and placed in a general ward. He died within a week. By then, “he had infected two taxi-drivers as well as three co-workers at the wholesale centre, and two family members, three healthcare workers, four fellow patients and a visitor to the ward” (Chua 2004: 60). The infection of the taxi-drivers, one of whom died, and the co-workers at the Pasir Panjang Wholesale Centre (PPWC) were the first instances when the epidemic broke out of hospitals into the community.
The PPWC, as the Minister of Health pointed out, “is a huge monster of a place with thousands of stallholders, all kinds of people visiting, branching out to the retail markets. You can't think of a scarier way for [SARS] to transmit to the community” (quoted in Chua 2004: 73). The PPWC was closed and the arriving vegetable vendors and all workers sent home, before they were registered in any way. This proved to be a costly mistake because it was immediately realized that each one of them would have to be traced, kept under observation, and quarantined if there were any signs of infection. The vast number of people who had to be contacted was beyond the capacity of the epidemiological medical staff. The idea that everybody was at risk materialized instantly. As shown below, a whole new strategy for tracing potential carriers of the virus was necessary, one that would comprehensively cover the entire social body and space. A new logic of social surveillance was needed and had to be devised.
The breakout at PPWC was the last, with only five infected. This was followed by two instances of false alarms, which delayed the lifting of Singapore from the WHO's list of SARS-infected areas. By May 30, Singapore was removed from the list; by then, only five SARS patients were in wards and four in intensive care. No more deaths were reported. The last patient left TTSH on July 13. Three days later, the government declared that SARS had been “eradicated.” The total count was 238 infected and 33 dead.2
Disease and Personal Responsibility
As the epidemiological history shows, three unwitting Singaporean tourists were infected in an elevator. What was to be pleasurable turned into a nightmare, with one of them transmitting and causing the deaths of several of her close relatives, and further having to suffer the ignominy of being the “index” case for the entire nation. They, like all victims of SARS, were innocent of intentions to spread the disease. This was consistent with the conventional general understanding that infection by a virus is involuntary on the part of its victims.
It should be noted that this conventional understanding has always been qualified by sexually transmitted diseases. For example, in the case of HIV/AIDS transmission, which is facilitated by blood of a victim, subsequent victims of the disease must come into direct contact with an infected individual, normally through sexual activities; an additional mode of transmission is needle sharing in drug injections. Consequently, with the exceptions of those who were infected by blood transfusions for medical reasons, all the other modes of transmission of HIV/AIDS imply that its victims are and be held responsible for their own infection, rather than being involuntary-thus-innocent. A discursive space for moralizing against those infected with HIV/AIDS – indeed, those infected with all sexually transmitted diseases – is thus made available. Into this discursive space may be inserted, for example, what has come to be known as “faith-based” programs in the dispensation of financial aid for HIV/AIDS prevention. Promoted by the Christian right in the US, such “faith-based” programs exploit the dire needs of the prevention initiatives and impose their ideological and sexual preferences, thus hiding moralizing against sex outside of marriage, including abstinence for premarital individuals, behind the prevention of the spread of sexually transmitted diseases. Against this morally qualified understanding of epidemic infection, SARS remains “old-fashioned”: it spreads “through the liquid in the nasal passage and saliva” (Cheng 2004: 77). Hence, involuntary contraction absolves its victims of self-responsibility.3
Nevertheless, once infected, a victim of the disease is immediately transformed into a “carrier” of the epidemic; one's status shifts from involuntary innocent victim to one laden with the responsibility not to contaminate others, not to become the source of a new chain of the epidemic's spread. It requires one to contribute to the eventual containment of the epidemic by checking oneself into the isolation wards of the hospital, an institution of both cure and imprisonment. The new “infected” status thus requires a self-knowing victim to act responsibly for the greater social good. If this new responsibility is not taken on voluntarily, then “society” has the right to impose such responsibility coercively on the already infected and isolate them, in the interest of the body social.
