Fake news lessons from Lee Kuan Yew

That shrinking feeling

The ‘Koro Crisis’ of 1967 presented the then Prime Minister Lee Kuan Yew (LKY) with undoubtedly the oddest, yet potentially serious, problem to arise concerning public health during the early years of Singapore’s independence. The event provides a bizarre, yet revealing, vignette of the challenges faced by the country’s officials in seeking to modernise national institutions.

It highlights the importance of political trust for effective public administration, and of co-ordination between the different arms of a government. Furthermore, fifty years later some of the political issues remain salient. Since the comparatively poor election results in 2011, the authorities have again sought to allay the anxieties of citizens troubled by the rapid pace of change.

The Koro mass hysteria began in Singapore around the middle of 1967. The immediate trigger for the delusion was alarm generated over rumours concerning unspecified health risks of eating pork from pigs inoculated with anti-swine fever vaccine. Why this worry arose at that time is unclear.

Popular anxiety over the transmission of the swine fever virus from pigs to humans was first reported in medical literature in 1958. The first case of swine fever in Singapore had been detected on 8 July 1967. Within seven weeks, 57 cases involving 680 pigs were confirmed.

The government responded with a mass vaccination campaign, covering about 113,000 pigs at 1,485 farms. Publicity in the press and over the radio and television advised farmers to have their pigs vaccinated as early as possible. The scientific evidence was, however, clear. Meat from vaccinated pigs posed no health hazard, so pork from such animals remained on sale.

In 1967, there were still about 10,000 pig farms (with more than 715,000 pigs) dotted around the island. The $120 million industry was sufficient to meet the domestic demand for pork. But the Primary Production Department (now the Agri-Food and Veterinary Authority) of the Ministry for National Development (MND) was concerned that pig farming required too much intensive use of land and water – increasingly scarce resources as Singapore sought to industrialise.

This policy position may explain why, in the ensuing weeks and months, the ‘urban legend’ (believed to have started, however, in rural areas) took hold that the government was hiding another threat to the existing way of life.

When the impact of the swine fever outbreak was raised in Parliament on 7 September 1967, the government revealed that compulsory pig vaccination was being considered but during October, sales of pork still remained unusually depressed. These events came together and resulted in an open public health crisis on 29 October.

That morning, local newspapers broke the news that many Singaporean men had become convinced that their genitals were at risk of withering away, due to eating pork from pigs vaccinated against swine fever—and that this would eventually lead to its permanent disappearance. Sufferers from the ‘genital retraction syndrome’ often sought to prevent further shrinkage by securing their private parts with red string or wooden clamps until medical assistance could be sought.

With the fear publicly surfacing, victims of the condition rushed in growing numbers to seek medical advice. An unrecorded number of patients consulted traditional healers in Chinese medicinal dispensaries or private doctors. In addition, over 500 sufferers sought treatment at public hospitals.

The records from Accident and Emergency (A&E) departments show that patients suffering from a disappearing manhood panic attack usually recovered within hours or at most a few days, either after being sedated or persuaded that the 'illness' was over or had never existed.

The only lasting medical damage occurred in those few cases where the wooden clamps, rubber bands, chopsticks or red string that patients had tied around the membrum virile to prevent shrinkage had unduly restricted normal blood circulation.

The MND imposed strict controls and required any pigs who died as a result of swine fever to be buried on the spot. As a result, consumers had no legitimate reason to fear that the pork that they were consuming was infected by swine fever and were also informed that meat from vaccinated pigs was safe to eat.

On 3 November 1967, the MND declared that “no one in Singapore need worry over the safety of pork from pigs slaughtered at the government abattoir where every carcass is carefully examined and stamped as fit for human consumption before they are released to the market.”

The reported Koro caseload peaked in the first week of November. On 2 November, Thomson Road General Hospital recorded eleven cases, and the following day at the Singapore General Hospital ninety-seven patients turned up. Worried parents brought their sons, and anxious mothers carried in their baby boys.

In one incident, a driver stopped for speeding by the police was supposedly given an escort to a hospital A&E department when the officers discovered the cause of his hurry. Female cases now also appeared, albeit in much smaller numbers.

The doctors on duty had been counselling their patients and, if unable to allay their fears, administered mild Valium tranquilisers and sedatives such as chlordiazepoxide. The spike in the number of cases and the rapidity of its spread across the island, however, now alarmed the medical profession and the Ministry of Health (MOH). The concentration of cases pointed to epidemic proportions. On 3 November 1967, newspapers ran on their front pages the MND instruction, Pork: 'Ignore rumours'. This uninformative order did nothing to alleviate public concern.

On 4 November, the Singapore Medical Association (SMA) announced that its experts had reviewed all the scientific evidence. The panel it had set up a few days earlier was spearheaded by Dr Ah Leng Gwee, then Senior Physician at Singapore General Hospital and Honorary Editor of the Singapore Medical Journal, who had already published a study on the cultural characteristics of the Koro phenomenon.

The SMA’s statement was simple and its message was clear: the physicians had reviewed all the evidence and had unanimously concluded that there was no threat to humans from the current strain of swine fever, the vaccine against it, or from consuming the pork produced from inoculated pigs. Despite this re-assurance, some alarmist newspaper reporting continued. Under the headline ‘Koro hits Tampoi,’ the Eastern Sun on 5 November 1967 stated that the condition had spread across the border to Johor Bahru in Malaysia.

Over the next few days, the MOH repeated the message, which was widely covered in the national newspapers and on television. Public respect for the medical profession seemed to have been the decisive factor in calming anxiety and quelling rumours.

