Sunday, November 30, 2008

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."


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.


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.


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.

Thursday, November 27, 2008

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.

Wednesday, November 26, 2008

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 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.

Monday, November 24, 2008

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.......

Sunday, November 23, 2008

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

Friday, November 21, 2008

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 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
(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.

Thursday, November 20, 2008

Melamine hysteria #9 - ...sigh....

TODAY carried a small report by Neo Chai Chin on the ensuing melamine saga. Melamine has pretty much been eclipsed by the unfolding financial tsunami nowadays. Good thing I suppose for the AVA... :)

But what caught my eye was a small reference to a comment made by Marketing manager Roger Seah of importer Meng Chong Foodstuffs- "
the public would be assured if the AVA released a product-by product list of what it found to be melamine-free. Such a list would be lengthy but consumers won’t mind”.

These comments resonate with what I have articulated before. I wonder why Agri-Food and Vet Authority (AVA) cannot be more transparent and forthcoming about this. I wish they would stop playing these 'games', and just come out and tell us what they have done, and passed and what they have not. We know they cannot do everything all at once, but why not tell us the score. Just be transparent. Seems like that's asking too much. Sigh...!

Tuesday, November 18, 2008

Pro-Enterprise Index

I stumbled across this interesting Pro-Enterprise Index. This is apparently based on an annual survey by Action Community for Entrepreneurship (ACE) of various government agencies, based upon a number of parameters. These are:
  1. Compliance Cost;
  2. Review of Rules;
  3. Transparency;
  4. Customer Responsiveness; and
  5. Pro-enterprise Orientation.
This year, the top12 out of 26 (why stop at 12, I wonder...?) agencies were:
  1. Maritime and Port Authority of Singapore (MPA)
  2. Monetary Authority of Singapore (MAS)
  3. Infocomm Development Authority (IDA)
  4. Singapore Customs (SC)
  5. International Enterprise Singapore (IES)
  6. National Environment Agency (NEA)
  7. Civil Aviation Authority of Singapore (CAAS)
  8. Public Utilities Board (PUB)
  9. Agri-Food & Veterinary Authority (AVA)
  10. Central Provident Fund Board (CPFB)
  11. Housing and Development Board (HDB)
  12. Inland Revenue Authority of Singapore (IRAS)
Champions were the MPA. The Agri-Food & Veterinary Authority (AVA) scored credibly at #9. Not too bad considering they were unranked in the top 10 of 24 (why stop at 10, I wonder...?) agencies surveyed.

Our kahkeenang (自己人) agency Health Sciences Authority (HSA) was pathetically unranked.
Insider information told me they were pretty much at the bottom of the table.

Don't know whether to laugh or cry...

Can $1000 buy my family back?

Early this morning over my regular teh see siew dai, I read this heart-wrenching winning essay from the recent Great Eastern 'Life is Great' competition, written by Miss Claudia Lim of Anglican High School. I am reproducing it here because it is so powerful in its message to us busy and self absorbed adults and parents. (Other assays can be found at the Great Eastern Life is Great site.)

We really need to listen to our children more.

My response to Claudia, ...'Hang in there, girl...keep the faith. It is difficult but you have the strength and obviously the spirit to weather this.'

And to
Claudia's parents, ' have a real gem of a daughter. Try to not let her down....

If I had one thousand dollars, I would be able to go to many places, try many things and buy accessories and toys that I have long wanted. However, after prioritising and sorting out everything in my wish list, I realise that there was one that was more important than the rest, one that was actually needed, one that was worth spending a thousand dollars on.

My family is in dispute. It involves my parents and my paternal grandparents. In the past, everyone would be happily chatting, laughing heartily and playing together when we meet. It was indeed a happy family anyone would wish for. However everything was changed. This happy family of mine is now a dull and cold family. You could easily tell that the adults are embroiled in cold wars when you feel the tensed atmosphere between them.

