The future of regulatory oversight in Singapore - Madoff and the AVA

As if to reinforce the point, there on pg 30 of today's (Dec 21) Sunday Times is another report on the Madoff Ponzi scandal. The subtitle of the article reads: "Scandal could have been prevented of the financial system's gatekeepers had been competent and independent".

Yeah. Competence and independence.

I have no problems with the competence issue. We got lotsa smart people. It's fundamentally a problem of how they apply their smartness. Which has to do with the second attribute - independence. I have commented on this before in an earlier post.

No regulatory agency can do it's job properly if it is unclear where to focus its eyes on. How do you regulate if you are more concerned about the impact on the health of the industry you are supposed to be regulating? That's surely the role of 'the other agency'! I mean, isn't the role of the regulator to protect the consumer public against the industry's excesses?

But our regulators are invariably too concerned about not offending the industry, and not to be seen as being obstacles to the growth of the industry.

No? Well....just look at the structure of the regulatory agencies we have. They are invariably organically infused with a promotional mission. Look at how these agencies rank their performance...."Pro-Enterprise Index"? What are the parameters of these PEI? Compliance cost; Review of Rules;Transparency;Customer Responsiveness; andPro-enterprise Orientation.

Errmmm...nothing about the consumer in there. Who really cares about them?

This was what failed in the Madoff scandal. The industry was more important. This was what sowed the seeds of the current financial crisis.

And this was what lay behind the melamine hysteria.

Interestingly, on pg 12 of todays Sunday Times, there is a small article on AVA's response to the melamine thingy. Tessa Wong reports that the melamine saga cost the AVA $2 million to do 'additional laboratory tests'. Apparently, melamine was never considered a food contaminant.

Ho hum. Really? Did they not read the newspapers back in 2007, when there was this massive pet food recall in the US? Did they not connect the dots? Or were they just too concerned about their Pro-Enterprise Index ranking?

Yeah. Competence and independence. That's what we so badly need.

Is this just just one of my PMT days when I rant on aimlessly, and take potshots at aything that moves? No. We have been debating more serious issues about euthanasia and human organ trades. Much of the acceptance of of these highly controversial issues depends on our ability to trust in the regulatory competence and independence of the agencies in charge. We need to know that these agencies are focused on consumer/public protection, and not being primarily concerned with the health of the medical industry.

It's never going to work any other way. We need a major overhaul of the regulatory environment, especially those related to health and safety. We need to know that the ethical review processes are truly objective and are genuine advocates of patients and volunteers/donors (and not defenders of doctors/surgeons' and scientists' rights to exploit). We need to be assured that the regulatory agencies (AVA, HSA, Singapore Medical Council?) are true protectors of the consumer/public and not disguised promoters of the industry. And we need to have more than just verbal assurances that these august bodies are competent and independent. They need to be organically structured to have that independence of regulatory decision making.

Are these too much for a Christmas wish?

The future of regulatory oversight in Singapore - Keep your eyes on the ball, guys!!

In the increasingly fast and furious game of tennis, players are constantly reminded to keep their eyes on the ball. Sure, you can run fast and hit hard, but take your eye off the ball, and your shot goes wild.

So it should be for our regulatory authorities.

Once again these recent days, we are painfully reminded of regulatory lapses which have led to possibly the biggest financial fraud of all time. Bernie Maddoff stands accused of engineering the largest pyramid scam (Ponzi scheme???) of all time, cheating investors of US$50 billion.

While we may not have all that much sympathy for the greedy silly investors, it is increasingly coming to light that behind this debacle, was a regulatory system that took it's eye off the ball.

Financial regulators (as do all other regulatory systems) have a responsibility to the public to do their job. While they cannot ever be completely failure proof, they are obliged to be vigilant and to take action where there is evidence of wrong doing. Where there are cracks in the dam, some maintenance work needs to be done.

But here is the sad truth of how real life works. No regulator wants to be the one to rein in a business that is on a roll...and on a roll big time. For a big name like Bernie Maddoff, in whose now discredited schemes other big name investors trusted in, no regulator wants to go in and stall a winning game. Even when evidence emerges that things are seriously amiss.

At some point itme though, the shit does hit the fan. The tsunami comes to shore. Another black swan? Hardly. There were ample warning signs before the storm. They just took their eye off the ball.

Remember the NKF problem in Singapore? Someone took his eye off the ball. NKF(National Kidney Foundation) was doing great. Successful charitable organization. Screw the gold taps, they were doing well. .. and saving the Ministry of Health millions. Someone took his eye of the ball, and the regulators kept their hands in their pockets.

Here is where we have a problem in Singapore. We have as a society that has defined success as being denominated primarily by economic gain. Our regulatory agencies are almost invariably harnessed to promotional agendas. Regulate with a light touch, ... and don't you dare screw up our economic growth.

It's not for me to say whether this is right our wrong. This is merely a strategy that has been adopted. History will prove it's rightness....or wrongness.

But I seriously doubt we will produce tennis champions who instead of keeping their eye on the ball, keep watching the guy on the next court with the bulging biceps, or the cute blonde with a short skirt and pink panties.

Human Organ Trade - Thank you Chris and Lay Guat!!

I reproduce for you here a letter to the Straits Times on 18 December 2008 by Dr Chris Cheng and Dr Ng Lay Guat. What a great letter from 2 wonderful transplant surgeons who are prepared to their values up front!

The thing that taints the organ transplantation programme is the prospect of it degenerating into a crass commercial trading activity. The sacrifice of ethics and human value for profit. If we want to justify the reimbursements of non-relative oran donors, then we must strip away the associations with trading and exploitation that almost invariably will accompany it.

But here are 2 transplantation surgeons who are prepared to step forward and condemn this trade, at the expense of losing professional business opportunities. Chris and Lay Guat, I take my hat off to you!