The not-infected-but-always-potentially-at-risk in the population are not completely without social responsibilities. They must avoid unnecessary exposure to risk of contagion. They must voluntarily reduce unnecessary movements away from the security of the home and to maintain an enhanced level of personal hygiene. For both, behavioral changes in the routines of daily life are required; such as, increased frequency of hand washing and taking one's own body temperature to establish that there is no infection. Beyond the self-examinations, prevention of contagion requires the managers of sizable establishments, such as shopping complexes, schools, or large office buildings, to enforce temperature checks on everyone who crosses their thresholds. As a result, everyone ends up “suffering” several temperature checks a day in the mere carrying out of the routines of daily life. Finally, these practices to avoid contagion, which themselves constantly remind one of the danger of impending infection, inevitably become sources of heightened anxiety and fear. Indeed, during the SARS epidemic, all the voluntary and enforced self-examinations in the face of a little known pestilence caused many people to suffer “panic” and experience “the psychological effects of the disease” (Cheng 2004: 77).
An epidemic, such as SARS, thus divides the population into the already infected and the yet-to-be infected. It assigns to each group new social responsibilities. It places the yet-to-be infected, the overwhelming majority of the entire social body, in a liminal state between a clean bill of health and potential “exposure” to those who, unbeknown to themselves, are already carriers of the disease. A state in which, having come into contact with victims of the disease, one might be infected but not yet aware of it and thus contagious to others. The temperature taking was therefore more accurately a process of self-discovery rather than prevention of infection. Once one's temperature surpassed the dreaded 38 degrees celsius, one would then be obliged to assume the infected person's role and the responsibilities of the “carrier.” The SARS epidemic thus demanded all residents of an infected location assume new responsibilities of self-discipline through a series of new mundane practices under a heightened sense of hygiene. Private interest in avoiding contagion is, therefore, solicited publicly and transformed into enhanced social responsibilities.
Militarization of the Infected Space
In spite of all the additional responsibilities and behavioral practices no one can be certain of having been “exposed” to SARS infection. Knowledge of exposure can only be gained by tracing backward the whereabouts of the already infected. All those who were co-present along the same route and at the same sites had to be deemed “exposed” and potentially already infected, as the three Singaporean women victims sharing the same elevator in the same hotel as the first infected man from the PRC. The means and medium by which SARS spread is therefore through the infection of a “space,” leaving the virus in the spaces in which an infected victim had previously occupied. Contraction of the disease is thus spatially mediated, without requiring direct personal contact with the infected.
In efforts to contain the spread of the epidemic, tracing all the exposed individuals is technically the most daunting and labor-intensive task. In the face of an epidemic that places everyone at risk, the state is the only organized body that is up to the task of tracing the exposed. It is also the only social institution that is politically empowered to enact new laws to enforce and police the infected social spaces and take subsequent actions against the exposed/infected. In sum, the enhanced policing of the entire social, spatial, and physical body was “naturalized” not only by the epidemic but also by the self-interest of individual residents and the society. This “naturalization” of the state's policing function is augmented when it is positively translated as the state's “responsibility to protect” the security of citizens from all forms of attack, including diseases and epidemics. Discursively, disease can be metaphorically rendered as an “enemy” and the afflicted body as a “battleground” in which the body tries to “defeat” the enemy in order to recover lost ground (health). In the same vein, an epidemic is, of course, akin to “biological warfare.”4 It is thus a battleground writ large, and a full-scale “war” should be immediately declared on the infection. The “need” of citizens and the “responsibility” of the state dovetail, apparently, seamlessly and the “militarization” of the infected space is engaged.
In Singapore, in the early stages of the epidemic “contact-tracing” was managed by the epidemiological personnel at the TTSH.5 However, as mentioned earlier, once the epidemic spread into the community then a new logic and regime of social surveillance was implemented, in which the idiom of war was explicitly deployed. The ease with which such military vocabulary was pressed into service in the containment of SARS was immediately obvious in the words of the director of the Intensive Care Unit at TTHS, Dr Desmond Tai, when his wife wanted him to quit his job at the height of the epidemic, he retorted: “It's like a soldier going to war. If a war broke out, you cannot just take off the uniform and say, “I don't want to be a soldier”. Or just like the World Trade Center, when terrorists attacked, the fireman cannot say, “I refuse to go in and fight the fire'” (quoted in Chua 2004: 39). Comparing SARS with the September 11, 2001 bombing of the World Trade Center seemed to come “naturally”; the Deputy Prime Minister, Tony Tan, calls the epidemic “Singapore's September 11” (Chua 2004: 197). During the SARS epidemic, therefore, media-mediated tropes ranged from a minimalist mode of “fight against SARS,”6 to the other extreme, headlined in the daily newspaper, “War against SARS” or a “SARS War.” Post-epidemic, presumably in more reflective mood, the documentation and memorialization of the event continues the war vocabulary; a book entitled The Silent War: 1 March to 31 May 2003 (Ng 2004) was produced by the TTSH, the hospital designated as the SARS treatment center. In this book, under the auspices of the “Silent War,” the vocabulary of war was sprinkled throughout the text, especially in the opening and closing of each chapter. It would not be excessive to suggest that the author appears to have derived some significant pleasure from the evocation of war vocabulary and imagery.
