Living through the coronavirus pandemic in Singapore, Joys Tan followed the rules that helped the city-state keep its cases low: keeping her distance from others, wearing a mask and getting herself vaccinated.

Nobody in her family had contracted the virus, and it was with confidence that she had dinner at her godmother’s house earlier this month, even with infections rising rapidly, fueled by the delta variant, as the government pushed ahead with a strategy of “living with COVID” as an endemic disease with a gradual relaxation of restrictions.

Two days later, Tan learned her godmother had tested positive for COVID-19, forcing her into precautionary quarantine herself. As she lived in a hotel room away from her husband and 2-year-old son for nearly a week, the 35-year-old graphic designer began to wonder, like many Singaporeans, if living with COVID-19 means living with permanent anxiety about possible infections.

“I am worried all the time, super worried all the time, because of not knowing what lasting effects COVID has on the body; and when you have a young kid, it’s constantly on your mind,” she said. “I’m trying to embrace the endemic mindset that the government is transitioning into, but it’s very hard.”

After almost a year of new daily cases in single, or low double, digits, infections have skyrocketed in the past month, hitting another new record Tuesday with 2,236 and laying bare the challenges of such a strategy. But behind the headline figures, there is evidence the plan is working, with its focus more on the severity of infections and hospitalizations than the number of daily cases.

With about 82% of the population over age 12 fully vaccinated, hospitals have not become overwhelmed, with 98% of new cases either asymptomatic or with mild symptoms.

Only 0.2% of infected people have required ICU care and 0.1% have died—more than 65% of whom were either unvaccinated or only partially vaccinated. Of the five deaths reported Tuesday, all were seniors with underlying conditions; two were fully vaccinated, one partially, and two were unvaccinated.

And the overall figures, while high for Singapore, are still extremely low.

As of Tuesday, Singapore has reported a total of 85 deaths from COVID-19 since the beginning of the pandemic. Across the narrow Straits of Johor, neighbor Malaysia counted nearly three times that many on Tuesday alone.

Malaysia has reported 791 COVID-19 deaths per million residents since the start of the pandemic; Singapore only 14.

After one of the most successful vaccination rollouts in the world, and the pandemic brought well under control with strict regulations and aggressive testing and tracking, Singapore began in August what it calls a “transition journey to a COVID-19 resilient nation.”

In doing so, the wealthy Southeast Asian nation of 5.5 million people tacitly conceded that reducing cases to zero was not a possible long-term solution, and instead decided it could start a gradual return to everyday life, said Tikki Pang, a visiting professor of infectious diseases at the Yong Loo Lin School of Medicine at the National University of Singapore and a former World Health Organization researcher.

“In the longer term, it is really going to become the norm,” he said of the approach. “Because I think most governments of most countries will accept the fact that this virus is not going to go away, it’s going to become endemic and we’re just going to have to learn to live with it like the flu.”

Officials calculated that Singapore’s testing is comprehensive enough to detect new outbreak clusters rapidly, its vaccinations are comprehensive enough to prevent widespread hospitalizations, and its health care system robust enough to deal with any increase in patients.

What they hadn’t reckoned with was the proliferation of the highly transmissible delta variant, and though they clamped down quickly on outbreaks in a group of karaoke lounges and a huge seafood market, it wasn’t possible to stop, Pang said.

“They came down pretty hard, they delayed the spread of the delta variant a bit, but it was already out there,” he said in a telephone interview from Geneva, where he splits his time with Singapore.

A month into the plan, Health Minister Ong Ye Kung sought to allay growing concerns among ordinary Singaporeans, saying the wave was expected and should be seen as a “rite of passage” for any country hoping to live with the disease.

“We are on a path of transition to a new normal of living with COVID-19,” the minister said.

Leo Yee Sin, executive director of the National Center for Infectious Diseases and head of Singapore’s pandemic response, told The Associated Press that the surge has reinforced evidence the delta variant can evade resistance to COVID-19 and that her office has determined it is important for at-risk individuals to get a booster dose.

And while vaccines have meant milder symptoms for most, even asymptomatic people carry the same amount of the virus in their respiratory tract and can easily spread it, she said.

“This is why safe management measures continue to remain important,” she said. “And if one experiences even mild symptoms, they should seek medical attention and get tested immediately.”

The Health Ministry has predicted daily cases could exceed 3,200 by the end of the week at the current rate of spread, and experts say they could hit more than double that before starting to come back down.

The government last week tightened some lockdown measures in response, reducing the group sizes for social gatherings and for dining in restaurants. Officials said the number of people needing oxygen and ICU care were “within expectations” but that many patients with mild symptoms were also seeking help at hospitals, and the medical system was growing strained.

The prime minister’s wife, Ho Ching, urged patience in a Facebook post this week, reminding people that the measures were nothing like last year’s “circuit breaker” shutdown.

“With vaccination, COVID is no longer a dangerous infection,” Ho wrote. “Those of us who are vaccinated can afford to be patient for a while more, and to have a heart for those who are still coming forward to be vaccinated.”

From Tan’s own experience trying to get medical advice on what to do after her godmother, who is recovering at home, tested positive, she said it was obvious that the system was becoming taxed.

“It took so long for me to come into this quarantine facility, as much as the government is trying to be conscientious in its efforts,” she said.

Still, she said, she was “very thankful” that Singapore has systems in place with someone to call to help with such arrangements, even if it did take time.

Singapore’s experience could “serve as a cautionary note” for other governments as they attempt to achieve a balance between “lives versus livelihoods,” said Ooi Peng Lim Steven, a senior consultant with the National Center for Infectious Diseases.

“Cautious reopening with phased periods of heightened alert has proven viable as governments attempt to reopen their economies and put an end to crippling lockdowns,” the epidemiologist said.

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