I wish there were more transplantation surgeons of their mold. But I suspect there will be few.

Here is a challenge to transplantation surgeons and the institutions that house them, to do the right thing. If you are truly concerned about the renal deaths, and wish to see more ethical live donor organ transplantations, show us how genuinely altrusitic you are. Forgo your professional fees. Waive the institutional charges. Let's not do this to fatten your wallets.

Let us see how genuine you are in your compassion for the terminally ill organ failures.

-----------------------------------


High price of compensating donors
By Christopher Cheng & Ng Lay Guat, For The Straits Times

EVER-LENGTHENING waiting lists for kidneys is an old problem not unique to Singapore. Almost every country in the world has a waiting list that is growing longer faster than the number of transplants done per year. The solution to this problem is of course to increase the number of transplants performed. Singapore is on the right track in encouraging live donor transplants, and the opt-out system of the Human Organ Transplant Act will increase the number of deceased donor transplants. Other measures such as raising the donor age limit and paired donor transplants can help shorten the waiting list to an extent.Compensating donors is another means the authorities have suggested to shorten the waiting list. We feel that this would be an overly zealous measure.
We do not object to reimbursing altruistic donors so they do not suffer from having only one kidney. As transplant surgeons, we have come across many families with several potential donors. The ones who finally come forward tend to fit a certain profile. We have seen many instances of sister-to-brother, wife-to-husband and sister-to-sister donations. This is not because women are more generous than men, but rather because they tend not to be the sole breadwinners in their families.
For example, we recall a young patient with end-stage renal failure who had nine siblings. We couldn't help but remark that she was, in a way, luckier than many patients with smaller families. However, the only sibling who came forward to donate was an older sister. When we examined the matter, we realised that the donor was single, whereas all the other siblings were married and were breadwinners.
The worry that their own families may suffer if they chalk up large medical bills years after donating a kidney is valid. But giving such donors a lump sum may not be the answer to their worries. Not all are shrewd fund managers. Assurance of help in the event of future medical problems relating to the donation would probably be more helpful.
Another potential problem with compensating donors is that it may turn away truly altruistic donors. Already, we are seeing potential donors delaying their decision because of pending legislation on this matter. The feeling is: 'If the patient can get a kidney by paying for it, why should I run the risks of donating my kidney?' People may also refrain from offering to donate a kidney for fear of being called greedy.
The most unacceptable effect of compensating donors is that such compensation may slip into organ trading. Some have argued that the poor have the right to decide what they can do with their bodies, and if they choose to 'commodify' their bodies so that they and their families can benefit financially, so be it!
Only people driven to desperation will consider parting with parts of their bodies. They are either in desperate need of money or in great debt. The money they might save from the organ sale may be very meagre indeed.
The Government should consider giving donors medical coverage so their fears of possible medical problems later in life might be allayed. The cost of such coverage is potentially high, but we suspect it would be affordable. This is because the criteria for selecting donors are stringent, and the people who qualify to be kidney donors tend to be fit. The possibility of their developing end-stage renal failure is very low.
A rich person with end-stage renal failure should not have the automatic right to buy spare parts from another person just because he can afford to do so. This would amount to causing bodily harm to another, not unlike in slavery.
Performing kidney transplants is a joy. Watching an end-stage renal patient recover from surgery and seeing a happy family leave the hospital is a blessing no money can buy. Legalising organ trading in Singapore will just degrade this wonderful experience into a purely commercial transaction.
Differences in opinion on this matter depend on one's point of view. For someone suffering from renal failure, almost any means to obtain a kidney would appear permissible. For those desperate enough to sell their body parts as the only available means of clearing their debts or bettering their lives, organ trading may also be considered permissible. However, from a society's standpoint, we must examine the moral implications of the new rules we are considering. We should as a community put rules in place to protect the poor, the weak or the otherwise underprivileged.
The rich already enjoy many privileges in our society. Allowing them to purchase an organ legally would be crossing a dangerous line. We are sure our system will ensure that there is an equitable, innovative and highly regulated set-up such that the donors will be protected. However, as Dr Lee Wei Ling, who is in favour of legalising organ trading, has acknowledged in these pages, it will not be the rich who will come forward to donate their organs. It will be the poor and the desperate. We have always championed the underprivileged in Singapore. Selling organs, whether the sellers be Singaporean or foreign, should not be the means to a better life.
How much is life worth? Transplanting kidneys is relatively safe but it has definite risks. While it may be acceptable to run the risks for a relatively young person to undergo a transplant from a relatively healthy donor, it will be difficult to justify a rich, aged individual suffering from renal failure (and possibly other illnesses) getting a kidney from a young individual just because both parties are willing. It will be even more difficult to extend the argument for kidney trading to live liver or cornea trading. Should we allow someone to buy a face? It is now medically possible to do face transplants. This is a slippery slope; we should not place ourselves on this slope.
Yes, Singapore has dared to blaze its own trail in many areas, as Dr Lee pointed out. Medisave, Newater and HDB - these have all proved to be the right things to do. However, organ trading is fundamentally wrong. It should not be legalised because it empowers the already powerful and exploits the vulnerable. It will not lead to a more moral, sustainable society.

The writers are consultant kidney transplant surgeons at a public general hospital in Singapore. The views expressed here are personal.

The Giraffe's long neck , ....or, the slippery road to hell

Ostensibly, the long neck lets the giraffe reach for the juicy leaves on the higher branches. Some people though, have pointed out that the giraffes neck is in fact too short; it can't reach far downwards enough to drink. Whatever, the fact is the giraffe has become somewhat of a biological oddity. Clumsy and conspicuous, if is really a matter of time before it becomes extinct, if not for commercial zoos and Natgeo.

