SINGAPORE: It was a Saturday evening in late February and Dr Gareth Lim was at home, scrolling YouTube mindlessly. Out of the blue, he received something on his phone that made him jolt off his couch. A text message. 

“It was from one of the senior doctors who plans rosters. She was very apologetic, but she told me manpower is needed at the National Centre for Infectious Diseases (NCID). They had to activate me on quite short notice.” 

He was told he could say no if he did not want to be deployed. But if he said yes, he would be on the frontlines of the fight against COVID-19 in a couple of days’ time. It would be the 29-year-old’s first experience working in an outbreak scenario.

Dr Lim is two years into his National Healthcare Group residency at Tan Tock Seng Hospital (TTSH), where doctors are rotated from one department to another every three months to gain experience. “I’m actually quite a junior doctor,” he said bashfully.

Even so, he stepped up to the plate without hesitation. “I was excited to be part of the frontline effort, it would give more meaning to what I’m doing. It’s like, this is what we are meant to do as doctors,” he said. 

But as Dr Lim settled into his new role at NCID, the excitement was quickly superseded by anxiety. 

“It was quite daunting at that time because everything was so new, protocols were changing every day and the turnover of instructions was so fast,” he said. He worried about his ability to perform on the job and whether he could keep up with new procedures such as putting on the personal protection equipment (PPE). 

“There’s always that fear of, what if I didn’t wash enough? What if I didn’t put the PPE on properly or what if I have contact with patients unknowingly?”

By mid-March, the World Health Organization (WHO) said that COVID-19 could be characterised as a pandemic – the number of countries affected had tripled and numbers were expected to climb. 

Dr Lim, while coping with a high level of stress at NCID, found himself “doing little things” that he usually would not do. 

“Like reading the news, checking almost two to three times a day to see the number of cases,” he said. As he read reports on the virus causing major strains on critical care facilities around the world, questions like ‘What if our ICU became like that?’ and ‘How would we cope?’ filled his head. 

KEEPING FRONTLINERS HEALTHY – MENTALLY 

Such apprehension and state of mind are not uncommon for healthcare workers at the frontlines, said Dr Lim Wen Phei, a consultant from TTSH’s Department of Psychiatry. 

“They are exposed to a multitude of challenges in their work. Firstly, they bear the brunt of the public’s expression of fear, uncertainty and difficulties coping with change. They also have to manage their personal and very real fears of being infected in the line of work,” she explained.

“And they have to do all these while navigating the present nebulous climate.”

This is why TTSH and NCID have ramped up its efforts in preventive and early mental health interventions, to look out for staff members who “face the risk of burnout, compassion fatigue and trauma”. 

“We have of course started noticing these symptoms with health care workers. But everybody has stress thumbprints – which means everybody’s stress responses will be unique,” added Dr Lim. 

The earliest signs of psychological distress would include burnout, which could manifest in the form of feelings of “helplessness and low accomplishment”.

“For example, people who have worked for 10, 11 consecutive shifts – the constant changes in workflows may reduce a feeling of mastery in their work.” Other warning signs of burnout include social withdrawal, where individuals may isolate themselves from their peers or even family. 

READ: Inside Singapore’s COVID-19 screening centre, on the front line against the disease

READ: COVID-19 circuit breaker extended until Jun 1 as Singapore aims to bring down community cases ‘decisively’: PM Lee

While frontliners fight to keep patients alive and physically well, the Staff Support Staff (3S) programme guards the mental health of healthcare workers. It is helmed by representatives from various departments, such as Psychology, Care & Counselling, HR Wellness and Psychiatry – and has its roots in the peer support given to frontline staff of the SARS epidemic 17 years ago.

“We learnt from SARS that healthcare workers can experience symptoms of post-traumatic stress disorder from working in the frontlines,” said Dr Lim Wen Phei.

“It was an important lesson in underscoring the need for mental health in ensuring a resilient healthcare workforce.” 

