It’s been over a month since the first dormitories were declared isolation areas, but many migrant workers are still testing positive. On top of that, a number of migrant workers infected with COVID-19 have died — but none of their deaths have been included in the national tally of coronavirus deaths.

As we tracked the developments of the outbreak, both Kokila and I were concerned about these deaths. So we set out to try to find out more about why they’ve not been included in the death toll.

Five migrant workers with COVID-19 have died. But none of their deaths are included in the national tally.

By Kirsten Han and Kokila Annamalai

It’s the highest number of confirmed COVID-19 cases in Southeast Asia: as of May 7, Singapore has reported 20,939 infections of the novel coronavirus. The vast majority of these cases are migrant workers, particularly those living in dormitories scattered across the island.

These low-wage workers largely come from countries like Bangladesh, India, and China, and work in a variety of jobs on construction sites, shipyards, petrochemical refineries, or housing estates. Unlike the female migrant domestic workers who live in their employers’ homes, these migrant men live in often crowded dormitories, temporary lodgings on work-sites, or in privately rented accommodation.

A stretched healthcare system

With an explosion of cases within the span of a month — the total number of cases went from 1,049 on April 2 to 17,548 on May 2, with further increases since — Singapore’s healthcare system is now under pressure to keep the situation under control.

The government continues to reassure citizens that it’s coping with the increased demand for medical resources, but ongoing measures give an idea of the scope of the challenge: hospitals are converting wards and beds to receive COVID-19 patients, former healthcare workers are being asked to volunteer to boost manpower, and work is underway to develop facilities to house patients who have mild symptoms, or are recovering. The numbers are huge, too: a mega-facility being set up at the 80-hectare Tanjong Pagar Terminal, for instance, is meant to be able to accommodate 15,000 people — and this is on top of those already being housed at community care and recovery facilities at places like Singapore EXPO and chalet resorts.

Testimonies point to how stretched resources are. In an article with accounts from multiple migrant workers, local NGO Transient Workers Count Too (TWC2) reported that workers who had either tested positive, or were waiting for further tests, had to sit overnight in waiting areas such as tents, on plastic chairs.

A frontline doctor who spoke to us on the condition of anonymity said that things are currently a little “uneven” on the ground, as “some hospitals are more stretched than others, because we have different infrastructure and capacities.”

But things are getting a little better: “There was a period of time before they started sending medical teams out to the dormitories, [where] the workers ended up in the hospitals directly. That put a lot of load on the emergency department, but now that we are sending teams down, it decentralises the load. Everyone also has a better grasp of workflows that work in that setting, [so] it's getting more efficient.”

Is youth a protection from serious COVID-19 symptoms?

It’s so far been fortunate that most of the workers who have tested positive for COVID-19 are said to only have mild symptoms. As of May 6, out of a total of 20,198 cases, 1,438 are hospitalised in general wards, with 23 in intensive care.

The authorities hope that this trend will hold; migrant workers tend to be younger, and are also assumed to be healthier given their fitness for phys ical labour. But Alex Au, the vice-president of TWC2, has raised the possibility of workers’ immunity being affected by stress and poor nutrition. And youth doesn’t necessarily shield one from the more serious effects of the virus, as the World Health Organisation’s director Tedros Adhanom Ghebreyesus has pointed out.

“Data from many countries clearly show that people under 50 make up a significant proportion of patients requiring hospitalisation,” he said at a virtual press conference on March 20. There are also reports from other countries of younger patients getting severely ill, or even dying. According to an April 30 press release, three of the patients in intensive care in Singapore are migrant workers.

The deaths of migrant workers

Singapore has so far not reported any work permit holders dying of COVID-19, but five migrant workers who tested positive for the coronavirus have died during this period.

The first was 32-year-old Indian worker Suppaiah Shanmuganathan, first identified by the authorities as Case 1604. He was swabbed for a COVID-19 test at the National Centre for Infectious Diseases on April 7 and advised to stay at his lodging pending the test result. He passed away the next day, and was confirmed postmortem to have had COVID-19. A follow-up in a Ministry of Health press release on April 9 said that the cause of death had been ischaemic heart disease, rather than complications from the coronavirus.

Next was a 40-year-old Malaysian work permit holder (Case 4754) who was found to have the coronavirus on April 17. He died of a heart attack the next day, but the Ministry of Health has said that this was not due to complications from COVID-19.

