Chief of Medical Corps

There are four noble truths in Buddhism, five pillars in Islam and ten commandments in Christianity. These religious edicts have a deep resonance with mankind and have remained relatively constant over time.

The laws of physics and mathematics are universal. The law of gravity on an apple is arguably the same whether it is on earth, or any celestial body with a defined mass. The Pythagorean theorem is also irrefutable whether you are in one galaxy or another.

In contrast, one cannot say the same for “leadership”. There is a vast amount of knowledge on leadership — theories, mantras, heuristics, models and creeds. These are neither constant nor universal. Some may be applicable to one culture, but become irrelevant or irreverent in another. Some may be useful for one circumstance, but become counter-productive or destructive when the situation changes. It is against this backdrop, and with trepidation, that I humbly offer a few observations about leadership, gleaned from my personal journey during the COVID-19 pandemic.

In preparing this essay, my research took me to an earlier work entitled “The SAF SARS Diary” published 17 years ago. That diary chronicled the SAF SARS experience scientifically with charts, statistics and flow diagrams. Fast forward to the present day, the information terrain has changed significantly, with much of the science and data freely available in open source literature. What is left then, perhaps, is for me to capture some of the less codifiable but no less important aspects of the crisis, the thoughts and dilemmas, the fears and triumphs, the texture, touch and feel of key decisions. And I shall borrow a few fairy tales to aid me in this delicate endeavour.

Unlike scriptures and scientific expositions, fairy tales are often relegated to the children's section, passed over as frivolous material, something to be grown out of. Yet, they are often translated into numerous languages, and enjoyed across cultures and ages. There is clearly more than meets the eye with old, wrinkly story tellers. The telling and retelling of these seemingly innocuous tales actually transmits gems, tacit and otherwise, across the generations. Much later in my adult life, I was finally able to appreciate the many leadership lessons hiding in plain sight. Perhaps, as the saying goes, “when the student is ready, the teacher will appear”.

The three little pigs

This fable is about how the straw and wooden huts were no match for the big bad wolf, and the little pigs were saved only by the brick house. First appearing in a nursery rhyme by James Halliwell-Phillipps, published in 1886, the moral of the story found its way into many aphorisms, including one by Mr Warren Buffet — “Only when the tide goes out do you discover who has been swimming naked”.

Metaphorically, this “brick house” was usually painstakingly erected by a previous generation. One example is the culture of cleanliness, handed down as the practices of “standby bed” and “area cleaning”. While countries have varying success dealing with the virus, large COVID-19 outbreaks within military installations were less common, despite our communal living conditions. We have to thank our sergeant majors for the hygiene standards indoctrinated at basic military training.

Specific to medical policies that put us in a good stead, the SAF started its annual influenza vaccination exercise in 2009, ten years before COVID-19 struck. Every year, we achieve around 85-90% vaccination rate with little fanfare. Hence, when the mission came for the SAF to vaccinate its people against COVID-19, it felt almost like we had already rehearsed for it.

Similarly for logistics. Our quick response in pushing out the surgical masks to Singaporeans during a time of global shortage was made possible by methodical stockpiling over the years, turning over expired stock, replenishing, and quality control, to make sure that when the tide goes out, we are not found naked.

At a time when people around the world were struggling to keep ICU patients alive with improvised ventilators, we were quietly confident because during good times, we had squirrelled away a few hundred transport ventilators. While these do not have the full suite of functions, they will do the job of keeping patients alive if their situation worsens. At the request of the Ministry of Health, we delivered them to the public hospitals. Thankfully, the situation stabilised and the transport ventilators did not see action, but our clinician colleagues were relieved that they need not carry the ethical burden of deciding who lived and who didn't.

The leadership lesson is the preparedness mentality. The man on the street will not worry about black swan events. It is the leader's unpopular job to be paranoid, to save for rainy days, and to delay gratification. Such a mentality is behind many of the things we take for granted. An example is Lim Chu Kang road which is designed as an emergency runway. Why plan for an emergency runway when Singapore already has so many operational civilian and military runways? Why stockpile surgical masks and hundreds of transport ventilators, when there are so many other pressing demands? Why bother with the annual influenza vaccination when the flu is just a mild disease? Why demand hygiene standards in barracks, when we could outsource this “non-core” function to migrant worker cleaners? These measures were put in place by leaders before us, and it behoves us to do the same, so that whether it is to fend against the big bad wolf, the outgoing tide or the next pandemic, we are prepared.