PAINTING A MENTAL PICTURE OF WHAT TO EXPECT 

A toolkit put together by her in 24 hours was among the initiatives that have sprung up during the COVID-19 pandemic. Based on feedback on the ground, she saw the need to psychologically prepare staff members who are newly deployed to the screening centre and outbreak wards.

“Because of the urgency of the situation and how things were moving really dynamically, we had to come up with it as soon as possible. I asked a few of our colleagues working in NCID, if you were to advise a colleague who’s going to be deployed, what would you tell them?”

To her pleasant surprise, word got around quick and “random people” contacted her to share their stories. Everyone had a valuable experience to share, she said. “It was quite touching for me to hear fellow staff saying, we were the first to be deployed, we didn’t know what we were getting into. But if you’re gonna write this up, please tell our people what to look out for.”

The document now covers a range of topics – from what to expect when you wear your PPE, the long hours and the number of people tested, to how to manage stress. Some stories that made it to the toolkit were:

“Be prepared to get really warm in the PPE! I wore the PPE for three hours and I was soaked in sweat right down to my undergarments. But everyone understands it’s for our own protection.”

“Little pockets of time you can find, like during lull periods or when commuting to work, can be used to be with your thoughts. Be mindful of your thoughts and see what is frustrating you so that you can sit with those feelings.”

While tips like how the mask is going to hurt and the goggles will give friction injuries seem “trivial and menial”, they cannot be overlooked. 

“Those are actually very real pain points, but it’s not intuitive for us to talk about it in a formal capacity. It helps people to paint a mental picture of what to expect, even if these are not really pleasant things to be expecting,” said Dr Lim.

“This helps to allay fear and anxiety in whatever capacity possible. The concept of the toolkit is to be practical and applicable.” 

The toolkit came in handy for Dr Gareth Lim when he realised he was getting lost in his thoughts.

“It had tips on techniques to prevent burnout and how to practice self-care,” he said. “These were helpful reminders along the way – to take a deep breath and remember to spend time doing other things if I’m getting too stressed.” 

24-HR HELPLINE AS “PSYCHOLOGICAL TRIAGE” 

Another morale-booster for staff is the 3S Helpline, which exists to help them through personal crises. It was available during peacetime or before the COVID-19 outbreak during office hours, but it has since been transformed into a 24-hour helpline. 

Ms Lek Jie Ying, the senior executive of TTSH’S HR Wellness department, once helmed the helpline alone, but she now works with a team of 13 medical social workers, psychiatrists and psychologists to respond to calls. 

“Before the outbreak, the majority of the concerns were about their personal issues, for example sudden loss of loved ones or abusive patients,” said Ms Lek. “But in this period of time, staff’s concern mainly revolves around the uncertain situation.”

“They can be concerned over job deployment because of the nature of the crisis, it can be anxiety or frustrations over the many changes in policies.” Healthcare staff also seek advice for other challenges like childcare and eldercare arrangements.

Ms Lek added: “The helpline gives them a safe outlet to voice out their concern and seek support.”

It also functions like a psychological triage, much like in the Accident & Emergency (A&E) department, where patients are assessed by the severity of their conditions, said Ms Chai Su Wi, a medical social worker on the helpline team. 

“For some of them, maybe in this period, they need a little bit more help than usual. We will then do a formal referral for them to see a psychiatrist or psychologist.” 

COVID-19: A MARATHON WITH A COMMON GOAL

While Dr Gareth Lim’s one and half month long deployment at NCID’s general ward and ICU was shorter than his residency rotations, the warmth and camaraderie of his colleagues there left a lasting impression on him.

“I remember one of our department heads who spends many sleepless nights planning all the rosters, sending me text in the midst of everything to ask me how I’m doing, what I’ve learned and if I’m enjoying the experience,” he said.

“That reassured me a lot … I was very moved by that. It makes me want to do more, in spite of the tiredness and uncertainties.” 

In times of crisis, staff support within the hospital is important – given that many healthcare workers on the frontline are not able to be with their families, said Dr Habeebul Rahman, chairman of the 3S Executive Committee. 