Everyone seems so tired, stressed and restless nowadays. No one tries and salvage the problem among them. Once I overheard Father telling Mother, "They claim that they have no time to talk, what else can I do?" No time, is the excuse everyone is giving to avoid the problem. Since they claim that they have no time, I will find time for them.

If I had a thousand dollars, I would use it for a day out with my whole family. I would use the money to buy food or a picnic at the beach, and other expenses for the day. Firstly, we would take a ride on the Singapore Flyer, where the children take one capsule while the adults another. Up in the Singapore Flyer, they would definitely feel more relaxed with the beautiful scenery and blur skies around them. Perhaps they will be able to sit down and talk to one another calmly.

After the beautiful scenic ride, we would proceed to the D24 durian stall at Joo Chiat Road, My family loves the durians there and would definitely engage in conversation while feasting on the delicious durians.

Then we would move on to the beach for the picnic. As we eat, we would watch the magnificent sunset. At this point of time, the adults should have already forgiven each other for the mistakes that they have made.

As the sky gets darker, we shall go for a karaoke. Karaoke always brightens up the mood in our family. Everyone would enjoy themselves, singing and laughing. At the end of the day, hopefully as all of us go home, tired but contented, to be one whole happy family again.

I strongly believe a simple day out will help to bond the family even more. Kinship is very important. Anyone could plan this, but the adults are not willing to take the initiative and children have no money to do it. A thousand dollars will definitely be put to good use. As for the remaining money, I will save it in the bank for a rainy day, or just in case history repeats itself.

- Claudia Lim, Anglican High School

Saturday, November 15, 2008

The future of regulatory oversight in Singapore

This morning's Straits Times carried a number of reports about the recent G20 Economic Crisis Summit. They have big problems to resolve and no clear solution may easily emerge. But it seems clear in people's minds at least that the current crisis was due a large part to to self interests perpetuated to the extreme, and the failure of that self interest and free market to adequately regulate the financial system. French President Nicolas Sarkozy aptly called it ..."the death of laissez-faire capitalism".

For a long time, this laissez-faire was attractive because it fed the greed and voracious appetites of the capitalist institutions. In recent times it also had consderable appeal to Governments struggling with ballooning budgets. Thus laissez-faire fitted in very well with the idea that governments had to shrink to survive. The regulatory roles of governments were therefore pruned off and hived off into the private sector as vague forms of self regulation. Somehow self interests were seen to be able to take over the government's role in regulating the environment they operated in. Cries of 'caveat emptor' meant the public was on its own. Look out for yourself!

I think the Singapore government took big steps to move down this road as well, when they began 'freeing up' the regulatory environment, and shrinking the size of government. Mantras about 'regulating with a light touch' and 'risk based approaches' are all codified expressions pointing to the shrinking regulatory roles of government. Regulatory authorities, which correctly should be well supported, independent units, are combined with, and often fuctionally subordinated to promotional entities.

The recent melamine fiasco was very much a public health mirror of the financial crisis. Like the financial crisis, it resulted fundamentally from a breakdown as a result of lax and ineffective government regulation. The AVA (Agro-Food & Vet Authority) had proudly proclaimed they operated through this now infamous '
risk based approach' paradigm. Now seeing how the AVA is struggling to contain the situation, the public should question if such laissez-faire continues to be tenable.

But it is unfair to just point the finger at AVA. The MAS (Monetary Authority of Singapore) had also been regulating with a light touch. And if you go to the HSA (Health Sciences Authority) website you will find at least 2 departments there, proudly laying claim to having a 'risk based approach'. Essentially, 'do less, earn more, ... and everyone look out for yourself.' HSA scares me a little, I might add....I mean, ....can regulation of medicines afford to be laissez-faire?

Now that lassiez-faire has been officially proounced dead, dare we hope the government will invest a bit more and provide us better regulatory service?

Friday, November 14, 2008

Morning call....