On April 23, Alagu Periyakarrupan was found motionless at the bottom of the stairs in Khoo Teck Puat Hospital, where he was a COVID-19 patient, and was reported to have died of his injuries. It is so far unclear how, as a coronavirus patient, he’d been able to move about the hospital alone, and how he’d ended up at the bottom of the stairs. According to Channel News Asia, a hearing in the coroner’s court into his death has been set for May 8.

A 47-year-old Bangladeshi national, only identified as Case 17410, was found to have COVID-19 after his death on May 1. The Ministry of Health has announced that investigations to establish the cause of death are ongoing.

On May 5, a 44-year-old Bangladeshi national (Case 16370) was reported to have died of an acute myocardial infarction, or heart attack. He had been admitted to hospital and treated for the heart attack on April 29, and tested positive for the coronavirus that same day.

Given the high number of migrant workers who have tested positive for COVID-19, we surmised that these two Bangladeshi nationals were migrant workers. We have reached out to the Ministry of Health for confirmation.

Apart from the deaths of confirmed COVID-19 cases, Subbiah Sivasankar passed away on April 22 from a pulmonary thromboembolism, which is caused by a blood clot in an artery in the lung. It is so far not known if he’d been tested for the coronavirus, although his wife told ItsRainingRaincoats that he’d been healthy and had just spoken to his family the night before his passing.

Why aren’t these COVID-19 deaths?

Five migrant workers with COVID-19 have died, some from heart attacks or blood clots. So far, none of their deaths have been included as part of the coronavirus death toll. There is so far one other case of an individual — an 80-year-old Malaysian — who tested positive for COVID-19 but whose cause of death was also said to be unrelated.

It’s a puzzling situation — how is it that multiple migrant workers, all in their 30s and 40s, all infected with the coronavirus, have died of heart disease or heart attacks in a short period of time, but none have been classified as related to COVID-19?

This could be due to guidelines laid out by the World Health Organisation, where a COVID-19 death is defined as “a death resulting from a clinically compatible illness, in a probable or confirmed COVID-19 case, unless there is a clear alternative cause of death that cannot be related to COVID disease (e.g. trauma).”

“Persons with COVID-19 may die due to other conditions such as myocardial infarction,” the WHO goes on to say. “Such cases are not deaths due to COVID-19 and should not be certified as such.”

We’ve asked the health ministry if they adhere to WHO’s guidelines when classifying deaths, but have yet to receive a response.

But despite the WHO’s guidance, a growing body of medical and news reports have pointed to links between the coronavirus and blood clots.

A study carried out by the Irish Centre for Vascular Biology, for instance, was reported to have found abnormal blood clotting in Irish patients with severe COVID-19 infections. Such occurrences of blood clots have also been observed to cause a higher risk of heart attacks and strokes. Reports from news organisations like the Washington Post and Agence France Presse have also highlighted cases of clotting leading to strokes and sometimes even requiring amputations. The Washington Post piece also described how younger patients who experienced blood clots were otherwise clinically well. According to a report by ABC News, doctors in Spain observed so many clotting cases that they began routinely treating COVID-19 patients with anticoagulation medication.

We have asked the Ministry of Health if similar occurrences have been observed in Singapore.

Dr Paul Tambyah, president of the Asia-Pacific Society of Clinical Microbiology and Infection, says that countries don’t have to follow WHO’s definitions, and that many do actually set their own criteria for statistics. “The WHO makes its definitions based on many considerations beyond purely medical or scientific, especially in novel emerging diseases where the data are emerging almost on a daily basis,” he says.

Classifying deaths is important for a number of reasons: not only does it allow countries to present a more accurate picture of their struggle against the pandemic, there could also be other practical consequences. As ItsRainingRaincoats points out, “[While] the bereaved families (in both cases widows with young children) are unlikely to get any insurance payment for deaths classified as heart attacks, they may be eligible to insurance payment for Covid related deaths especially if transmitted at work sites or related to work.”

Media reports and updates have so far been sparse; not much is known about whether these workers might have had pre-existing health or heart conditions, or how the authorities arrived at the conclusion that their deaths had nothing to do with COVID-19, thus excluding them from the national tally.