Significantly, in Singapore's national effort to contain the epidemic, the language of war was not merely metaphorical but also practical and technical, unlike in other affected countries in the rest of East Asia. As we have noted, as the only organized body capable of policing the entire social body and space, it was the logistical and tactical role of the state that was of crucial significance in the “fight” with SARS, not the medical services of its hospitals. This policing function of the state first penetrated deep into the medicalized space of the hospital: a tight control system was necessary within the hospital to prevent the spread of infection to other patients and medical staff and to prevent misdiagnosing infected individuals and setting them free into the community. In the words of the Minister of Health, Lim Hng Kiang, an ex-brigadier general familiar with military procedures, “In the army, we call it battle discipline. I don't need generals, I told the hospitals, I need RSMs [regimental sergeant-major]” to maintain discipline among medical staff in observation of infection-control measures (quoted in Chua 2004: 65).
Outside the hospital, what was of utmost strategic importance was coordination and execution of all the processes that culminate in the hospitalization of the infected. Of these, the most important and difficult task was the tracing of individuals that had inadvertently come into contact with those affected. “Contact-tracing” and ensuring the subsequent quarantine of the “exposed” to prevent further spread of the epidemic in the community became the pressing problem, which required precise logistical coordination across different government agencies. The epidemiological staff at hospitals was stretched but nevertheless able to cope with contact-tracing work when the infection was confined to medical staff, hospitalized patients, and their visitors. Unfortunately, it was the failure of the contact-tracing of the (SGH) staff that led to the breakout into the community; the man who spread the virus at the PPWC had visited his SARS-infected brother at the SGH, before the latter died of the disease. Once the epidemic spread into the community, through the outbreak in the PPWC, the scale of work exceeded the capacity of hospital personnel, and other governmental agencies with grassroots presence were roped in to help in the contact-tracing work. In the end, the military, trained to execute precise logistic activities, were called in.
The job was given to a brigadier general, Neo Kian Hong (see Chua 2004: 77–79).7 As the most important piece of equipment necessary for speedy and successful contact-tracing was a reliable database drawn from different and seemingly disparate sources, the epidemic, a medical problem, was transformed into a problem of information technology. The Defense Science and Technology Agency (DSTA), the national authority of defense technology and weapons acquisition, was given the task of setting up an IT system within a National Contact-Tracing Centre. Beginning with the names of patients and visitors, their addresses could be found in the National Registration Office, and their telephone numbers traced through the different telephone companies and other sources; the data – addresses, telephone numbers, and records of hospital workers – from these sources needed to be linked up to a computer-based information infrastructure that would enable speedy contact-tracing, issue home quarantine orders, and prevent those possibly affected from leaving the country, to avoid the spread of the epidemic internationally. With the IT system in place, the volume of people that had to be traced due to the breakout in the community was managed: the Ministry of Health would pass the names of people to be traced and issued with home quarantine orders (HQOs), these names would be fed into the system, which would provide personal details of those named, and home quarantine orders would be immediately communicated.8
According to Chua's reconstruction of the events (2004: 81), even before the military was called in, the 2,400 workers at the PPWC were already contacted and about half were issued home quarantine orders within two to three days of the closure of the center; the massive task was carried out by the volunteers and staff of the People's Association (PA), a government-sponsored community-based agency with branches in all the residential estates throughout the island. It would appear that the IT system was in place at the tail end of the epidemic (Chua 2004: 196), and it remains unclear how many of the nearly 6,000 quarantined during the three-month period of the epidemic were contact-traced by the high-tech system. However, its efficacy was to be tested again months after the military personnel had left their posts in the medical emergency: “The systems helped ensure quick contact-tracing when a researcher tested positive for SARS in September, 2003” (Chua 2004: 79).