Peeped out of my window in response to those familiar piercing chirps. Oliver, was there almost on cue hopping blithely from bloom to bloom, totally oblivious to the fact that I was watching. My garden is in a mess, but I think he likes it that way. He completed his exploration of the overgrown shui mei, then moved on to the straggly heliconias (h.rostrata).

Oliver is an Olive Backed Sunbird. Very shy. But he visits regularly, often when the early rays of the sun hit the plants in the front garden. Sometimes he is there with a couple female sunbirds, but they are not as attractive as he is.

We have a one-way relationship. I love him, but he doesn't know I exist.

I think I need a life.

(Image borrowed from Peng Eik's beautiful photos)

Human organ trade - mind blowing...!!!

The revelation that really blew my mind, was that, to date, bona fide altruistic donors had to foot all their own expenses for the donation. This was unbelievable!! I had not realized this before, and I must admit I was really offended and angry to realize this. I mean, how money minded and calculative a society have we become? Someone steps forward, to altruistically donate his/her kidney, and the hospital says....."...step this way know we can't really accept your kidney unless you can pay for your own medical and surgical costs!" And all this while we hear the hospitals, nephrologists and transplant surgeons preaching to us about altruism and how many lives we are going to save if more people willing came forward and gave their kidneys for free....of course, as long as they can pay their 'A' class hospital bills.

These people should be the very least they should come forward and tell us why they have been making their fortunes off the backs of altruistic organ donors.

Shouldn't the cost of donor related procedures be waived by the hospital, or at the very least, be borne by the recipient? These are the beneficiaries of the donor's altruism.

Thursday, November 13, 2008

Euthanasia #6 - closure

When I first started on this thread I really had no idea where I was heading. Can't really say I had thought about it much. Working through this issue has been somewhat unsettling, I have to admit. I don't think I have 'arrived' at all the least I don't think I can come up with a definitive statement to make about it. I don't think I can persuade anyone to my point of view either, nor do I want to.

It seems to me however that an approach based on either ideology or on some sort of theoretical morality does not work. I can understand where these would be coming from, but it seems pretty inadequate to make sweeping applications of these principles to euthanasia.

It is very clear to me that when applied correctly, euthanasia cannot be equated with suicide (as commonly understood). Neither can it be considered murder (which implies some malintent). Euthanasia, as correctly intended, is both rational and motivated by care and concern for the patient.

The real problem in euthanasia is in its implementation. The fear in peoples' minds, and that which probably underlie most objections, is that no matter how well-intended, the process can go out of control. People fear the creeping extensions of justifications for euthanasia. I can well understand these fears. Euthanasia can easily be the wedge edge that leads to exterminations of the sick and defenseless in society. But such fears cannot be the reason for denying relief to the suffering. It is good to remember that action and inaction are two faces of the same coin. The humanity in us compels us to preserve well as to palliate suffering. Sometimes these are incompatible. To preserve life we have to deny real palliation. Therein lies the dilemma with respect to the provision of a 'good death'.

Human organ trade - latest MoH press release

So another balloon has been floated... (for the full press release...go here).

"The Ministry of Health (MOH) is proposing three amendments to the Human Organ Transplant Act (HOTA). They are:
(a) Lift the upper age limit for cadaveric organ donation;
(b) Allow donor-recipient paired matching for exchanges of organs; and
(c) Compensate living donors according to international ethical practices."

It certainly looks a fait accompli despite the soliciting of public views...

So far, the proposed scale of 'reimbursements' appear reasonable... "
these donors (will) be compensated for direct costs incurred as a result of the donation, and indirect losses such as lost earnings and future expenses due to the donation. The compensation framework will be in line with international and local ethical recommendations." But the devil always is in the implementation...and especially with respect to the variable component in the reimbursement rate for 'lost earnings and future expenses'. But I am sure some systematic way can be found to consistently apply these principles.

Although I couldn't find it in the press release, it was reported in Channel NewsAsia that foreigners were not excluded although the focus was on Singaporeans and Permanent Residents. This is the 'trade' element that bugs me. I wish that it could be more specific about excluding the import of organs.