But how did it become that way? This has become a bit of a biological enigma and people have spent fruitless hours debating this over absinthe and wine. An interesting discussion about this can be found here. Many believe the longer reach of the giraffe conferred some survival advantage, and each successive generation got longer and longer necks. But that's probably only half the story.

Initially there might have been some survival advantage. A minor one perhaps, but that didn't matter. That would have been OK if it had just remained that way. As usual though, things got complicated when we ladies got into the act. At some point in time, the lady giraffes decided that male giraffes with longer necks were attractive. Apparently longer is better. I mean, who wouldn't want offspring to have that critical advantage to reach for the 5C's, ....ooops, sorry, I meant higher branches.

Once that paradigm was set, each generation of lady giraffes sought partners with progressively longer necks....regardless of survival (dis)advantage. Result? A biological oddity consigned to nature's museum of dead ends.

Here was an example of the development of a slippery slope. While the original intention was sound, (long necks were good because they could better reach high branches), the paradigm got overly fixated around a false criteria - sexual and physical attractiveness.

Lesson for us? So much of our debate today is poised astride the beginnings of various slippery slopes. Many have clearly good intentions, or at least couched in language that suggest noble intentions...We save lives if there are more organs available for transplants. We are merciful if we can only euthanize away human suffering. Why let unwanted unborn kids be born into this cruel world? Commercialized medicine is good for our economy and development of medical excellence, etc....

All good stuff until the paradigm gets shifted along the way. At some point the focus of the paradigm will shift so that the ends become more important than the means. It then becomes more important that we have good economic growth, high globalized performance rankings for whatever we choose to do, that our emperors and mini-emperors have have progressively beautiful clothes to wear on the global stage.... Then our necks will become increasingly longer. Overextended. Too long to manouvre ...too short to drink, too clumsy to survive. And then we will become consigned to world's museum of social dead ends.

Tragic.

Tuberculosis - hysteria in development

There was a letter in the Straits Times talking about the problem of TB is schools and the re-emergence of multidrug resistant TB etc... This is a bit of hysteria in the making, fueled somewhat by the Ministry of Health recently announcing it had place TB on the IDA (Infectious Diseases Act) Schedule 6 bugs list.

Hysteria? Yeah....because TB isn't that much of a problem really. We already have a TB immunization programme at birth (BCG; Baccille Calmette-Guerin). This confers a certain degree of immunity throughout childhood. Its efficacy wanes as the child gets older as is variably present in adulthood. We used to re-vaccinate at about 12 years old, but apparently this practice was discontinued in 2001 because of doubtful value of the program in protecting against future TB.

Most of the TB cases are in the elderly and do not represent new infections. Rather, they are a re-activation of what is called latent TB. Most of us, regardless of our 'immune status' are exposed to TB and go around carrying TB bugs in our bodies. Mostly these are sleeping dragons that don't bother us. However, when our immunity falls, these sleeping dragons are reactivated. Common causes for a fall in immunity are HIV, cancer and the use of immuno-suppressive drugs. It is therefore highly unlikely most of us will develop active TB sitting next to a patient with active disease.

What about the multidrug resistant TB problem? It seems to be a developing problem. Like all bugs, when they are exposed to inconsistent and incomplete treatment, the TB bacteria develops resistance to the drugs used. Fortunately this seems to result in rather wimpy bugs that are not very virulent and infectious. They seem to be a problem mostly for populations with reduced immunity such as those patients with HIV.

All in all, the problem of TB is not anything to lose sleep over. The incidence in Singapore is only about 35 per 100,000, i.e. about one infection out of every 3,000. If you consider these are mostly re-activated cases....it is really not that big a problem. The age group affected is mostly elderly (peak 40-60 yrs old), but like all distributions, there is a tail, and some young people with reduced immunity may succumb to the infection.

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Regardless of the MOH recent announcement of an increase in TB....(those are only projected numbers based on only 6 months of data, and the year is not over yet)....the trend over the last 40 years is a major and consistent reduction in TB incidence with no evidence of a reversal.

Hysteria? Definitely!

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What is a curious phenomenon though is the differential ethnic risk for TB...Malay > Chinese > Indian. I can't really explain this.

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good bugs...

Many of the bugs floating around us are actually friendly bugs. Our gut is full of them. These bugs that live happily with us are generally called commensals (as in 'share the same food'). Often the balance is in favour of one over another....i.e., they make use of us more than we do them, or we make use of them more than they do us...more likely the former. These would be more exploitative relationships. The bugs on our skin and hair are very much like that. Often they are just different balances of a 'mutualistic' relationship, i.e. both derive some benefit.

The bugs that have colonized out gut are very much in that category. Mostly we don't know to what extent we benefit from their presence. Unlike the herbivores who clearly use these bugs for their large gut 'fermentation chamber' to digest stuff, we are not so inclined. Still many believe, the presence of these gut bugs do help us establish some sort of health balance.

The concept of the whole Yakult industry is based primarily on the idea of seeding the gut with friendly bugs. Occasionally the colony of bugs gets thrown off balance by overgrowth of a 'renegade' strain of bugs which have no respect for the host....That's when disease manifests.

Toilet paper, anyone?

Euthanasia #8 - an option of last resort

Euthanasia cannot be an option of first choice in any society. It is always an option of last resort. I am not a champion of euthanasia, but grudgingly recognize that it may represent a final solution to a small group of patients for which palliation has failed.

If euthanasia is to be legalized and offered as a solution, society will have to pay a high ethical/moral price.

Euthanasia, thus should only be an option only for the members of that society. It should not be part of a commercialized set of activities. I could never condone euthanasia, if offered in the context of a globalized medical hub concept. I could never ever support Singapore becoming an euthanasia capital of the world, which it will definitely be should we offer euthanasia services to non-citizens.