These are some of the questions we sent to the Ministry of Health on Tuesday night (May 5) and Wednesday afternoon (May 6):

How does MOH decide what should or shouldn't be classified as a coronavirus death? Does MOH adhere to WHO's guidelines, as published here?
There have been reports emerging (such as this and this) linking COVID-19 to blood clotting that can in turn lead to heart attacks and strokes. Have similar occurrences been observed in Singapore? Given these reports, will there be a need to relook cases and perhaps reclassify them?
When the cause of death for COVID-19 cases are being investigated, do they involve autopsies? If yes, what is the extent of examination that is being undertaken?
What evidence would be necessary for MOH to consider reclassification of these cases (ones with blood clotting leading to stroke or heart attack) as Covid-19 related?

We asked for a response by the end of the day on Thursday (May 7), but have not received answers to any of our questions.

A need for transparency

There are now more than three million COVID-19 cases worldwide, wreaking havoc over healthcare systems and among vulnerable populations. But there’s still so much that’s not known about this virus, and there hasn’t been enough time for researchers and experts to arrive at more certain conclusions. As new evidence emerges over time, there might be a need to rethink, revisit, and perhaps even reclassify cases.

The anonymous frontline doctor acknowledged possible links. “My team is now paying closer attention to possible cases of heart attack, keeping a closer eye on workers who complain of chest pain,” he said.

He added that since new research is improving our understanding of this disease, it makes sense for the Singapore government to keep two tallies, for the sake of transparency: one for confirmed COVID-19 deaths, and another for those who have tested positive and died, or died and then tested positive, but where the link between COVID-19 and their death is so far inconclusive. This is so that we can look back at our mortalities with a fresh perspective as further data and trends may emerge in the future, he explained.

“Everyone who is at high risk of contracting the virus, including migrant workers, healthcare workers, and those who have had close contact with COVID-19 patients, should be tested if they are hospitalised or die from any condition where COVID-19 cannot be ruled out, such as blood clotting, pulmonary embolisms, heart attacks, and strokes,” he said.

This way, there can be a complete and comprehensive data set to contribute towards global understanding of this novel coronavirus. This would also allow us to reanalyse and reclassify cases once more evidence is gathered about how COVID-19 affects the human body, sometimes fatally.

The Humanitarian Organisation for Migration Economics (HOME) has called for more transparency regarding the COVID-19 positive workers who have died, pointing out that the opacity around these cases is only adding to the stress and anxiety experienced by the migrant worker community.

“We are repeatedly told that the graveness of the COVID-19 situation in Singapore is mitigated by the fact that the bulk of the cases are made up of young migrant workers,” the NGO wrote in a May 7 statement. “However, a pattern has emerged, where migrant workers in their 30s and 40s have contracted the disease, and passed away due to heart-related problems. We cannot ignore this phenomenon, and this requires that the authorities acknowledge this issue and offer clear explanations as to why these deaths have not been attributed to COVID-19.”

As some dormitories with large clusters of COVID-19 infections have shifted towards isolating men diagnosed with respiratory illnesses even without testing, the government should also provide the number of cases in this category. Although Kenneth Mak, the Ministry of Health’s director of medical services, has promised that “the numbers will reconcile” as these suspected cases are eventually tested, there is so far no timeline provided as to how and when these numbers will reconcile.

While it’s a relief that most of the infected migrant workers have only exhibited mild symptoms, we cannot afford to be complacent about the situation. Behind every report of a serious case or fatality is a person with worried or distraught families and friends, many of whom will be left bereft and vulnerable without their loved one and breadwinner.

Furthermore, experts have warned that even mild COVID-19 symptoms could quickly escalate into much more severe symptoms; alarmingly, doctors have reported seeing patients crashing suddenly, going from “walking out the door” to “sudden respiratory arrest” in a short amount of time.

In such circumstances, every COVID-19 case has to be taken seriously, and every effort made to protect individuals from the virus. This involves not only the rapid reduction of density in dormitories — as NGOs have repeatedly called for — but also clear and transparent information about the outbreak in Singapore, and how it is affecting different populations differently. The fact that some migrant workers who have tested positive for COVID-19 are experiencing different health trajectories from the rest of the population, and dying in unexpected ways, needs to be accounted for.

If you would like to support the bereaved families of Alagu Periyakarrupan, Suppaiah Shanmuganathan, and Subbiah Sivasankar, Member of Parliament Louis Ng and Dipa Swaminathan of ItsRainingRaincoats have started a crowdfunding campaign for them.

Five migrant workers with COVID-19 have died…

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