“They may face some degree of isolation or not be able to interact with their usual support systems.” 

For Ms Lek and Ms Chai, peer support is crucial because talking to a fellow staff member is “less daunting than seeing a professional”. 

Ms Lek said: “Sometimes it may be very hard to explain to our family members or friends outside the hospital. When our staff talk to someone in the hospital, they do feel that the other person can relate to a lot more.”

Since 2009, the 3S programme has held psychological first aid classes, which trains staff to “help themselves help other people”, said Ms Chai. To date, about 100 staff members in TTSH have been trained in psychological first-aid and some of them volunteer to attend to helpline cases as well. 

With these psychological safety nets in place, it is with hope that frontliners would be able to regulate emotions of distress and “keep themselves well for the long haul”. 

“Frontliners always try to push the limits to do more, but they are only human. They are the ones who see how patients deal with the disease and how families have to deal with their loved one being sick and that can be quite traumatising,” said Ms Chai. 

“Our job is to let them know what support is available. Battling COVID-19 like running a marathon – there’s always an end point and we will move towards there together.”

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LIVERPOOL: Recent lockdowns, movement control orders and circuit breakers around the world have meant that all manner of face-to-face activities are now being done remotely, or are “home-based”.

You know, all the essentials – home-based working, home-based learning, home-based-bubble-tea-bingeing (to get free delivery).

Even the military is getting in on it. In Singapore, fresh conscripts who would otherwise be confined in-camp for Basic Military Training (BMT) are getting remote instructions over the Internet.

It makes me wonder how Warrant Officer Mani would make Recruit Heng get down on the ground for some push-up punishments.

“Eh, knock it down! Are you knocking it down? I can’t see. Can you angle the webcam lower? Ah, thanks. Knock it down!”

EVERYTHING IS GOING ONLINE – WEDDINGS TOO

It’s not surprising that, where possible, the everyday activities that we do (and need to do) are the first to go online. Of course, that still masks the unequal distribution of labour and privilege in society – certain jobs will always be easily done at home, some not so.

But what about those special, one-off events? The kinds that are “once in a lifetime”?

Next week, the Singapore Parliament will discuss the possibility of allowing weddings to take place online, with caveats about ensuring both bride and groom are physically in Singapore, among other restrictions.

This has already happened elsewhere around the world, like in New York, where virtual weddings appear to be the only option for a city in lockdown. Virtual toasts and virtual guests, but all still able to share in a happy occasion.

READ: Commentary: We cannot allow COVID-19 to disrupt our relationships too

READ: Malaysian couple opts for Skype wedding amid COVID-19 curbs – in their respective homes

WEDDINGS GO BACK TO BASICS

On the face of it, streaming a wedding ceremony where a couple exchanges vows is a very good idea, especially when physical distancing rules are in place.

Such ceremonies lend themselves well to digitalising (the act of turning something physical into something virtual) because there is a particular focus (wedding couple) and the audience’s role is largely observational and passive.

Just think back to attending weddings or Registry of Marriages (ROM) ceremonies. There wasn’t much for you to do as a guest, and at large events, you may not even get a chance to interact with the wedding couple.

(Unless you were that one uncle who thinks he’s a wedding photographer because he owns a camera, and proceeds to get into every. Wedding. Photograph.)

In a time when weddings are becoming increasingly commercialised, the idea of minimising the ceremony down to its bare, legal essentials is a tempting proposition.

By disregarding the bells and whistles and layers of ostentation, the virtual wedding, as it currently stands, offers us a chance to disengage from pomp and focus on people.

READ: Commentary: Bridal studios and deposits – beware of putting too much down for your big day

READ: Commentary: Getting married at year’s end is a Battle Royale

Virtual weddings also challenge us to question what is really necessary for a wedding to be successful and meaningful.

Whatever the circumstances that have forced us into these arrangements, it is nevertheless an opportunity to slow down the credit card spending just a little bit.