Quarantine: Logic of a Total Surveillance
Central to the containment of contagion of an epidemic is the speedy isolation of not only those who are already stricken by the virus but also, even more importantly, those who might already be infected but who have yet to develop the observable symptoms of infection. The latter group has to be identified quickly and placed under quarantine. In the case of SARS, the traced-exposed were placed under home quarantine for the disease's incubation period of ten days. In Singapore, the total number of people quarantined during the epidemic was 5,798, a small number relative to the 4 million residents of the city state. However, the logic behind the entire process of containing the epidemic was one of total surveillance.
From the exhortation to wash hands frequently, to the voluntary and imposed repetitive temperature taking, to registering one's presence in all public places, from taxi rides to restaurants, to observing home quarantine if ordered to do so by the Ministry of Health, a web of surveillance was put in place by the state. Different modes of encouraging self-monitoring were devised. School children learned ditties about hand washing. Thermometers were issued to students, teachers, and army personnel, so that they could check their own temperature. Thermometers and face-masks were to be sent to all households – consequently, many households ended up with more than one thermometer. There were suggestions that even the thermometer should be individualized as an additional measure to prevent infection. Television incessantly broadcast advertisements for observing hygiene. The competing television stations jointly set up an additional, exclusive SARS channel, which broadcast television actors doing their bit to encourage self-monitoring. A hip-hop song was commissioned by the Ministry of Community Development and Sports, “SARS Rap,” performed by the local well-known comedian, Gurmit Singh, with instructions of what to do and what to avoid. Popular culture, including the officially proscribed Singlish (the colloquial name for English as spoken in Singapore), was pressed into service.
As not everyone could be trusted to take on voluntarily the new responsibilities of self-policing without skepticism and resistance, organized efforts to enforce the new responsibilities were necessary. New modes of surveillance were introduced and new laws enacted to control and punish those who were recalcitrant in disregarding the new restraints on their everyday behavior, especially home quarantine. Violations of individual privacy and rights were justified in terms of the public good and the state's “responsibility to protect” the security of individual citizens against the epidemic; “authorities needed to know each and every person who comes into contact with a SARS patient. These contacts had to be isolated or quarantined until the incubation period was over and it was known for sure that they were not sick” (Chua 2004: 124).
Again, not all those served with home quarantine orders accepted the self-isolation without resistance. In the course of the epidemic, policing of the quarantined progressively intensified. Initially, only the Health Promotion Board personnel would telephone the quarantined to check that they were indeed at home. Subsequently, uniformed security guards were used to issue the quarantine orders and also to make the checking calls. Eventually, a “video surveillance camera system” was installed in the homes of all those who were quarantined. When a civil defense officer telephoned the home, the quarantined individual would have to appear in front of the camera and switch it on to verify that he/she was indeed at home. If this were not deterrent enough, an electronic tag would be installed on the body of the quarantined to monitor all movements. Finally, if all the home quarantine measures and devices failed, incarceration followed. In addition, those who broke quarantine were brought to criminal court, fined, and imprisoned according to the provisions of the Infectious Disease Act, which was amended to increase the mandatory punishment of imprisonment and fines.
These measures were taken with the full awareness of their intrusiveness into the lives of the residents of Singapore:
Asked if these [concerns about the impact of video cameras on civil liberties] featured in ministerial meetings, Mr Wong [Minister of Home Affairs] said: “We discussed them. We said: “What is more important? Public health, the safety of all Singaporeans or just some of these concerns about lack of freedom, liberty, etc. when you quarantine a person?'” He added with a laugh: “You better quarantine him. Otherwise, he'll get more freedom after that but he may be dead. Or he's infecting other people and causing them great disasters.” (Chua 2004: 137)
The end result was, according to the BBC, that Singapore had the toughest anti-SARS measures. Being the “toughest” was a badge of pride for a government that has been pervasively interventionist in every aspect of citizens” lives for the past forty years of its undisrupted hold on governing power. The People's Action Party (PAP) government has always insisted that it is willing to make “tough but unpopular” decisions, as long as the outcome is desirable. It believes that the outcome will justify and rationalize its decisions. This determination to put aside questions of the rights and civil liberties of those it governs has given the single-party government its reputation of being an authoritarian regime, a criticism that does not apparently cause it much discomfort. The political attitude of the long-running party regime of being result-oriented rather than popular was thus reinscribed once again on the social body via the epidemic.