If you are observant you'll see the pigeon orchids (Dendrobium crumenatum; anggerek merpati) make their appearance during this time of year. They are a lovely sight, these wonderful sprays of white shy blooms. Very lightly scented, they look very much like small little pigeons in flight. You'll find them dancing in clusters, often hanging onto large branches or tree trunks.

They are really very shy, and fade quickly within a day or two. So if you don't catch them soon, you will miss them.

I really don't know what forces them into bloom. I know they have lovely showings a couple of times a year. Perhaps its the rain and strong sunshine.

I have a bunch in the garden and was very very pleasantly surprised by their presence this morning.

Medicine a calling and not just a career? Really??

Dr Lee Wei Ling is back n the news with a letter addressing the above issue. But she is right this time.

Medicine is a calling. Sadly for many doctors, and medical students, it has become nothing more than a career. Many doctor friends counsel their children never to take up medicine, believing that this is no longer a satisfying and fulfilling career option.

This shift in our value system has been due largely to the national push for commercialized medicine. This strategy, articulated in the late 70's at the very highest level of our government, steered us smack down this road...at full speed. Medicine was to be one of the major pillars of our economic growth. But we can't really deny the economic sense this strategy made. It is just that the philosophy was totally wrong. It was another nudge that increasing turns us into little more than mere economic digits.

Can our lives...can doctoring be denominated just in terms of a dollar value?

But there are broader implications, and associations of this very materialistic philosophy that we need to be aware of, and concerned about. This has far wider implications.

a] The commercialization of medicine, and the strategy of establishing us as a medical hub, is in itself not necessarily wrong, but it has caused every doctor to begin to evaluate his/herself in terms of the dollar value of their contributions. There are few who are strong enough, and clear enough about their personal value system to withstand this constant and very public pressure to excel in dollar terms.

b] Medical education, is increasing being subverted by this intense pressure for our students, not to become good caring doctors, but famous award winning clinician researchers. Nobel prize anyone? I mean...do you really want your family physician to be a Nobel prize laureate? Yet the medical school is increasingly diverting must needed teaching resources into research laboratories, and losing valuable educator positions to scientists with long credentials but cannot teach.

Good teachers are increasingly belittled as dinosaurs, and new staff who care little for students clamour for attention and public acclaim. *sigh*

Who are their role models? No more the humble GP who gives his life to serve the community, but the attention grabbing stem cell clinical researcher.

c] The gradual corruption of the medical ethos will be seen in the the increasing pressures to 'bend' morality and ethics to serve mammon. Observe the increasing pressure to push the medical profession into serving the organ trade, ....and euthanasia perhaps...?

What can we do to stem the slide? Precious little, I am afraid. Another example of the slippery road to self destruction? Perhaps.

Dr Lee Wei Ling, will you be our flag bearer to reclaim the noble values in doctoring?

Euthanasia #7 - are we missing the point??

Well, it looks like we're jumping right back into the euthanasia debate. The Straits Times carried a Saturday special report on the issue, and Sandra Davie posted something in her blog...

The debate is important to have....but sadly it is beginning to sound tired,...kinda like a broken record that does not go anywhere.

People's positions get hardened around extreme and unrealistic positions. There are deliberate obfuscations so that it seems like everyone is playing in their own soccer fields. There is a general confusion about the AMD which is unfortunate as it is in a totally different playing field. Then there is the almost deliberate blurring of the line between murder and euthanasia, as if it is something done with the patient's full and informed consent. Sadly, after a protracted period of these confused meandering, the government will step in and proclaim that there is enough public debate, and that adequate public opinion has been sought, then proceed to implement its agenda.

How sad. How tragic.


I believe, if the discussions are to be meaningful:

a] The topics and definitions need to be carefully and clearly circumscribed. We need to deal with each problem clearly and specifically.

b] The main points of contention must be clearly identified and dealt with. In this regard, I see one of the major sticking points is the apprehension that the essentially noble idea, will eventually be abused, and extended to less noble ends. In the ST report, bioethicist Margaret Sommerville pointed out this 'slippery slope'. She says, "Once euthanasia is legalized, its availability expands.". She is right.

The government, and proponents of euthanasia must therefore spell out how this creeping availability, and extensions of the application of the euthanasia principle, can be managed and controlled.

c] The government must make more effort to manage the perception that this is somehow linked with the commercialization of health care. Why now?? It didn't help that this was brought up almost in the same breath as the organ trade issue. The public should be rightly concerned that euthanasia is only being surfaced now as an alternative medical option, just when there is this massive national push to establish Singapore as a 'grandmother of all medical hubs'.

If legalized, euthanasia should never ever be part of any activity associated with commercialized medicine. And it should never be offered to anyone who is a non citizen.

Hand Foot and Mouth Disease

There is a bunch of funny picorna viruses which tend to infect babies and young children. They produce a febrile illness accompanied headaches and characteristic rashes over the body with ulcers on the palms, soles and the insides of the mouth. Although usually mild and self limiting, the illness does rarely affect the brain and produce fatalities. Locally apparently the virulent and more dangerous EV71 virus is quite prevalent.

I became interested because there was a recent apparent fatality due to Hand Foot and Mouth Disease (HFMD). He was only 12 years of age. This was apparently only our second HFMD death since 2001.

The incidence of HFMD in Singapore has been increasing. The figures in 2008 are alarmingly higher than 2007. There was a large spike earlier in April-May this year, and another smallish one extending from November through into December. Both these periods had numbers which brought the disease into epidemic proportions

.Graph from MOH site. Click picture for a larger view.

Although understandng the Ministry of Health's reluctance to create any sort of public panic about what essentially is a relatively mild childhood disease, the single reported death last Sunday is a cause of concern.