The emperor's new clothes

This quintessential cautionary tale against hubris speaks of a swindler hoodwinking not just the king, but his entire populace into believing that they had beheld the world's finest robe on parade, when their eyes were clearly showing them just an old man in his birthday suit. Written in 1837 by Hans Christian Andersen, children over the ages enjoyed the spectacle when the lies were finally exposed and the stark naked king was roundly humiliated.

In leadership parlance, this tale warns against “groupthink”, where people avoided conflict, despite knowing better, especially in a setting with an overbearing boss. Vanity and pride are major components, where everybody, the king included, claimed that they could see the invisible woven fabric. One error perpetuates the next, until a full blown disaster is imminent.

An example of averting disaster during COVID-19 was how leaders were agile and humble enough to examine the latest evidence, instead of holding on to previously held positions, fearing embarrassment. At the national level, when new findings on viral transmission surfaced, we changed our position to mandate mask wearing. Another episode was the decisive statements and actions surrounding the TraceTogether contact tracing app debate. These were examples of leaders acknowledging that they indeed could not see the invisible fabric.

I sat in numerous meetings held by JTF(A), which was tasked to look after migrant workers. Seldom was consensus reached without a good dose of disagreement. Examples included the methods for testing, whether it was nasopharyngeal swabs, or oropharyngeal mid-turbinate swabs, or saliva, the indications for using pooled samples to conserve the scarce reagents, the mechanisms and durations for quarantine. The secret sauce is the quality of conversations with people playing the roles of the proponent and the opponent; the former speaks with honesty, and the latter, counters with respect.

At a personal level, I also had to deal with vanity. To prepare for the Pfizer BioNTech vaccine, I directed my team to procure a few ultra low temperature (ULT) freezers, so that the SAF could store our own frozen vaccines, giving us operational flexibility. I had under-estimated the efficiency of the cold chain capabilities in the country, which turned out to be so robust that all vaccines could be held centrally, thawed and delivered to vaccination centres every day. The SAF need not deploy our own ULT freezers. Embarrassed by my earlier decision to buy these freezers, which looked increasingly like white elephants, I continued to try and deploy them at SAF medical centres. After coaxing from my team, I conceded that the ULT freezers would not see much action, and returned them to the main warehouse as back ups. This episode reminded me of the vanity in the fairy tale, except that my team, sensing something amiss, was willing to alert me. All I needed to do was to put aside my pride.

While parading naked in front of his subjects, it took a young child to see past the lies and shout the truth, “The Emperor has no clothes!”. This “young child” is a metaphor for the “ground”, people who know what is going on. Unlike courtiers, young children are not beholden to kings.

Throughout the pandemic, I have witnessed how leaders kept themselves close to the ground. One particular leader at JTF(A) kept copious handwritten field notes, detailing his observations as he spoke with the “young children” on his ground visits. This translated into clarity of thought and good decisions that eventually turned the tide. The lesson is for leaders to be unafraid to re-visit and reverse dated decisions, and listen deeply to the ground in search of the truth.

The brave little tailor

Many fairy tales paint a distinction between good and evil, catered to young readers who are naive to the varying shades of grey. In real life, such a binary separation rarely exists, and protagonists are often multi-dimensional, such as in the case of this brave little tailor. Published in the Brothers Grimm collection in 1812, the story tells of how a lowly tailor overcomes numerous obstacles, including attempts on his life, to eventually become king. The tailor boasts of killing “seven with one blow”, conveniently omitting that his foes were mere flies. With an inflated reputation and a confidence to match, the tailor attracted giants in many duels who, despite an obvious strength overmatch, were outwitted and outclassed. It tells a story of gumption, confidence, resourcefulness, but also trickery, manipulation, cunning and ambition.

At the start of the pandemic, fear was rampant throughout Singapore. Such an environment prompted leaders at all echelons, despite their own uncertainty, to step up with messages of confidence. It was a statement of defiance, that we too, could defeat “seven with one blow”. The SAF set up task forces to help — JTF(A), MOTF, CSSTF, EHTF, and HSTF. Apart from the task force commanders, ground commanders also stepped up. They had to fight many “giants” — woes and problems which seemed insurmountable. Contact tracing when the R-naught was shooting upwards, food provision for thousands with varied dietary needs, re-housing migrant works in barracks, and to look after dormitories when they were falling like dominoes to the spread of the virus.

On the medical front, to deploy thousands of pulse oximeters to pick up hypoxia before patients deteriorated, to coordinate the transport and isolation facilities for positive cases, to curate the “single source of truth” for swab and serology results, to set up a “field hospital” in the form of a Community Care Facility, to vaccinate at speed MINDEF/ SAF personnel who were required for essential ops. These were the “giants” that we needed to outwit and outclass. Like all grey zone threats, this foe wouldn't be cowed by a force-on-force method, but must be subdued with operational cunning, nimbleness and more brains than brawn.