Tuesday, November 11, 2008


darkness uncovering
my sleep
heavy breathing
comforting yet
somehow suffocating

ceiling fan whirring
softly slicing
drifted moon beams
peeling off layers
of my life

that tickless clock
counting away
milestones of my life
the menarche
of my womanhood
like menopausal aunties
awaiting passage of day

tired eyes
finding no rest
scanning shadows
for answers
to unasked questions

i sigh
stilling my heart
letting the darkness
claim me once again

Euthanasia #5 - a silent passage

Not so long ago, my pastor asked if I could accompany him to visit a parishioner who was dying from terminal colonic cancer and had just slipped into coma.

At her home, the grief was palpable. Clearly, she was a very much loved woman in the family. The cancer had taken its toll and her body had been reduced to mere skin and bones. She lay on the bed hardly breathing; her eyes staring vacantly towards the ceiling. She was totally unresponsive and uncommunicative, and I could understand why the family thought she had gone into a coma. But in that small HDB flat, as I stroked her forehead and held her hand, a silent tear rolled off the corner of her eye. The poor woman wasn't in a coma. She was just too weak to respond to anything. Couldn't even move her eyeballs let alone breathe or speak. She was on death's door, and just needed some reassurance and comfort.

We prayed over her, and held her hands for a bit longer. I told her loved ones to keep speaking those words of comfort to her because I was sure she heard all they said.

She passed away soon after.

Euthanasia would have been wrong for her. All she needed was the comfort of her loved ones around her... for someone to hold her hands and to be with her as she stepped across the threshold. As Christians, we were confident God was waiting to receive her as she stepped over, but on this side of the great divide, most would appreciate the company of a loved one until the very last moment.

Euthanasia #4 - the end is nigh

The anti-euthanasia group tends to craft their arguments in black and white tones. Pity. Because life really isn't black and white. It takes wisdom to discern the shades of gray...or better still, to resolve the subtle colours of life and living.

I suspect many of the people who are stridently against euthanasia have not had much of an experience at the bedside of people struggling through the closing stages of their life.

Quite a few years back, my uncle died of lung cancer. He was a smoker. The last days of his life was spent in pain because the cancer had already spread through his body, and were making big holes in his bones. It was agony for him. I think as we gathered around his bedside, if we could have read each other's minds, we would probably have seen how everyone was more or less thinking the same thing..."
Was this really necessary? Couldn't something be done to put him out of his misery?"

As it transpired, something was done. The attending physician began giving him larger and larger doses of morphine for his pain. But even as he sank into a deepening narcotic induced coma, the grimace on his face told us he was still very much in distress. Finally after a few days, he passed away. As I watched him then, I held my peace...because my medical background had told me pretty much his passing had probably more to do with the morphine than the cancer itself.

The last days of a terminal illness is often not a fun time. Often there is only pain and distress. Though he/she may be surrounded by loved ones, his/her journey is a lonely and miserable one. Drugs don't help all that much. And we falsely believe that if the patient does not complain, he/she is free from pain. Often he/she is just too weak to say anything. Too weak to argue, or to say any more goodbyes. Just silent tears of resignation from the corners of his/her eyes.

Euthanasia is not the antithesis of palliation, though it is often presented that way. Palliation and euthanasia should be seen as partners in the same process of assisting a fellow traveler in life across the threshold into death. Euthanasia allows him/her to do so in peace, and with grace and dignity. This much we owe to our fellow men.

Melamine hysteria #8 - Minimum acceptable levels

Finally....finally the AVA (Agro-Food and Vet Authority) has released its acceptable limits for melamine. They are:
  • 1 part per million (ppm) melamine, for food products for children below 3 years of age, and
  • 5 ppm for all other food products.
These are extraordinarily tolerant compared to other jurisdictions. The US FDA, and most other countries following suit, have used 2.5ppm of melamine plus related compounds. For reasons best known to itself, AVA has used a limit that is at least twice as lenient compared to other agencies.