A Mobilized Society
However, as then Deputy Prime Minister, Lee Hsien Loong noted during the epidemic: “[Society] is the most critical battlefront. If we lose this front, we will lose all the other fronts, and lose the war” (quoted in Chua 2004: 110). And the Prime Minister exhorted all Singaporeans to exercise social responsibility, to monitor their temperatures daily, to “see a doctor and not venture into crowded places if they felt unwell” and to stay home if quarantined (Chua 2004: 110). In the end, it was this “set of stringent and traditional control measures – hand washing, temperature taking, isolation, contact-tracing, quarantine, and travel restrictions – that beat the disease; it was beaten by “social, not medical protocols”(Lee 2004: 6), as a cure for the viral infection has yet to be found.
As the agencies of the state had limited capacity in monitoring the entire social body and social spaces, voluntarism from all, not only to observe but also to help to execute the imposed measures, was absolutely essential to implement those measures throughout the entire social space. On the other hand, the citizens in self-interested avoidance of infection and in the absence of individual efficacy to deal with the epidemic had severely reduced responsibilities in the battle against the disease: to obey and behave according to the dictates of the state, for their own good and that of everyone. For example, as mentioned earlier, temperature-taking exercises had to be imposed by the management on all those who entered public buildings and the latter had to be willing to comply with the intrusive jabbing of the electronic thermometer in the ear or heat sensor on the forehead. At the home front, children were mobilized to “educate” their parents regarding the need for daily temperature taking:
213 nurses and dental therapists visited 971 kindergartens and childcare centres to brief 7,585 teachers, coordinators and childcare assistants on temperature-taking and infection-control measures such as hand hygiene. The 360 schools and 25,000 teachers under the Education Ministry did their bit by spreading the message to the 500,000 students under their charge.
Within days, even seven-year-old Primary One pupils were diligently recording their temperatures using oral digital therm-ometers … In fact, pupils become educators, bringing back the messages of hygiene and temperature-taking to their parents at home. Pupils singing jingles – complete with hand gestures – to remind parents of the correct way of washing their hands were a common sight in homes across the island.” (Chua 2004: 130)
The unintended infantilization of the adults/parents was in full accord with the sharply reduced responsibilities of everyone, adult and child alike, to obey and execute the infection-prevention measures voluntarily as an additional element in the “technologies of the self” as a responsible citizen.
Such voluntarism was multiplied in many other areas of routine life. Nothing could be taken for granted. The taken-for-granted must be broken and transformed into a new horizon of concerns and attentions. For example, the closing down of schools disrupted the daily lives of the students and their families, which could translate into preventing at least one of the parents from going to work, thus disrupting the routines of workplaces. Alternative child-minding arrangements therefore needed to be made and where individuals were unable to find immediate assistance on their own, existing institutions, such as trade-union-ran childcare centers, had to be roped in to take on additional charges. Another example, those who were quarantined had food delivered to them routinely by others, such as members of the family, neighbors, church members, and friends. Where none of these individuals were available, voluntary social workers and officers of paragovernmental agencies, such as the Community Development Councils, had to be deployed.
The most important sector of the mobilized society was undoubtedly the medical workers. The hospitals, especially TTSH, were the centers of contagion and everyone was potentially exposed. Indeed, as we saw above, doctors and nurses were among the early victims of the virus. All hospital workers, from medical staff to cleaners, were therefore keenly aware of the threats to their lives. It is significant to note that among the hospital staff were many foreign workers; every one in three nurses at TTSH – or 430 out of 1,500 nursing staff – is a foreigner, from countries like China, India, Malaysia and the Philippines. As testimony to their professionalism, “no one was known to resign because of SARS” (Chua 2004: 47); some willingly volunteered to work at the SARS intensive care wards.
The mobilized society was driven by a combination of a high degree of professionalism, voluntarism, self-interest, and a lack of self-efficacy in the face of a problem that required collective solutions. These are the fundamental ingredient sentiments for the formation of an active civil society. One could say that during the SARS epidemic, Singapore showed an instance of a mobilized civil society. However, it should be noted that it was a mobilization of the society initiated and managed from the top, with a clear line of command and obedience, much like a battle; the government provided the leadership and the society abided by its instructions. It was collaboration in consensus between leadership and the led, the way the PAP government would like to envisage the organization of state–society relations.