One interesting phenomenon was how at the beginning of the pandemic, Singapore was rated as the country with the highest infection count in the whole Southeast Asia. We soon realised that we were extremely efficient at testing. In the face of a laboratory test reagent scarcity, we adopted a different tack. We were careful not to become an ostrich, and dial down the testing, but rather, we used area testing methods like pool testing and sewage testing to help us identify high risk clusters, before zooming in to isolate the individual cases.

Operational cunning carries a slippery slope risk when the ends justified the means, but I observed a high degree of integrity in the decision-making process, preserving the trust and social compact between the leader and those being led. At every stage, the well-being and health of the people were the primary focus, overriding other political, defence relations and economic calculus. This was evident in another anecdote related to the transport ventilators mentioned earlier. We had enough in the SAF, and shared the excess with the public hospitals in Singapore. But the global shortage also presented an opportunity to strengthen our relations with key foreign partners facing their own ventilator shortages. In the end, it was decided that we would keep all the transport ventilators in Singapore, given the uncertainty of the situation, placing our people's well-being above all else. As a fly on the wall, I understood acutely the dilemma involved in such a decision and was heartened by the well-placed trust.

The elves and the shoemaker

The final fairy tale in this essay is also part of the Brothers Grimm collection published in 1812. The story is about little elves helping an old and impoverished shoemaker who is about to wind up his ailing business. While the shoemaker and his wife sleep at night, the elves busy themselves at the workshop, making beautiful leather shoes, which they leave behind every morning as they disappear to rest. This mysterious nightly affair makes the old couple a comfortable fortune and they decide to stakeout at the workshop to identify their benefactors. The couple see the elves hard at work but also notice that they aren't wearing any clothes. So the couple makes elf-sized shirts and pants, leave them at the workshop, and see how the elves happily put them on.

Ostensibly a whimsical tale of an unexpected windfall for the shoemaker, the fable is actually a tribute to the many little elves who toil while we sleep. And it reminds leaders to always look out for the unsung and unnoticed. Every time we wake up to things that work, clean water from the tap, the toilet flushes, the trains move, we should realise that they are not the result of happenstance. Similarly, when the medical centres open shop to treat flu patients and swab them; the medics and MOs who were not infected by COVID-19 themselves, the dispensary that was restocked every day, the SMS notifications of swab results, the vaccines that go into our arms. These are not by accident. At the peak of the pandemic, medics and MOs adopted a stay-in posture to reduce their infection risk from the community. Healthcare workers donned full Personal Protective Equipment in sweltering two-hour shifts. Laboratory staff manning their stations, doing PCR tests. IT colleagues working on the electronic medical records to send out the swab results to our mobile phones. Logisticians working overdrive to procure and deliver essentials to the ground. Manpower staff managing allowances and other tokens of appreciation to prop up morale. And NSmen made personal sacrifices showing that they could be counted on in times of need.

Like the old couple who hid at night for a peek, leaders too, will do well to see for ourselves the industry and commitment of those who toil. For not only does it strengthen our conviction to lead, it also affirms those whose labour is often unnoticed, and accords them the recognition they so richly deserve.

Conclusion

I return to the “SAF SARS Diary” published in 2004. That article was co-authored by Chief of Medical Corps, the late BG (DR) Wong Yew Sie, and the Head of the Preventive Medicine Branch, LTC (DR) Gregory Chan. The authors gave us a glimpse of their world and it was apparent how similar were the challenges. It was also apparent how the Medical Corps, the SAF and the country ultimately overcame the odds and the seemingly insurmountable. What the authors and their team had bequeathed wasn't just those pages of writing. The essay was a mere summary the actual treasure trove left behind — the mindset of preparedness, the humility of leadership, the spirit of resilience and optimism, the culture of gratitude, the wisdom of mentorship, the vast stockpiles, the repository of know-hows, the practices of pandemic drills, rehearsals and vaccinations.

Unlike the “SAF SARS Diary”, this essay is devoid of statistics and charts, but I hope it has captured the less measurable aspects of our current fight. When we opened the treasure box left by BG (DR) Wong and LTC (DR) Chan, we were heartened to find many tools that helped us tremendously. On behalf of the current team at the Medical Corps, I hope to pass on the same treasure box, replenished and stocked with new tools and insights, to the next team, so that when they open it, they too will find a useful nugget or two.