However, I am not so naïve as to believe the wedding industry would not eventually find a way to get people to spend virtually. Ultra high-definition streaming, custom emojis and multiple angles from remote mini-drones all come to mind (that last one exists somewhere in science-fiction already).

WHAT ABOUT THE OTHER CEREMONIES?

At the same time, once we start examining cultural practices, the reality is virtual weddings will struggle to mimic dearly held and longstanding rituals that have come to become an integral part of that ceremony but require multiple instances of physical interaction.

After all, as I’ve mentioned in other commentaries, weddings are rarely just about the couple, but a conundrum of kinship, social and commercial networks assembled in a concentrated burst of activity.

Tea ceremonies in Chinese weddings are a good example of this, where a wedding couple offer cups of tea to family elders.

On the surface, they are about “paying respect”, but sociologically, they are also about constructing and affirming familial bonds. To some, this affirmation of bonds exceeds the legal ceremony in importance and legitimacy.

Some of these tangible rituals can be made symbolic. They can even be digitised. But for this to succeed, one requires the buy-in from not just the state, the celebrants and the wedding couple, but also the complex networks of individuals that make up the wedding.

This is not always so simple. And turning something that has been physical for so long into something digital means encountering resistance.

READ: Commentary: The wild world of pre-wedding photoshoots

READ: Commentary: What’s wrong with being a single woman?

To digress, this is also why apps that purport to replace religious rituals (like burning offerings) have never really taken off, because they ignore the deep and stubborn precedents of practice.

NOT EVERY BRIDE, GROOM OR GUEST HAVE THE SAME RESOURCES

Apart from the challenges involved in digitising very physical actions, it is also important to remember that not everyone has the same access to the resources required to conduct a virtual wedding.

While the digital divide goes some way in helping us to understand unequal levels of access, I offer two more points for us to think about.

One, place both matters and does not matter. While a virtual wedding can be conducted anywhere (that’s the whole point), not everyone can stream live on a chic rooftop overlooking the city skyline. And not everyone wants extended family and friends peering into their living room.

While it could be argued virtual backgrounds could address this issue (who would not want a wedding on the bridge of an Imperial Star Destroyer?), such solutions are situational and yet again dependent on the different resources available to different people.

To this extent, town halls and marriage registries are still vital for virtual weddings to succeed, because they offer a way to level the proverbial playing field of “my virtual wedding venue is nicer than yours”.

Two, virtual weddings run the risk of excluding entire groups of individuals who do not have the technology, which could include the networks of family and close friends that weddings comprise of.

To assume that all of one’s family and friends have laptops, smartphones and Wi-Fi to stream a 30-minute video likely assumes too much.

For any legislation of virtual weddings to succeed, it must take into account the same challenges individuals and groups face when working or studying at home. That is why support from institutions that provide spaces and the requisite tech (like ROM perhaps) is crucial.

WHERE DO WE GO FROM HERE

Technology continues to shape and influence the way we socialise, interact and ritualise.

That couples now regularly create custom hashtags for their weddings and include livestreaming even before lockdowns began suggests that society was already developing a hybrid mix of tangible and intangible wedding practices.

READ: Commentary: How not to be a Zoom bore

READ: Commentary: Singaporeans more adaptable than they give themselves credit for

The question that we must now raise in a post-COVID-19 world is this: When we make deliberate and dramatic shifts to familiar ways of life, whether out of preference or necessity, we need to first think of the human before the technology.

Around the world, those who create the technology (and the rules that come with it) are often overly enamoured with the utopian possibilities and opportunities afforded to those they genuinely intend to help.

The belief that technology or technological advances are either only neutral or beneficial fails to take into account the unevenness of everyday life.

While there are many things to gain from going online, there are also many things to lose. Intimacy, closeness and shared social spaces are still fundamental to the human experience.

In other words, we should not be so quick to disregard the tangible.

​​​​​​​LISTEN: COVID-19 and the outlook for Singapore’s residential property market in 2020 and beyond

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Terence Heng is a senior lecturer in Sociology at the University of Liverpool, UK, where he is also an associate at the Centre for Architecture and the Visual Arts.