A Comparative Frame
The efficacy of the PAP government in getting things done is legendary. This is its claim to longevity in political power and legitimacy to rule. While the government's single-mindedness, decisive leadership, and the cooperation and coordination of its ministries and state agencies in the execution of a plan might be something new and to marvel at for outsiders, like the WHO observers during the epidemic, it is totally expected, even taken for granted, by Singaporeans themselves. This characteristic leadership style was brought into relief when placed in comparative perspective with events in other SARS-affected sites. Here, Hong Kong is a useful comparative reference.9
In Hong Kong, when the epidemic started in the Prince of Wales Hospital, the teaching hospital of the Chinese University of Hong Kong, where the infected doctor from Guangzhou was hospitalized on February 21. Within ten days, thirty-three people, including doctors and medical students, at the PWH were infected. The dean of the medical school then “pointed out that some of the SARS patients at PWH came from the community and openly warned that there could be a community outbreak” (Ma 2004: 101). This was denied by the Secretary of Health, Welfare and Food, Yeoh Eng-kiong, who “insisted that the spread was limited to medical staff and relatives of patients and that there were no signs that the disease was being spread to the community” (Ma 2004: 101). However, after that the infection rate reached twenty persons per day forcing the government to take stronger measures. Princess Margaret Hospital was then designated the SARS treatment hospital and all infected patients were transferred there.
Similarly, failure to act was found in the education sector. The government only agreed to shut down schools after the classrooms were already half empty, with parents keeping their children from school, and some principals had taken their own initiatives to shut down classes. The government agreed to close the schools and universities on March 29. At the same time, the virus broke out among the apartment dwellers in Amoy Gardens, a private housing complex, and other places. “Even then, quarantine measures were not imposed until after half of the residents had left the infected block – thus spreading the infection more widely” (Ku and Wang 2004: 124).10
As for quarantine, the bureaucracy, staffed by medical professionals from Secretary Yeoh to the top executives of the Hospital Authority, “objected to quarantine and home confinement measures in the beginning, because they believed that the scared patients and their relatives would refuse to be quarantined and would hide away”; however, “to their surprise, when they did carry out the quarantine – as in Singapore, those who came into contact with the patients were to quarantine themselves for ten days – the Hong Kong people were very cooperative and most did not resist the quarantine measures” (Ma 2004: 107). What we found in Hong Kong were summary judgements on where the government failed:
Overall, the SAR (Hong Kong Special Administrative Region) decision makers lacked a crisis mentality, and the SAR institutions were ill-prepared to tackle an infectious epidemic of such magnitude. The state institutions responsible for health care were also too fragmented, partly a result of recent public-sector reforms, which led to indecisive decision making during the crisis. The SAR executive, in particular CE (Chief Executive) Tung, was unable to demonstrate political leadership to mobilize community resources to transcend the institutional constraints. The result was a sluggish bureaucratic response that proved immensely costly for the Hong Kong SAR. (Ma 2004: 103–4).
It was a response filled with “clinical blunders, administrative flaws, and social injustices in the system that were also to blame for the outcomes that could have been avoided. (Ku and Wang 2004: 132)
Faced with lack of government leadership, civil society groups took initiatives of their own:
On March 31, some fifty Catholic, Protestant and Buddhist groups organized public prayers and called for community efforts to overcome the crisis … Some religious leaders urged the people to forget the government's faults for the time being and rally behind its emergency campaign … Then in the haze of fear and dreariness, the mass media found [reported] many doctors and nurses had been risking their lives, working around the clock under enormous stress, and isolating themselves from their families. Despite concern about insufficient protective gear and other supplies, they displayed calm, persistence and professionalism … During the outbreak, a few doctors and nurses sacrificed their lives. The community together mourned their deaths with love and tears, and their bodies were buried with the highest honors at Gallant Garden … Various other fundraising projects were launched by charity groups, media organizations, performing arts groups and the business sector … [finally] an emerging sense of civic responsibility found wider expression, in the ways people voluntarily took precautionary measures to protect both themselves and others. (Ku and Wang 2004: 131–132)
The society had mobilized itself, in purpose and solidarity, faced with the absence of political leadership. However, once the epidemic appeared to be overcome, “the government was quick to capitalize on such initiatives from the people and sought to regain credibility and play a leading role in the community … mobilized 30,000 civil servants and 10,000 volunteers to cleanse and disinfect all parts of the city … quickly prepared to build up the image of a hygienic city and revitalize the economy through further programs and measures. The ‘community' that was in the making began to slide into a different form” (Ku and Wang 2004: 133).
