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Zhen Goh

Constraint Management in Practice : A 3-week participant-observer account

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I am officially on Day 13 of my strict Stay Home Orders. I have not stepped out of my house for 13 days, not even for groceries. The irony is that while my 14 day order expires on the 7th of April, Singapore has just announced a round of additional restrictions which means that all non-essential businesses will close on 7th of April. It might come as a surprise to many that Singapore who is one of the earliest countries who was affected by COVID-19, and who has had their measures so widely talked about in the media has actually not yet implemented strict lockdowns.

There have been a myriad of responses since the start of the disease, and many countries have swung into extreme lock-downs quickly. In part because of a late start in their response measures – a swift and decisive move to apply strict lockdowns might be a way to compensate for a late start. What I have observed in Singapore though, is a deliberately tentative safe-to-fail approach of testing ideas, and implementing them with reinforced confidence as feedback is received from the system: a careful management of constraints.  I thought it might be interesting to explore these in relation to the typology of constraints that Dave has developed.

This represents in no way exhaustive account of all the different measures taken. It is a 3-week long selective participant-observation account of some key measures that the government has put in place, and how the system reacted. Useful to note as well is that Singapore has a protocol in place, referred to as a DORSCON (Disease Outbreak Response System Condition) system which provides varying alert levels to any new communicable diseases. On 7 Feb, they had raised the alert to Orange, one level below Red (the highest). The Orange rating helped to communicate a break in “business as usual”, disrupting the system (moving Ordered systems into the Aporetic or Complex) so they could put new measures in place. The Orange rating provided a joint national framework that helped to communicate a clear domain transition to everybody.

 

My account begins 15 March

Singapore started recalling its citizens. This recall meant that the frontline for the fight against COVID-19 was at the border, as returning citizens brought cases back with them. 

In the beginning of this fight, Singapore started off with offering free treatment for all COVID-19 cases regardless of whether or not one was a resident. This started to create an attractor that drew many people from the region seeking healthcare. This, coupled with the recall, meant that imported cases rose exponentially. More intense measures had to be put in place to manage this frontline.

 

Medical access –  The government announced that from 7 Mar, that free treatment for COVID-19 would be reserved only for citizens and long-term residents. What started as a loose constraint (free treatment to all) was deliberately shifted into a more rigid one as they recognised that there was a finite limit to the healthcare system’s ability to absorb patients.Screenshot 2020-04-05 at 7.53.26 PM The transition was made to preserve capacity. The change in policy on medical access was coupled with early travel restrictions. Singapore was one of the first countries to restrict travel from China, and had progressively put restrictions on people returning from certain infected regions. However, from 16 Mar they started extending this list to more countries, and instilled  compulsory 14-day Stay Home orders for travelers arriving from certain countries (i.e. Japan, UK, South Korea).

 

Travel restrictions – I think of these travel restrictions as a type of permeable constraint, albeit fairly porous ones, which allowed the government to test the idea and monitor the system for feedback. They saw a drop in imported cases, but this still allowed too many new cases through its pores. After a week (23 Mar), this 14-day Stay Home order was extended to all people arriving in Singapore regardless of where they had arrived from (this is the restriction that I got caught in). Some returnees started flouting the rule. One famous case that was documented (26 Mar) was linked to a resident who upon his return had gone out for a meal instead of heading straight home, and publishing his meal on social media, claiming that he was not aware that his first day back made for part of the 14-day Stay Home order.

 

Reinforcing constraints – This inspired several response measures. The government chose to use this one case to create a lesson for the public. It was widely covered in the media, and received widespread attention from other citizens which described the man’s behaviour as irresponsible and inconsiderate. This made visible the dark constraints that social norms and social shaming bring about. The citizen’s passport was also revoked as a punishment. The dark constraints further reinforced the constraints implemented in this round of measures.

 

Next-level travel constraints – Next, from 27 Mar, all new arrivals were also required to sign a health declaration upon arrival, as well as for them to serve their Stay Home orders in hotels, instead of at home, to reduce the likelihood of cases spreading to family members (but also the easier to ensure compliance). To absorb the impact of the lack of tourism on hotels, the government absorbed the costs and provided the hotel rooms for this purpose. Interesting to note as well, is that these are some of the top hotels in Singapore, with the 5-star hotels serving as an attractor to encourage people to shelter in place. Additionally, Singaporeans who continued to flout the travel advisory to avoid unnecessary travel also had access to free healthcare in case of COVID-19 infection removed as a citizenship right. Over several iterations of these travel restrictions,  the permeable constraints start to get tightened, and more finely grained. 