I am puzzled. Care to explain, AVA?

Sunday, November 9, 2008

Starbucks...bad coffee....

Didn't have to send the kids the school so had a bit more time today. At the hospital carpark, some Starbucks promotional activity was handing out free coffee and a cupcake.

I don't normally like Starbucks coffee....but since it was free, and I am such a kiam kana (salted olives; stingy), I thought I would give them another chance.

It was such bad coffee. I just simply cannot understand why people accept such bad coffee, and are prepared to pay the premium for bad brew.

Give me a 80 cts teh tarik anytime. Actually the best coffee is found in our local know the thick black ones with a layer of condensed milk at the bottom. Mmmmmm....heavenly.

Euthnasia #3 - a good death?

So this morning the Indonesian government executed the 3 islamists who were responsible for the bombing in Bali. The Singapore government has been characteristically silent. Nothing to say really...considering we had similarly executed 2 Indonesian saboteurs back in 1968. What has been perhaps the most hypocritical was the Australian government's silence about the execution. Typically belligerent and vocal in its anti-death penalty stance, it suddenly seemed acceptable for the Indonesian government to execute these terrorists. Apparently since the Bali bombing had claimed 91 Australian lives, it somehow seemed acceptable to expect their pound of flesh (albeit with a few bullets). Apparently, the morality of taking human life even in the context of a death penalty, can be situational.

The word euthanasia really means "good death". It typically refers to "the practice of killing a human being or animal, especially one suffering greatly or with poor quality of life, as when suffering from an incurable illness or condition."

The attempt by the anti-euthanasia lobby to reduce it to suicide (physician assisted suicide) is I believe quite mischievous. It is correct to equate the two only from a technical perspective since they both involve the taking of one's own life, but truly, the two contexts are really quite different.

In a typical suicide, although the person is in an extreme state of emotional or psychological distress, there is nevertheless some hope (though often perceived as distant) of rescue or of recovery.

In the situation when euthanasia is contemplated, the situation is far from rescuable. While it is true that there is often some degree of depression, often the psychological distress is a reflection of the failure of palliation. It is clear to both patient and care giver that it is really the end of the road, and it is only a matter of time. How often have we as doctors, watch from the sidelines, and wondered about the unnecessariness of the pain and suffering. Words are quite ineffective at times like that.

Once at a well known hospice in South East London, I was briefed on the activities of the care givers. While a large part of the time was spent in managing the palliative component of the care given, I was impressed by how much effort was made to prepare the patient for death. Domestic and interpersonal conflicts needed to be resolved. Wills needed to be written. Debts settled. Reconciliation and forgiveness encouraged. Patients had to be guided towards a recognition of the reality of death. Spiritual help and solace was provided when appropriate. Then, when all has been said and done, if a patient had been prepared well, he or she would be at peace, awaiting the finality of the moment when he/she would depart this world. This was hospice care at its best.

Then when all that's left is just waiting for the final moment, one cannot help but wonder why the suffering need continue. Why would it be wrong for the patient to choose his/her moment of departure? To leave when goodbyes have all been properly said. To leave when your loved ones are all by your side.

This is truly what euthanasia is all about. A good death.

I am not supposed to support euthanasia. But I am not so sure it would be wrong if the context is correct. Death is not the end of life. It is merely a passing of life. Surely a doctor's role is also to assist that passing when the time has come.

Saturday, November 8, 2008

Melamine hysteria #7 - ...still sleeping

While the organ trading issue has been raging in the press as if some major government decision is going to be announced soon, the Agro-Food & Vet Authority is plodding on with its melamine investigations. It has proudly informed us that "As of 24 Oct 08, 3,200 types of milk and milk products, chocolates, biscuits, non-dairy creamers and other products imported from more than 40 countries have been taken for laboratory analysis to check for melamine." Then a bit further down it tells us, "...has also intensified and completed its checks on more than 640 types of the major brands of imported and locally manufactured biscuits available in Singapore."