The picture of Hong Kong was almost diametrically opposite to that of Singapore, under the same epidemic. In contrast to Singapore's single-mindedness, decisive leadership, and unified ministries and state agencies in execution of all necessary steps toward the containment of the virus, each step of the way supported in both attitudes and actions by a mobilized society under firm leadership, one finds in Hong Kong a government in disarray, taking the lead from the initiatives of actors outside the government, leading to questions of its “competence” and “legitimacy” to govern; in the end it was only able to recuperate itself after the mobilized society had already built enough momentum to contain the epidemic.
A Nation Proclaimed
Singapore was removed from the WHO list of SARS-affected areas on May 30, 2003, three months from the admission of the first case to TTSH. The last patient left the hospital on July 13. SARS was proclaimed “eradicated” on July 16. On July 22, a commemorative ceremony to grieve for victims and to celebrate the end of the “SARS War” was held at the Botanic Gardens. An estimated 4,000 people turned up. During the ceremony, the Prime Minister gave thanks to all the healthcare workers (Straits Times, July 23, 2003): “We saw the courage in our doctors, nurses and other health-care professionals; in the attendants, security officers and cleaners in our hospitals”; obviously, “[t]hey were frightened. But they conquered their fear with courage. Courage in tending to an infected patient. Courage in taking respiratory fluid samples from the throat. Courage in cleaning the wards every night.” He further singled out the foreigners among them who “stood shoulder to shoulder with us” through the epidemic. The “courage” theme in the speech was a continuation of the Courage Fund for assistance to those infected by SARS, including families of the fallen healthcare workers.
During the epidemic, individuals at different levels of activities were oriented toward the matter at hand. Doctors and nurses tended to the infected; individuals took their own temperatures and washed their own hands; and other volunteers worked their designated tasks, without any being necessarily aware of the idea that they were, each and every one, contributing to the “crisis of a nation.” These daily acts have been retrospectively transformed and reassembled, after the epidemic, under different semiotic regimes, including the constellation of ideas under the sign of the “nation/national.” The professionalism of the hospital staff, from cleaners to doctors, was proclaimed as the mark of “national” heroes. To allow for gender difference, they were transformed into “heroes and angels” in the song penned in tribute to healthcare workers in the middle of the epidemic.11 The behavior of residents, citizens, and non-citizens alike in maintaining personal hygiene, largely motivated by self-interest in avoiding infection, was transformed into responsible acts oriented to the greater good of the “nation.” The altruism of individuals who volunteered to serve others in need transformed into serving the “people,” the “nation.” The “nation” is the metasignifer, the overarching reference under which the efforts of all individuals and groups, regardless of the multiplicity of motives, were retrospectively assembled as the substance and the instantiation of the imaginary “nation.” The commemoration at the Botanic Gardens was only the first of a series of a “nation” in ceremony, both in grief and in relief.
On August 9, 2003, National Day, the “national” status of the healthcare workers was affirmed. National awards were conferred on a total of sixty-nine hospital staff: the Chief Executive Officer and two of his doctors received the highest awards, the Public Service Star. And, during the National Day Parade, an annual extravaganza of military colors and fireworks, in which the nation celebrates its “birthday,” a large contingent of hospital workers took part in the parade for the first time; they were being incorporated into the “nation” on parade, like the military, police, and other civil defense units. The chronicler of the SARS episode concludes: “Psychologically, a nation came together, battling a common enemy. Having come through a crisis that was both deadly and swift, Singaporeans emerged stronger, with more resilient systems and with the sure knowledge that together, if they could beat SARS, they could overcome other challenges” (Chua 2004: 192). This euphoric sentiment about the “nation as a community” was reiterated by the Minister of Home Affairs, “As a nation, we will always remember the SARS crisis as a period which brought the entire nation to work together towards a common cause” (in foreword to Chua 2004). The SARS epidemic was for the government evidence of the substantiation of the presence of a “nation” as a community.