I tried to find out more from the MOH website but couldn't get much other than the figures displayed here.

Some missing information which should be of public interest include:

a] How many of these numbers reported were actually HFMD? Were they all lab diagnosed with specific HFMD serlogical tests? Were they specifically examined for the virus type...were they all EV71?

b] What is the frequency of EV71 infections as compared to other milder versions of the picorna virus.

c] Was the recent death examined for EV71? Was it clear that this was HFMD? Why does it take so long to do a PCR virus analysis.

For an infectious disease of this sort, I found it quite discomforting that these info were not readily available to the public. For parents to be reassured, and for them to be able to make sensible and rational decisions about their children, the Ministry of Health really needs to be more upfront about telling us what's going on.

Just like the AVA, the people in MOH tend to treat the public as if they were morons or immature children who cannot deal with information other than highly sanitized ones, and are totally incapable of making rational decisions.

Bugs, friend or foe? - consider the mitochondria

Bacteria are not necessarily our enemies. The TB bug (Mycobacteria tuberculosis) has been around for a very long time and has co-evolved with us. For the most it is quite content to grow slowly and hide in our tissues without much fanfare...flaring up only when our immunity is down. You would consider that a smart bug will not try and kill its host.

Another smart bug began collaborating with us from our very origins. The earliest cells enveloped them into their internal environment, and outsourced their energy requirements to them. In time they got incorporated into the energy functions of every living cell, and even insinuated themselves into our reproductive cycles. These bugs, now called mitochondria (singular, mitochondrion) gets transmitted with our mother's eggs.

Many scientists believe that the health of these mitochondria may underlie much of human health and disease.

We still do not know what is the ancestral bug that gave rise to the mitochondria, but we are all agreed, this is one very smart bug.

Syzy...what?? Syzygium campanulatum

The other colourful event on the roads that never fails to lift my spirits every evening on my drive home, is the florid coloration of that line of shrubs alongside the Bukit Timah canal directly opposite Hwa Chong Jr College.

It took me quite a bit of effort to track down the identity of this beautiful shrub, but I finally found it!! It is apparently the Syzygium campanulatum (variously known as Eugenia oleina and Kelat paya)

The shrub is particularly beautiful as its new leaves are orangey red. The National Parks people did a fantastic job in planting a dense row of these lovely shrubs opposite HCJC. The new leaves are all out and that short drive is so delightful because there is this tall wall of autumny colours flanking you. It's one of the rare occasions that I actually enjoy being caught in the traffic there!

There is a nice blog post about this shrub here...go check it out.

Human organ trade - ...and so it begins...

It was easy to contemplate reimbursing kidney donors. It just made sense to do so. Just as it did legitimizing the process.

Now when the discussion and dialogues begin it is starting to look pretty scary.

Minister Khaw Boon Wan was reported in today's Straits Times, as having said at the first HOTA dialogue session with some 300 grassroot leaders, that Singaporeans and foreigners should receive the same reimbursements. Far'nuff, I thought. Except that this is probably the first clear indication that we were clearly going to be purchasing organs from overseas, that we were not going to limit this reimbusement for organ donors thing to just a Singapore activity. Viva la Singapore Medical Hub!!

What was also worrying for me was the almost unanimous voice that supported the organ trade lobby. The reimbursements, far from originally proposed that it was only to cover costs of medical procedures and associated costs for time etc, would be in the tune of $50,000-$100,000.

Whoa....!

This was human organ trade getting into full swing. Let's not bother about those airy-fairy ideas of inducements and exploitation. If we need those organs, just go ahead and buy them off those poor sods for whom $100,000 would represent several lifetimes of income.

I hope that Minister Khaw will consider (and I trust he will because I believe he is at the core, a good and ethical person) that the opinios solicited at his dialogue do not represent the universe of opinions and are heavily biased towards the recipients position as many of those represented there will have friends, relatives and constituents who are potentially recipients of the donated kidney. There are no voices there that effectively represent the potential donors, and the populations from whom the potential donors will come from if the great kidney sale extends to the international community.

Yellow Flame - Peltophorum pterocarpum

One of the very pleasant surprises on our roads these days is the sudden flowering of the Yellow Flame (Peltophorum pterocarpum). Sometimes they are called the Yellow poinciana, and contrasted to the Red Poinciana (Flame of the Forest). These bright yellow blooms have brightened up some of my long drives on the expressways. If you want to catch a nice display, there is a beautiful scattering of these trees around the Moulmein exit of the northbound CTE (Central Expressway). Go catch it before it disappears.

Human organ trade - Lee Wei Ling's rant

Dr Lee Wei Ling has jumped back into the fray once again with respect to the kidney trade issue. Today's Straits Times carried carried half a page of her rants about this much debated issue.

I have great respect for Dr Lee. At other times she has given voice to segments of society that have been marginalized, and otherwise voiceless. But on this issue, I believe she is way off course. There is no doubting her passion in wanting to save the lives of patients who are dying of kidney failure. But her passion is misplaced, when she chooses to dismiss the exploitation problem. In doing so, she has chosen to take the side of the wealthy sick against the poor. Is the life of a wealthy Singaporean worth so much more than the welfare of the poor that she should so readily brush off any suggestion that they may be exploited in this transaction?