Fantastic!!! So far it has identified 33 products worthy of recall.

Now please tell us :

a] What is your 'minimum tolerable concentration' of melamine used by AVA to decide if any food product be allowed for human consumption? Why is the AVA being so secretive, when every other regulatory agency has made their position clear. Surely you cannot be hiding anything?

b] What are the 640-33 = 607 products tested and found safe? Surely you can tell us this? Why so secretive?
c] What are the 3200 - 640 = 2560 products taken for testing by you as of 24 October, but have not yet been tested? Are they still on the shelves? When will we have an idea which products on supermarket shelves are clear, or not yet tested? Why so secretive?

C'mon AVA, your 'managed risk approach' is not an excuse to treat Singaporeans as complete imbeciles who cannot digest more than baby food (melamine free). We know that melamine is not that toxic. But there are things you need to do for us to maintain food safety. Checking for melamine is one of those. Please tell us some real information.

AVA, why can't you be more transparent?

Meanwhile people in the food industry complain of stacks of food products being held up in warehouses because AVA won't let them through, but yet has no way of clearing them. Their attempts to get approvals to release their products is thwarted by this wall of silence and bureaucratic maze which surrounds the whole process. They have absolutely no idea what standards the AVA uses, and what AVA expects for their products to be allowed into the market. I think the AVA really needs to get itself up to scratch. I don't think it's managing its regulatory role very well. I think we are very fortunate that melamine is not that toxic, and there is a certain ability for society to 'forgive' present regulatory shortcomings, but I really hope the AVA will use the opportunity to upgrade its professionalism so that we can look towards future incidents with more confidence in their ability to protect us.

Friday, November 7, 2008

Human organ trade - a necessary evil....NMEC???

A really funny thing happened to me just now on my way to the toilet. I heard a report over Channel NewsAsia that the National Medical Ethics Committee (NMEC) has proudly declared its acceptance of the recent Bioethics Advisory Committee's recommendations on the egg donation thingy. It's now carried on the news portal and in the Straits Times.

A very funny thing this NMEC. It was a committee set up in 1994 by the Ministry of Health "to assist the medical profession in addressing ethical issues in medical practice and to ensure a high standard of ethical practice in Singapore". But somewhere along the way, they seem have become lost. Even the Ministry of Health doesn't seem to want to know they exist. I tried Googling them and came up empty. No information. Zilch. The Ministry of Health portal has no links leading to any information about this Committee. The BAC site carried a dead link.

I don't know if they still have a mandate anymore...who they are and what they do nowadays.

What is very telling is that the MoH apparently proclaimed acceptance of the BAC recommendations without seeming to have consulted with them. Today the NMEC then kind of sheepishly accepted the recommendations....kind of after the fact. I mean, could they have said 'No', after the Ministry had accepted the recommendations?

Who is the NMEC, I wonder? Why does the Ministry of Health, who birthed them, not seem to know they exist?

Euthanasia #2 - sanctity of life ...or lack of

Life is so fleeting, precious...we cling to it. We say there is a sanctity to life. And because God created life, we have no right to take it.

Yet we do.

We take life. Often unflinchingly. Abortions have been legalized not just in Singapore, but many other places in the world. We don't blink. We don't even look away now, so hardened has our hearts become. Sure...we make all kinds of rationalizations...about the age of foetus, about the safety of the mother...But these are all rationalizations. We kill when we execute murderers. Another round of rationalizations. And we kill going to wars.

Sanctity of human life. Hardly.

We are hypocrites, because we profess something and do something contrary. There is an appropriate passage in the Bible, when Jesus turns to his disciples and warns them about the hypocrisy of the Pharisees..."I tell you, my friends, do not be afraid of those who kill the body and after that can do no more. But I will show you whom you should fear: Fear him who, after the killing of the body, has power to throw you into hell."

Jesus makes it abundantly clear. It is not the physical body that is holy...that is worth protecting. It has never been about the physical body, about the physical life.

