Sarah Tan Yingli & Kai Yuan Tey
B was leaving Singapore that weekend, heading home to Bangladesh. His workplace injury compensation case had finally been resolved. We asked if he was excited for the reunion with his family after so many years abroad, and the subdued acceptance in his sad smile—“[I’m a] little bit happy”—was striking. B had fallen from scaffolding and severely injured his back, leaving him unfit for further work. Under the orders of his employer he spent months bouncing between various hospitals and clinics, looking for the “cheapest rates”. His eventual injury compensation fell far short ofhis entitlement. Ongoing disputes with his employer about his injury compensation culminated with a heated argument during which B was struck in the face. His search for help had brought him to HealthServe, and it was there he was generous enough to share his story.
It is a story that would resonate with the experiences of many low-wage migrant workers in Singapore. A review conducted by the Ministry of Manpower (MOM) in June 2017 found migrant workers account for a 37.9% of the Singaporean labour force. More than half are employed as low-wage labour or in service industries. Despite serving as the cornerstone for Singapore’s booming economic and architectural development, B and his fellow low-wage migrant workers constitute an especially vulnerable population,[2,3] subject to exploitation and often left shouldering significant burdens of illness and injury.
HealthServe is a not-for-profit, non-government organisation that reaches out to a community whom its small staff and indispensable volunteers pointedly refer to as their “migrant brothers and sisters”. Dr Goh Wei-Leong founded HealthServe in 2006, offering migrant workers medical care, social assistance, casework, personal development classes, and a hub for communal recreation. The 2017 Singaporean of the Year title awarded to Dr Goh (and the HealthServe organisation as a whole) has fuelled the long waiting list of medical students keen to assist with its operations. We were fortunate to complete our 6-week internship at HealthServe over the recent summer university vacation.
Working at the clinic
HealthServe began as a clinic in Singapore’s Geylang district providing general practice (GP) and dental services two evenings a week and Saturday afternoons. It has since expanded to include regular specialist dermatology and orthopaedic consulting and two additional worker-dormitory-based clinics offering similar healthcare services.
As interns, clinic days meant arriving 3 hours ahead of advertised opening times to prepare for the imminent rush. Migrant brothers and sisters would come in throngs—busy days, with more than 50 patients waiting before even the first had been seen, necessitated the emotionally draining process of turning some away. HealthServe saw patients from a range of occupational backgrounds. Although most of the patients were men, staff also assisted the occasional female domestic worker referred from the Humanitarian Organisation for Migration Economics (HOME).
The clinics themselves were unlike anything we had experienced. Every role relied on volunteers, from doctors to receptionists. The clinic manager helped interns fill staffing gaps as needed, becoming temporary dental assistants, receptionists, triage ‘nurses’ and medication packers. We soon learnt that even the seemingly menial jobs played pivotal roles in the clinic’s operations, underlining the importance of an effective multidisciplinary team in delivering quality patient care.
Resources were scarce. It was eye-opening to witness how the clinic’s financial dependence on grants and donations impacted healthcare. Proton pump inhibitors were often replaced with H2 antagonists. Measuring tapes substituted for height charts. ECG machines left over from the 1990s tested our abilities to adapt and make do. We embraced the challenge.
We were soon eagerly conversing with the migrant brothers as we triaged the waiting patients, finding joy in the supposedly mundane vitals measurements. They had many stories to tell—of Bangladesh’s six seasons in a year, of the food back home in China, or of their dreams and aspirations. Triaging was an opportunity to exercise our clinical judgment supported by the safety net of the clinical manager’s review. The conversations that unfolded while doing so were potent reminders of the individuals behind the pathological processes it was so easy to become absorbed in. As Sir William Osler once said, “The good physician treats the disease; the great physician treats the patient who has the disease.”
Chronic conditions like diabetes and hypertension were rife, exacerbated by poor diets and a reluctance to seek medical attention understandable when a standard consultation could cost the equivalent of 3 days’ wages. A large proportion of our patients presented suffering from muscle strains, ligament sprains, back and soft-tissue injuries, and chronic pain—the inevitable results of gruelling 12-hour shifts 6 or 7 days a week. Patients with injuries severe enough to stop them working were stuck in a jobless and incomeless limbo between the termination of their work permits and the payment of their workplace injury compensation. Our hearts went out to those who described their predicament—the perpetual uncertainty of the process, the months or even years waiting for resolution, the scheming employers intent on cutting costs, and the meagre compensation eventually received.
Beyond the clinic
The inherent precarity of migrant worker life discourages outspoken resistance against exploitation for fear of pay cuts and retrenchments. Movement restrictions, squalid housing conditions, and passport confiscations are alarmingly common practices.[7,8] In 2014, one manager was jailed after pleading guilty to breaching employment regulations and underpaying wages. But the enforcement of accountability is rare. Many workers arrive already in debt from the 6000 to 15,000 Singaporean dollar employment agency fees paid to secure positions before departing their home countries, leaving some convinced “it’s better to be underpaid than not paid at all.”
Dr Goh, a strong proponent of learning through immersion, would encourage interns to explore migrant worker haunts, travel to dormitories, and encounter the plight of the migrant workers firsthand. We visited some of HealthServe’s dormitory-based clinics and were taken aback. The fencing erected following the 2013 ‘Little India’ riot was reminiscent of a penal institution. A dormitory floor housed 20 rooms, each shared by 8 to 10 migrant brothers. Washing machines and refrigerators were bought by the workers themselves and every floor contained one communal bathroom. The migrant brothers’ days were strictly regimented— waking up at 5:00 AM, taking the shuttle bus to work, and then returning to the dormitories to cook, bathe and sleep.