She makes the point that "If the seller makes an autonomous decision and, in return, receives a substantial payment that may improve his and his family's quality of life, why should that constitute exploitation?" I would find nothing objectionable in that statement, other than the fact that in a dependent and vulnerable position, the donor is not likely to be able to make a fully autonomous decision. Yes, he/she remains lucid, and rational. Yet we know that given a real choice in the matter he/she would rather not have to sell his/her kidney, whatever the price. She herself acknowledges: "Let's get real: Who would willingly donate his kidney to a stranger without profiting from that act?" She herself would not. She should therefore ask herself why a poor man/woman would go under a knife and 'donate' his kidney to a stranger unless the financial reasons were so compelling. This is the very nature of an 'inducement'. A fully autonomous decision needs to be free of inducements. It is true however, that in life, our decisions are always compounded by some element of inducement, but taken to the extreme, inducements compromise our autonomy. And in the situation of reimbursing kidney donors, the greater the payout, the greater the financial need of the donor, the greater the inducement will be, and the greater the likelihood that the decision was not made with full autonomy.

Much as we may be motivated to save the life of a dying patient, this must not be at the expense of another individual. Therein lies the dilemma in regulating organ trade. Our wealth must not be an instrument of exploitation of the poor.

But perhaps I am too idealistic. (See my other comments on this and related issues...)

I take further offense with respect to her comment : "Why the rigid insistence that the remuneration for the seller should not be so high as to be an inducement to part with a kidey? To be blunt, the main reason is because there is not enough independent thinking here."

Errmmm... 'not enough independent thinking'? Does she imagine that the only independent thinkers are those who agree with her? Legitimizing the organ trade is really a no brainer...and the far easier path to trod. Afterall, who doesn't want to save lives? Standing the moral high ground is a far more difficult choice to make. Wealth empowers. But it takes a stronger (and a more independent minded) person to exercise wisdom and forego that power in defense of the weak and poor.

C'mon Wei Ling....who is more deserving of your support?

Tuberculosis and the IDA Schedule 6

It's very stange that the Ministry of Health reported rather proudly in 2007 that the incidence of TB is dropping.

"Over the past ten years, Singapore has seen a steady decline in the number of TB cases. There were 1,256 cases in 2006, compared to 1,712 cases in 1997. In 2006, the incidence rate of TB declined to 34.8 new cases per 100,000 resident population, from 37.0 per 100,000 in 2005 and 54.9 per 100,000 in 1997. In 2006, men accounted for 863 (69% percent) of new TB cases in Singapore, and more than half (55%) of the patients were aged 50 years and above.

The concerted efforts carried out under the Singapore Tuberculosis Elimination Programme (STEP) and by the medical community have contributed to the decline in TB cases in Singapore."

Hooray.

Then all of a sudden, they come out with a statement that the projected 2008 incidence based on the first 6 months reporting of 700 cases was 38.8/100,000 as compared to 35.1/100,000 in 2007. This sudden projected spike, suddenly precipitated the need to place TB in Schedule 6 of the Infections Disease Act.

Huh??

Add to this strange bit of reasoning, the inference that as most (86%) of the new cases were over the age of 50, it was likely that the postulated, projected increase was due to re-activation rather than new infections.

Double huh...???

If these were mostly due to reactivation, then it couldn't have been due to transmission. So why the urgent need to put in place intrusive methods to limit spread??

The only conclusion must be that this grandiose act is primarily directed towards interfacing with the international community so that we can tell other agencies and airlines who the active cases are.

Hmmmm.....Stranger and stranger.

Infectious Diseases Act

The Singapore Infectious Disease Act (IDA) can be found here. I was looking through it to try and understand the various published Schedules. This was in the context of the recent rescheduling of TB to Schedule 6. Like many of our statutes, it requires a bit of detective work to try and figure out what's really happening. I must admit it took me quite a while (maybe because I don't have the the mind of a lawyer, or statut-ologist).

Essentially it seems to me that the distinctive feature of Schedule 6 was that it empowered the Director to disclose information to relevant authorities to enable him to take steps to prevent the spread of the disease. This of course includes the identification of the infected individual. Fair 'nuff, I thought. The only other disease identified under this Schedule was the Severe Acute Respiratory Syndrome (SARS) (also fair 'nuff!).

Then I wondered why only these two diseases? In today's press, there was quite a lot of publicity about the Human Immunodeficiency Virus (HIV). Then I wondered why HIV wasn't listed under Schedule 6? Surely HIV is much more of a problem compared to TB in Singapore. True, the absolute incidence was still lower than TB (In 2007, HIV was 118/million as compared to TB 351/million), but its incidence has been increasing at an alarming rate. Between 2006 and 2007, the incidence in Singapore rose by 18% . Even discounting for improved reporting, this is an alarming rate of increase. UNAIDS and WHO has identified it as one of the most destructive pandemics in recorded history, having killed more than 25 million people since 1981 when it was first diagnosed.

HIV is actually covered under Part IV of the IDA. There is a lot there prescribing procedures to limit the spread of the disease. But astoundingly, there is a specific Para (25/25A) that specifies the protection of the identity of the infected person. Disclosure is only allowed only under certain conditions, mainly when the patient consents, and to the exposed/infected person.

....duuuuhhhh.....

Why this double standard? Today's Straits Times carried an Op-ed by Salma Khalik arguing that HIV should be treated like any other infective disease thereby qualifying for subsidy etc... "How can the Government expect to fight the disease when it discriminates against HIV patients by not providing them with the treatment that they need?

This is not about giving special privileges to HIV/Aids sufferers. It is about treating them like all other citizens in the country, with the same right to basic medical care."

She's not wrong. But in the same vain, HIV should be treated like any other infectious disease so that it's spread can be effectively contained. Why the need for confidentiality? Why constrain the flow of information that may allow other relevant authorities to take measures to control the spread?
Why are HIV sufferers entitled to more human rights than the rest of us? Is TB placed under Schedule 6 simply because the ah pek TB patients do not have a voice as powerful as the AIDS/HIV lobby? Its not wrong to do so....just that HIV should also be on Schedule 6.

OK...'nuff said.