The EEG and the lubdubs of the heart beats are not all there is to the story.
They cannot be.

Euthanasia #1 - views on life...and death -

Copyright © 2008 BBC, Jellyfish Pictures and Marco Iozzi.

I've been struggling with this. This recent spate of discussions about euthanasia has got me thinking, and it's really not an easy issue to wrap your mind around. The issue has been further clouded by a lot of emotive arguments..most of which not very rational. Often public positions have been deliberately hardened around extreme unrealistic situations, which do not help in advancing our understanding.

I'll try and put my thoughts down in a number of posts. I think they will eventually pan out into something rational...I hope. Meanwhile do bear with me. Your comments will help me see though the fog, so please feel free to input your ideas.

It is perhaps unfortunate that the line between life and death is really not something clearly definable other than by means of a empirical physiological measurement. A heart that has stopped beating. A silent EEG. Somehow we know these are inadequate.

As a doctor, we see more than our fair share of death. Perhaps more so than any other profession (possibly more than the clergy). I have seen more than I have wished to. The times I have witnessed death by the bedside have been sobering, humbling...sometimes traumatic moments. When we speak to relatives we use terms like.."(so and so).. has passed away." An euphemism for something we don't want to articulate. Somehow we feel it say the obvious..."he has died". But then, it's not really an euphemism to refer to a passing away of life, because somehow, witnessing death at such close range, it forces you somehow to recognize that there is something else not accounted for...that perhaps the patient has truly passed on to another existence. Another life.

Perhaps it is because of my christian beliefs, but cliched or not, death is not the end ... but a beginning. Notwithstanding this, it is heartwrenchingly painful.

Once I had to deliver an abortus. Seventeen weeks old, it was no bigger than a newborn puppy. I watched it die in the gynae ward sink. No...not die...because technically it wasn't alive, despite moving, gasping. That night, I wept. As a young houseofficer in a cold sterile ward of the old KKH, the sight of that abortus passing away from 'non-life' to death in the cold kidney dish, was far too much for me. That image has stayed with me all my professional life.

Later in my life, hardened by life, I have had to turn off numerous respirators, and watch life pass from lifeless bodies.

How do we draw the line between life and death? Somehow, the beating heart...flat EEGs...seem hopelessly inadequate. We use those only because we have no other means to demarcate that time of passing.

Wednesday, November 5, 2008

Human organ trade - a necessary evil? Fait accompli #2

In a relatively small report we see that the Ministry of Health has accepted the Bioethics Advisory Committee (BAC)'s recent report of the 'donation of human eggs for research'. Ho hum....was there any reason to doubt that the MoH will accept the recommendations? Singapore is after all, a very agreeable society. It would seem quite expected that the BAC would not issue a disagreeable recommendation, and that all this would have been 'cham sionged' all the way through already.

Few things are left to chance in our very agreeable society.
I just wonder what else has been cham sionged away already, and I wait with bated breath for more news. I am quite sure, the MoH will very quickly push through all the well thought through initiatives. And I am quite resigned to having all this rammed down our throats in the 'spirit of public consultations' etc....sigh.....

Watch this space for more to come...

A moment in history - President Barack Obama

President Barack Obama

Never liked the Americans. Liked them a lot less when George Bush was president. But if they can overwhelmingly elect a black man to be President, especially one with a middle name like Hussein, I can give them another chance. So President Obama, don't let us down!

Surprise visitor...

Black Capped Kingfisher
Halcyon pileata
(Pekaka Kopiah/Kepala Hitam)
(Pic from

Speaking of eggs....I had an early visitor early this morning. A lovely kingfisher posing majestically on top of the TV aerial. It wasn't that close I could see the markings it was silhouetted against the sun, but from the characteristic call...I would hazard a guess it was the Black Capped Kingfisher.

It was a very pleasant surprise...and it certainly made my day.

Monday, November 3, 2008

Human organ trade - a necessary evil? Whoa....eggs for sale...???