Screenshot 2020-04-05 at 7.56.19 PM

 

Shifting the frontier – In the past week, new infections that arise from imported cases have reduced tremendously. However, there have been increasingly more infections that arise from local clusters. This shifted the frontline from border control to the need for community-level control, which inspired more stringent social distancing measures. On 31 Mar, it was announced that entertainment establishments (i.e. bars, nightclubs) would be closed to avoid people congregating in large numbers in closed spaces. Just a week after this announcement, there has been another round of measures announced to reinforce what the government refers to as Circuit Breaker Measures. These came just 2 days ago (3 Apr). Very similar to the measures imposed in other cities, people are now advised to leave the house as little as possible. Essential services will continue, but all non-essential businesses have to either allow their employees to work from home, or cease operations. Over a course of 1.5 weeks, we have seen again with regards to local community level constraints, the same decreasing of the porousness of permeable constraints. 

A lot has taken place, and this observational analysis takes into account only some of the measures that have been put in place over the past 3 weeks. The announcements have been made progressively, and there is a clear systematic nudging of the system through small system-level constraints that shift behaviour progressively. Starting with loose permeable constraints that get slowly tightened and less porous over time. Perhaps the metaphor of the frog sitting in a pot of water as it boils comes to mind. 

However, most interesting to me are the dark constraints that are catalysed through the government’s publication and sharing of patient details, and all contact tracing information.

Screenshot 2020-04-05 at 6.50.12 PM

Initially I found it a little confronting, and some might decry it as a violation of privacy; but the government shares the profile and information of every single patient openly. None of this is personally identifying. The profiling includes each individual patient’s age, their gender, recent travel history, and where and how they contracted the virus. Whilst staring at statistics can help to understand the situation, understanding the personal background and details of each patient forces us to confront the reality that these are real people. Each patient is unique, and not a statistic. This stimulates the dark constraint of mutual responsibility – an onus on each and every one of us to cherish the life of the person linked to each case, and not merely approach the situation as an exponential curve. 

I read a beautiful article from the NY Times the other day, “What Shakespeare teaches us about living with pandemics”. In this article, the author notes how Shakespeare wrote King Lear when he was in quarantine from the plague. Notable though, is the absence of any mention of pandemic in his work. His writing chooses instead to celebrate the agony of personal struggle. The impact of the plague on the play is completely oblique, and not a single character in King Lear dies from the plague or illness! 

“Shakespeare is not interested in the statistics — what in his time were called the bills of mortality. His fictions reimagine the macro-narrative of epidemic as the micro-narrative of tragedy, setting humane uniqueness against the disease’s obliterating ravages. His work is a cultural prophylactic against understanding disease solely in quantitative terms, a narrative vaccine.” 

We have to engage in the personal nature and the human face of the virus to stimulate the communal care and links that are necessary conditions for stimulating the dark constraints that catalyse community participation in things like social distancing measures. 

 

Tethers and System level constraints

Before I close, I want to acknowledge that all the measures that Singapore has put in place are only possible within the context of its unique system and culture. That is where I found the tether-like constraints come into place. Singapore is small and is governed by a single party. Its decision-making therefore takes place much more quickly – in crisis, centralised decision-making supports quicker coordination. With its size and hyper-connectivity (the government invested in installing fibre optic networks in every single household a few years ago), Singapore enjoys a very rapid feedback loop, as well as the ability to manoeuvre quickly. It has put these measures in place balancing against the understanding of its capacities, but these are not without limits. 

All decisionsimage have to balanced against the amount of burden the healthcare system can absorb (beds, intensive care units, ventilators, medical professionals), as well as what the government can afford to draw from its reserves. These are comforting safety mechanisms, but there is constant awareness that while they form a safety tether, there is also a definite limit to the stress and weight it can take, as well as how far it can stretch.

One can never be complacent. 

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