The PAP government was obviously happy with the outcome of the “crisis” because the people followed its lead and the epidemic was “eradicated” within a much shorter period than all other seriously affected nations, except Vietnam. To the government, its “unity” with the people had been an elusive phenomenon, in spite of the forty years of sustained economic prosperity and its efficacy and ability to constantly improve the material life of the population. It had never eradicated the nagging feeling engendered by the question of whether a “nation” exists on this island after close to forty years of political independence. Or whether given the racial and religious divisions, a national community of Singaporeans exists when the proverbial “chips are down.” This anxiety persistently expresses itself in different modes and on different occasions. Mundanely, it can be seen in the constant questioning of “what is the Singaporean identity.” In more august ways, the Prime Minister himself declared that Singapore is “a state without a nation,” during the 2000 national rally speech, the occasion for reporting on the state of the nation. This anxiety has been awaiting an opportunity to be tested.
The SARS epidemic was just such a testing occasion. The government had seen the result and was satisfied with the evidence: individuals had sacrificed themselves and pulled together in the same direction, with the government leading at the front, everything a nation should be! The epidemic had to substantiate the presence of the “nation.” In this sense, it was a crisis that the PAP government had been waiting for.
Conclusion: A Nation Confirmed
The SARS epidemic required all residents of Singapore to observe several novel responsibilities of self-discipline through a series of mundane practices or technologies of the self under a new regime of hygiene. In self-interest of avoiding infection and in the absence of self-efficacy in dealing with the epidemic on their individual terms, the citizens obeyed and behaved according to the dictates of the state, for individual and the larger social good. After the epidemic had receded, these new behaviors of self-discipline were reassembled and framed, retrospectively and retroactively, under the metasignifier of the “nation.” Everyone was reframed as acting as “Singaporeans” – an ideological signifier rather than an ontological fact of being born on Singapore island – oriented, both individually and collectively, toward a unified nation, Singapore. That this was necessarily a “looking back” suggests that the “nation/national” is a signifier that is externally and discursively ascribed to the activities during the epidemic, rather than an intrinsic quality of the activities themselves. The “nation” is an empty signifier that actively reorders the past to substantiate and instantiate itself, rather than one of an imagined present suggested by Anderson (1983).
However, such attempts to instantiate and affirm the “nation” are weakened by the fact that they are necessarily and unavoidably retroactive. First, the affirmation can be destabilized by the refusal of any actor (re)assembled under its sign to be so included, and so it was in the case of the SARS epidemic. For example, “the doctors and nurses who tended to the SARS patients do not consider themselves heroes, saying what they did was in line of duties” (Chua 2004: 41), thus exposing the “nation/national” as an extraneous framing of the healthcare workers' individual motivations and actions.
Second, as a retrospective and retroactive signifier, the “nation” may be only “good” for the “crisis” that has passed. It provides no guarantees for the next time a crisis looms. The affirmation of the substance and presence of the nation each time is therefore only good until the next time it is tested again. Consequently, the anxiety over the absence of a nation is not and cannot be erased once and for all. Such is one of the predicaments of the nation as an imagined community and one that the PAP government's anxiety about the absence/presence of Singapore as a “nation,” in spite of the successful management of the SARS epidemic, cannot escape.
Empirically, the epidemic has come to pass. The disease has disappeared as stealthily as it appeared. It has not been “terminated.” It has been “normalized.” It will “come and go,” as any disease would. Furthermore, it is the permanent possibility of its return that is emphasized. Everyone continues to be haunted by its promised return to kill patients in the silence of isolated wards of hospitals. That one does not know when it will return intensifies the fear. This state of apprehension inheres not only in individual citizens but also in the Singaporean State. The strategies that it deployed during the 2003 SARS epidemic have been incorporated into the intelligence of the state and archived for the next time.
Significantly, East Asian countries had been reluctant to discuss the idea of “human security” in international relations; the concept would oblige them to protect citizens not only from external threats but also from internal abuses in the hands of domestic security forces – until after the outbreak of SARS. Since then, the concept has been slowly creeping into the language of Asian politicians; see Evans (2004: 270).
“Fighting SARS Together” was the title of Prime Minister Goh Chok Tong's direct letter to the public, an extremely rare event (Streats, April 23, 2003).
Another elaborate system using light technologies enabled the hospital to keep track of all the movements of its staff throughout the day.
Another possible site for comparison is Taiwan in which, due to lack of trust in state authorities, the medical workers were most reluctant to work in the hospital in which SARS first broke out; for details see Ku and Wang (2004).
A Hong Kong friend informed me that a small group of individuals took it upon themselves to “track” down the apartment blocks where SARS was found, a fact that the government kept secret, and posted the list on the internet.
The full title of the song is “Through Your Eyes (Heroes and Angels).”