Tuberculosis in Singapore

We've been having a bit of a bug fest recently. News about HIV, Chikungunya etc....and the resurgence of Tuberculosis. From this month (1/12/2008), the Ministry of Health will place TB under Schedule 6 of the Infectious Disease Act, only the second infection to be so honoured. The first was Severe Acute Respiratory Syndrome (SARS).

"Placing TB under the Sixth Schedule of the IDA enables MOH to disclose particulars of the TB patient to the relevant authorities in a timely manner. Preventive measures can then be implemented without delay. These include:

• Contact tracing for infectious TB patients who have travelled on long-haul flights,
• Prohibition of infectious TB patients from travelling on commercial flights, and
• Management of recalcitrant TB patients to undergo treatment"

Unlike the SARS virus, the TB bacteria (Mycobacterium tuberculosis) is a very old bug...and has probably been co-evolving with us for thousands, perhaps millions of years. Through all these years it has learnt how to deal with us. It probably enters our body through a lung infection and then subsequently remains dormant for long periods of our lives. In most people, it never awakes from its apparent slumber (latent TB). But in some individuals whose immunity has been weakened in some way, it re-emerges/re-activates and seeds itself into various organs. If untreated at this time, it eventually consumes the patient. The TB bacteria is usually not very infective and is very slow growing. But it has learnt how to survive in our bodies without being detected by our immune system, Even when activated it hides, multiplies and sleeps in the immune cells that are supposed to kill it. Despite having been immunized and even having immunity to TB, most of us continue to harbour the bacteria in what is called the 'primary focus' within our bodies. Latent infections like this is not infectious, but may at some time become activated to the infectious form. More about TB here (Wikipedia) .... and here (MOH FAQ). TB can be treated...but the problem is because it is such a slow bacteria, drug treatment over a long period of time is required. Patients often default and this contributes to the chance of the bacteria developing resistance to good anti TB drugs.The vaccination we receive as babies in Singapore, (BCG; Bacillus of Calmette and Guérin) has been very effective in preventing the TB meningitis of babies, but later on in life, its activity is very much attenuated, we many of us pick up some TB focus at some time in our lives.

The problem globally and in Singapore is that the incidence of TB is increasing. The projected incidence of Singapore TB in 2008 is 38.4 per 100,000, which is higher than the 35.1 per 100,000 in 2007. Most of this increase is thought to be due to re-activation.

Palliating terminal cancer - a reality check

With the ongoing discussions on euthanasia, a number of doctors/agencies have made use of the opportunity to advertise their services. There was a letter in the Straits Times Forum yesterday, which I won't reproduce because it was just blatant advertising. Today's ST carried short report about the Palliative Care Clinic in the Tan Tock Seng Hospital which is worth looking at because it is admirable for a hospital that has to look after its financial bottom line, to set aside resources to manage what is very likely be a loss making service.

Palliation of the terminal cancer patient is not an easy task. It is certainly a complex one. It does not include just treating the cancer pain, but also includes managing the patient's social, emotional , psychological and spiritual needs. You can generally tell the inexperienced doctors from the caring ones by the way they 'chiong' (local slang refering to mindless charging, some what like a bull in a china shop) around the place and waxing eloquently about the use of new expensive, fancy painkillers, and how great the care giver is in being able to provide all this.

Truth of the matter is, the science of managing pain hasn't really moved too far from the use of either anaesthetics or analgesics. The former knocks off all sensation (not really desirable) and the latter tries to selectively reduce the pain without greatly affect consciousness. Neither are fully effective. A majority of patients though can be effectively managed because the pain is not so severe. However, cancer pain can be so wide spread, so severe and intractable that the only way to manage the pain is to increasingly anaesthetize the patient. Narcotic painkillers remain the main mode of managing this severe intractable pain. The downside is with the increasing dose of narcotics, the patient will gradually drift into a deepening coma, and increasing risk of just stopping his urge to breathe. Doctors don't like to discuss this, nor will they readily admit it, but here is where the thin red line between palliation and euthanasia blurs into a broad murky band.

One of the important features of effective palliative care is honesty and true concern. The terminal cancer patient is not a moron, and is trying his or her best to deal with an essentially hopeless situation. Giving false hope or blindfolding the patient is not the solution. The patient knows when he/she is being lied to. Pain in this kind of situation takes on a totally different perspective for the patient. Unlike the usual pain we suffer, for which we know will be self limiting and can only see recovery going forward, terminal cancer pain is intractable and will only get worse. Its presence is a constant reminder to the patient that he is dying. He sees no light at the end of the tunnel, and he knows that it can only get worse. Much worse. He is plagued with fear and uncertainty because he cannot foresee how bad and terrible it will become, and how long it will drag out for.

Therein lies the critical need for a good, sincere friend and caregiver. Often what the patient needs most is to be assured there is someone who will walk with him or her through the final steps. That the best is being done. He doesn't need to lied too that the pain will magically disappear with fancy expensive drugs.

Nature and infidelity - a venus and mars thing?

There was a report in today's My Paper (yes, yes...I read My Paper...'cos it goes well with my teh see siew dai!!), about a kinda pointless study done in the Virginia Commonwealth University about men and infidelity, and such...The New Scientist reported on it as well.

"Paul Andrews at Virginia Commonwealth University in Richmond and colleagues gave 203 young heterosexual couples confidential questionnaires asking them whether they had ever strayed, and whether they suspected or knew their partner had strayed. In this, 29 per cent of men said they had cheated, compared with 18.5 per cent of women.

The men were better than women at judging fidelity. "Eighty per cent of women's inferences about fidelity or infidelity were correct, but men were even better, accurate 94 per cent of the time," says Andrews. They were also more likely to catch out a cheating partner, detecting 75 per cent of the reported infidelities compared with 41 per cent discovered by women (Human Nature, vol 19, p 347). However, men were also more likely to suspect infidelity when there was none."

