In theory, employers are required by law to provide medical treatment for work permit holders they bring into Singapore. In practice, the more unscrupulous employers will try to get the employee out of Singapore before the worker realises he is being deprived of treatment and learns to use official channels to get his employer to provide.

It is bad enough when a worker has suffered an injury and is rushed home without sufficient medical attention. But this story is unusual because it’s about a worker with an infectious disease.  What public health issues arise when an employer tries to avoid the cost of treatment? We argue here that when employers get away with making private cost savings, they come, as in this case, with quite serious public risks.

Razzak (not his real name) had a chest injury at a shipyard. Several months later, he was operated upon to remove a blood clot which didn’t clear up by itself and was causing problems. Following the operation at Alexandra Hospital, the surgeon penned a note asking for the patient to be tested for tuberculosis. Perhaps he noticed some lesions in his lungs.

An article your writer found would shed some light on what the surgeon might have seen:

When the lungs become infected with [Mycobacterium] tuberculosis, the body’s immune system walls off the bacteria into lesions called granulomas, explained co-senior investigator JoAnne Flynn, Ph.D., professor of microbiology and molecular genetics, Pitt School of Medicine.

“It’s long been thought that the patient with a weakened immune system or some other immune vulnerability was more likely to develop active disease,” Dr. Flynn said. “But to our surprise, our study showed that every infected individual has a collection of granulomas, some containing live bacteria and some that are sterile because the immune system has killed all the bacteria. So in this sense, there’s no such thing as a latent or active granuloma.”

— Science Daily, 15 Dec 2013, Lung lesions of TB variable, independent whether infection is active or latent

The tests on Razzak were done and the results came back positive. Immediately, Alexandra Hospital referred Razzak to Tan Tock Seng Hospital (TTSH), the main hospital for infectious diseases, providing him with a referral letter for a defined appointment date. Treatment typically involves a six-month course of medication. Highly symptomatic cases — patients who are coughing badly — may be quarantined, since TB spreads through airborne particles.

Razzak appeared to us at TWC2 to be asymptomatic, though the medical practitioners might have reason to think differently. Nonetheless, as the above-quoted article indicates, even if his is a case of latent TB, he would still have active bacteria in him and is potentially contagious.

As soon as he presented the letter to the employer, it was taken away from him. This action suggests that the employer did not want him to go for treatment. Nonetheless, without appointment letter in hand, he still showed up at TTSH where he was told he needed to start on a course of treatment though it is not clear whether he treatment actually commenced at that very appointment. Regardless, it was soon overtaken by events. The employer cancelled his work permit and made arrangements to send him home, which naturally made him very unhappy. This was when he first showed up at TWC2.

We sent an email to MOM to enquire if the company would still be held responsible for TB treatment, but before we got any reply, we learnt that the worker had been repatriated, and the matter became moot. We have no idea if he was forcibly put onto a plane.

Beside the question of whether the worker’s best interests were served by the employer’s attitude, or whether MOM could have stepped in with a kind of Code Red response once they received our email about tuberculosis and the question of treatment, what troubles TWC2 are public health risks should an employer behave in a manner like in this case. What if an employer, refusing to pay for treatment, stops a worker’s course of treatment, and we have to engage in a lengthy bureaucratic battle to sort things out? We know that these bureaucratic wrangles can really take a while, from our many experiences trying, through MOM, to get recalcitrant employers to provide treatment for worksite injuries. When it comes to infectious diseases, delay presents a heightened danger to the public as well.

In Razzak’s case, one might be tempted to breathe a sigh of relief that he was quickly sent out of the country, though he was moving around Singapore for at least a week post-diagnosis. But lest we think that urgently repatriating a worker is a “better” response than starting him on immediate treatment, consider this: What about the planeload of passengers who shared the same flight as him?