On days when the clinic did not open, our intern responsibilities included everything from sorting medications and autoclaving dental instruments to organising the specialist referrals some migrant brother patients required. These pro bono specialist consultations relied on the goodwill and altruism of Dr Goh’s friends and colleagues who share his outlook on migrant worker health. We would accompany the migrant brothers during these appointments to alleviate their anxiety and offer emotional support. Cases we witnessed ranged from foreign body removal to the diagnosis of kidney stones secondary to horseshoe kidneys (ren arcuatus or renal fusion). Diagnostic reasoning and management plans were tailored to a population so different from the Australian and primarily Caucasian patients we had dealt with in medical school. The social determinants of a patient’s health were a factor in every decision about appropriate treatment options. No matter the outcome, the migrant workers showed gratitude towards their treating doctors and were generous in expressing appreciation towards us for accompanying them to the clinics.
Behind closed doors
Every Thursday afternoon, the staff gather for a lunch meeting at the heart of Little India. As food and laughter are shared, ideas on improving the services supporting the low-wage migrant worker community are exchanged with equal passion. The English lessons and computer classes now run by HealthServe volunteers are just two of the fruits of these weekly meetings. Dr Goh was always open to informal meetings with staff and interns to reflect and recalibrate.
Our experience at HealthServe was enriching to say the least. While there is much more to be done to help the migrant brothers and sisters driving Singapore’s economic progress, it is heart-warming to witness the ever-increasing awareness and support for migrant worker advocacy. Organisations such as Transient Workers Count Too (TWC2) and Migrant Workers’ Centre (MWC) are contributing to one day achieving what Dr Goh sees as his advocacy’s ultimate aim: “Our job in HealthServe is to make sure that we are out of job.”
We appreciate the time taken to read this article. Var Lock Tergo (“God bless” in Bengali).
The authors would like to thank HealthServe for providing the consent for writing this report on their experiences. The authors would also like to express their gratitude to HealthServe for the opportunities and experiences provided, and extend the same to everyone they met during their internship who together made the experience so enriching.
Images 1–4: With permission from Xi Zhe Sim, fellow HealthServe intern.
Conflicts of interest
1. Summary Table: Labour Force [Internet]. Singapore (SG): Ministry of Manpower; 2018 Jan 26 [cited 2018 Mar 25]. Available from: http://stats.mom.gov.sg/Pages/Labour-Force-Summary-Table.aspx
2. Harrigan NM, Koh CY. Vital Yet Vulnerable [Internet]. Singapore (SG): Singapore Management University; 2015 Nov 4 [cited 2018 May 22]. Available from: https://www.smu.edu.sg/sites/default/files/smu/news_room/Research%20Report_Vital%20Yet%20Vulnerable%20%28FINAL%29.pdf
3. Lyon E. Wage challenges faced by migrant workers in Singapore [Internet]. Singapore (SG): CSR Asia; 2017 Mar 29 [cited 2018 May 22]. Available from: http://www.csr-asia.com/newsletter-wage-challenges-faced-by-migrant-workers-in-singapore
4. Toh WL. GP Goh Wei Leong and healthcare charity he co-founded named The Straits Times Singaporean of the Year 2017 [Internet]. Singapore (SG): The Straits Times; 2018 Feb 6 [cited 2018 Mar 30]. Available from: http://www.straitstimes.com/singapore/gp-and-healthcare-charity-he-co-founded-named-the-straits-times-singaporean-of-the-year
5. Centor RM. To be a great physician, you must understand the whole story [Internet]. Medscape General Medicine Vol. 9 Issue. 1; 2007 Mar 26 [cited 2018 Mar 30]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924990/
6. WICA versus common law [Internet]. Singapore (SG): Ministry of Manpower; 2017 Jun 28 [cited 2018 Mar 26]. Available from: http://www.mom.gov.sg/workplace-safety-and-health/work-injury-compensation/wica-versus-common-law
7. Singapore: Events of 2016 [Internet]. New York (US): Human Rights Watch; 2017 [cited 2018 Mar 26]. Available from: https://www.hrw.org/world-report/2017/country-chapters/singapore#f176e9
8. Rajah M. What plagues the migrant worker? [Internet]. Singapore (SG): Transient Workers Count Too (TWC2); 2014 Nov [cited 2018 May 22]. Available from: http://twc2.org.sg/wp-content/uploads/2014/11/what_plagues_migrant_worker.pdf
9. Chelvan, VP. Manager jailed 34 weeks for exploiting more than 100 foreign workers. Channel News Asia (International Ed.). 2017 Feb 24 [cited 2018 Mar 26]. Available from: https://www.channelnewsasia.com/news/singapore/manager-jailed-34-weeks-for-exploiting-more-than-100-foreign-wor-7602678#main
10. Han, K. Singapore’s migrant workers struggle to get paid. CNN (International Ed.). 2018 Feb 25 [Cited 2018 Mar 26]. Available from: https://edition.cnn.com/2018/02/24/asia/singapore-migrant-workers-intl/index.html