Kinda silly and pointless because you don't really need to do expensive research to tell you what you already could have figured out.

Considerations of love and such aside.... the females of our species are biologically more concerned about raising their offspring. Once they got the sperms they want, all they are interested in is to ensure that her offsprings are adequately resourced and can be raised safely. That's really all they need the males for. And if they are unfaithful, they are not likely to fess up and risk losing their source of support. They are also not very hung up on the fidelity of their male partners...as long as their family resources are not compromised.

The males of our species however, are really only interested in sowing their oats. If they are unfaithful they are not shy about advertising it...kinda like a badge of honour. What they are concerned about really is that their women are faithful...because they are concerned about whose children their women are bearing. Hence the fidelity of their partners are paramount.

Hence men are biologically more likely to confess their infidelity and also more sensitive to the spouses' infidelity. Women however, hide their infidelity and forgive their spouses' sins, as long as they are able to preserve the family integrity...and resources.

Common sense.

But we humans are complex creatures. We layer our biology with things like love and respect...and ideas of morality. We regard much of our biology as part of our animal and baser instincts....that have to be suppressed. What is sin but that deep dark biological urge that must be kept under control?

But it is love and morality that keeps order in our lives, and generally keeps us sane. 

Funny thing this thing called love.

Jacaranda? - no....

What I had thought was a jacaranda ....was not. A jacaranda has a compound bipinnate leaf, whereas the tree I saw with the large lilac blooms had large simple leaves.

What I saw was the Lagerstroemia speciosa. My mistake.

Why not study in Singapore?

Yesterday's My Paper reported on the Health Promotion Board (HPB)'s new poster girl Miss Felicia Chua for this year's National Healthy Lifestyle Campaign. Miss Chua, previously from Anglo Chinese Junior College (ACJC), will as a youth ambassador, help to plan and run events and workshops for young people on behalf of the HPB.

It was further reported that Miss Chua will be heading on to Melbourne to study Medicine at Monash University.

I wonder why she has to go to Monash to study Medicine? Was our National University of SIngapore (NUS) not good enough? Or was she not good enough for our NUS?

Although her academic performance was not mentioned, Miss Chua impressed with not just with her intelligence, but her compassion and social consciousness. She will make a fine doctor one day. I wonder how our NUS medical school here selects students for the medical course? Has our fixation of academic grades blinded us to recognizing the softer attributes that go towards making a good doctor? Has the shift towards producing award winning clinician scientists blinded the school to the core mission of producing excellent medical practitioners?

I understand though, the school admission system has a selection interview. I wonder how this is done? Did Miss Chua fail the interview? How did the school miss out on selecting Miss Chua for the medical course?

I wonder.......

Flowering trees - flaming in the forest

As we enter into the monsoon season, not many of the beautiful trees we have around are wasting their energy making blooms. Many of them are looking kinda heavy laden with foliage.

I saw a straggly jacaranda (j. obtusifolia) trying to flower....and a lone Flame of the Forest putting out some flowers (poinciana regia). Oh yes ... a couple of the Rain Trees (Samanea saman) have got some of their shaving brush looking flowers out. But the most outstanding showing has been that of the African Tulips (Spathodea campanulata). These beautiful trees are best viewed along the expressways, especially those sections of the BKE and KJE that overlook the reserves.

If you haven't really noticed these, I highly recommend you go take a look. There are wonderful copses of these trees. You can't miss them. They are characterized by these beautifully striking reddish orange blooms against rather dark foliage. They are the only ones in bloom now. They are sometimes called the flame of the forest, but we don't recognize them as such here, as that nickname has been pretty much reserved for the poinciana.

Better go quickly if you don't want to miss this showing. I don't know how long the blooms will last.

Awakened - Crimson sunbird

Awakened from my Sunday afternoon nap by the shrill shrieks coming from the garden. Popped my head outside and spotted 2 Crimson Sunbirds chasing each other through the hedge. Competing for a female I reckon. But they were beautiful, even though they didn't stay long enough for me to really enjoy them too much.

Still it was worth waking up for.

Picture borrowed from Neo Kok Lee's collection in ClubSnap

Rise of the dragons - xin yi min

Today's Straits Times carried an insightful report on the new Chinese immigrants by Leong Weng Kam entitled "Rise of The New Dragons". He has a blog about this too..

Singapore society has been gradually changing because of the influx of these new migrants from China. One of the more high profile ones is the recent admission of the Chinese actress Gong Li. But these migrants are not just restricted to the rich and wealthy, they are seen everywhere in all stratas of society.

Their presence sometimes causes some discomfort among us because despite their apparent chinese-ness, their ideas of chinese-ness do not necessarily mesh easily with ours. Quite clearly, as they continue to make their presence felt in Singapore society, we will be changed by them, just as much, I hope, as we will also change them. I cannot foretell how Singapore society will look like in another generation or two, but it will certainly not be the same as it is now.

Does it bother me? A little, yes....but that's just the parochial side of me speaking. In truth, I really have no deep discomfort....in fact I find the changes somewhat exciting. Our society will change, and evolve...but such is life.

Once we ourselves were regarded as 'singkek' (新 客; new guest) when our forefathers moved out from China to South East Asia. They changed South East Asia, just as she changed us. Now we view ourselves as Chinese, though not quite Chinese. Therein lies the 'discomfort' at integrating our new citizens. We label them xin yi min (新 移民;new immigrants). But they are no different from the 移客 (new guests) of before.

I have met and worked with many of these xin yi min. Most are honest, diligent and desire nothing more than the chance to make a living and to raise their families in safety and comfort. Just a decent chance at life.

I for one, will extend a very warm welcome to those who genuinely seek to make their home here with us.