From then on, A&E visitor numbers rapidly declined. The Singapore General Hospital caseload fell from 38 Koro patients on 5 November, the day after the first SMA announcement, to 17 by 7 November. That day, the Straits Times prominently declared that Koro was a delusion due to psychological worries and reported on another MOH press conference in which a panel of experts headed by MOH permanent secretary, Dr Ho Guan Lim, repeated the message that Koro was purely a psychological ailment caused by mass hysteria.

The next day, however, the story appeared in the foreign press. The Canberra Times, under the headline KORO ‘NOT THREAT TO MANHOOD’ reported that the Singapore government was seeking to calm thousands of men who feared that their manhood was being threatened by a mysterious ailment sweeping the city.

The epidemic scare faded away as rapidly as it had appeared. The price of pork had returned to normal by mid-November and had completely disappeared by the end of the month, though occasional individual cases were reported over the following years.

Lessons for public administration

The first lesson from the Koro episode is the importance of ‘whole of government’ co-ordination. The vaccination campaign against swine fever was implemented by the Primary Production Department of the MND. The director of the department, Cheng Tong Fatt, despite (or on account of) being a trained veterinarian, evidently struggled to win the trust of pig farmers.

He had brought swine fever under control but was clearly frustrated that its complete eradication was thwarted by ignorant farmers adopting a ‘wait-and-see’ attitude to the epidemiology, instead of following the scientific advice and getting their pigs vaccinated as soon as possible. Such pig-breeders were mainly people with either no or limited education who felt their small-scale livelihood was under threat.

The subsequent Koro epidemic and the public’s trust in the SMA and MOH ultimately resolved the resistance to the vaccination campaign. In 1967, the MND’s veterinary experts from the Primary Production Department were regarded with suspicion by some pig farmers, and thus apparently lacked credibility with the citizens.

As a result, official efforts to halt the swine fever vaccination rumours through public education using scientific evidence failed. By contrast, the SMA and MOH doctors had evidently established the trust of their patients, and their factual non-emotive guidance was believed.

People evaluated individual and collective risk against the perceived reliability of public institutions, and evidently trusted Western medicine even while the threat was premised on traditional Chinese beliefs that the penis could shrink under certain conditions of ill health.

The medical authorities were able to build on the trust that the public had in doctors, in order to bring the epidemic under control. The government learnt the importance of clear messages. One possible source for the crisis may have been inadvertent comments by an official at the MND about the anti-swine fever vaccine.

A second lesson from the episode is that any immunisation campaign - an essential ‘public good’ to reduce the collective threat posed by communicable diseases - requires public trust in both the government and science. The early efforts at building trust in public health in Singapore have implications for public administration everywhere.

Such trust is strongest within social groups, while distrust often prevails across different social divides. As society becomes more complex, people are increasingly reliant on the quality of public administration. On the basis of trust and common values, societies learn to delegate their collective protection to public authority. Technical solutions can only work in context, even during a public health crisis.

Since 1967, the government of Singapore has improved its approach to public fears about health crises. But the political context has also sheltered public health administration from public criticism. One example was the outbreak of severe acute respiratory syndrome (SARS) in Singapore that occurred in February 2003. 33 people died before the country was removed from the World Health Organization’s list of SARS-affected areas on 31 May 2003.

The strategy involved educating the public on the disease while the MOH invoked the Infectious Diseases Act on 24 March 2003 to quarantine and monitor all SARS patients. The use of infra-red scanners and home quarantine surveillance cameras was an important technological breakthrough.

Airlines operating flights to Singapore were required to screen passengers. Visitor arrivals and hotel occupancy rates plunged, revenues at shops and restaurants dived, taxi drivers reported fewer passengers, the stock market fell, and some people lost their jobs.

The politics of trust influences policy effectiveness. When politics and science get badly intermingled, public trust in the authorities can quickly evaporate in ways that do not help improve public policy. Tan Tock Seng Hospital held its Annual Dinner and Dance as scheduled on 14 March 2003, even though the World Health Organisation had issued a global alert, and the hospital had alerted the MOH to a rare infection not responding to antibiotics.

The landmark research papers published in the world’s premier medical journals such as The Lancet came from Hong Kong, not Singapore, even though the outbreaks occurred in both places at about the same time. In other political contexts, there might have been more media criticism of such limitations.

The third lesson is the role of education. An informed citizenry is essential to an effective polity. With the adult literacy rate having improved from 73 percent in 1965 to almost 100 percent in Singapore today, it seems that kongtow, or the traditional Chinese belief in magic, has waned. This makes it inconceivable that a similar outbreak of mass hysteria could happen today. But education itself is not sufficient to ‘modernise.’ Indeed, in the episode in Singapore, only 5 percent of those patients who agreed to a follow-up interview (some 236 out of the 469 tracked) were uneducated.

Today, a better educated population might be more sceptical of the government and the media. In 1967, television underpinned the credibility of the public health message. Although televisions were still new (service began in 1963), it was widely trusted and seen as speaking directly to every viewer, thereby helping forge national identity.

The collective neurosis that the episode revealed reflected dis-empowerment and the lack of adequate political ‘voice’ or influence at a time of political instability. When the hysteria appeared to be growing, with the authorities uncertain on how to respond, the political credibility of the government was threatened.

Even if the PAP intuitively fostered crises to generate a widespread collective psychosis, nevertheless, an effective interface between a country’s political and administrative leadership proved critical to address public concerns at a time of upheaval and transformation. The challenge was not of medical science but, at a time of deep concern over rapid social change, of public trust in the authority of the state.

Max Everest Phillips is the Director (retired) of the UNDP Global Centre for Public Service Excellence in Singapore. These are excerpts from his book ‘The Passionate Bureaucrat’.