I was astounded by the timing of the BAC (Bioethics Advisory Committee) 's report, released yesterday on the donation of eggs for research. It is an excellent document, and a very timely one....but the timing of it, being so closely juxtaposed with the recent comments by Minister of Health on amendments to the HOTA (Human Organ Transplantation Act) really blew my mind.

Are they related? Or course they are? Are they consistent with each other....? Totally not!!!

The BAC says....No commercialization. Period. No compensation beyond transport, time and inconvenience. Period. I don't necessary disagree. But the BAC conveniently forgets that the whole purpose of egg research is the generation of a commercial advantage. Only the naive would think that egg research, as currently carried out is completely altruistic. Because if it is, then we should ban any attempt to patent and commercialize the outcomes. Why place the entire burden of altruism on women? Has the BAC blinded itself? Absolutely!

The reimbursement of organ donors...(read payment of organ sellers)... surely cannot be limited to reimbursements of transport, time and inconveience. Inconsistent? Absolutely. Are the 2 activities really that different, after all one can argue one is for 'research' and another for a treatment option? Errrr.... An academic difference at best. Shouldn't they both be governed by the same set of ethical principles that forbid the heinous commercialization of body parts? Shouldn't they both be dictated by altruistic motives? Inconsistent? Absolutely.

Clinical trial volunteers are reimbursed fantastical amounts for participating in drug studies. Sources tell me these 'reimbursements' can be in the range of $10,000. No mention of commercialization of body parts here. No need to be altruistic here. So its okay to reap huge profits while taking part in risky drug trials but giving up an egg must be strictly altruistic? Where is the logic? Where is the consistency?

I am just waiting for the body of blood donors to now jump onto the band wagon. These poor donors are lucky if they get compensated beyond a cup of tau chui and one png kueh at HSA's Centre for Transfusion Medicine. Inconsistent? Bloody!!

I just wish the BAC could have taken a more holistic view of these ethical issues and used the opportunity to develop a more consistent set of principles for us all. I am disappointed this august committee have chosen just to be politically correct.

Sunday, November 2, 2008

Human organ trade - a necessary evil? Let's get it correct....

Well, it certainly looks like we have to accept the reality that human organ trading will be legalized in Singapore. Perhaps, there isn't much of an option. I don't think we can will it away, or pretend the problem doesn't exist. It may start off with the kidneys, but will quickly extend to other organs.

Minister Khaw was actually reported in August 2008 (The New Paper) as having said that, "...SINGAPORE may have an acceptable model of organ trading in the next one to three years."

This fairly mobile time frames which change from reports to reports may just reflect the uncertainty on the Minister's part. It is a rather difficult issue to deal with...and to his credit, he has been consistently trying to deal with it up front. I am not sure though, that I agree with him that, ..."...while the debate rages on, patients are dying and the poor are being exploited to part with their kidneys at a low price.....If we don't do anything about it, we will be guilty ourselves." Sometimes inaction is better than a wrong (though well intended) act.

I was thinking through this issue through the weekend, and I think if we are determined to go down this road, we will need to seriously deal with the problem of exploitation. The entire process must be stripped of any commercial potential, which to my mind provides a fertile ground for abuse.

I suggest the following be put in place, as part of the regulatory environment if organ trading is to be allowed.

a] Organ trading to be limited only to buyers and sellers who are domiciled Singaporeans. This will better limit any socio-economic disparity between different buyer-sellers, as well as exploitation of sellers from extreme regions of poverty in neighbouring countries. It is vital that the program clearly and unambiguously distances itself from any activities that are related to developing Singapore as a medical hub.

b] Run the organ-trade-transplant service as a not for profit activity. The intention here is to discourage over-servicing by transplant surgeons and profiteering.

c] Appoint a special organ-trade-transplant ethics review committee at a national level, so that the review process is fully independent of domestic institutional interests.

d] Strict adherence to price controls.

e] Above all, reasonable and appropriate reimbursements to the seller, with long term medical insurance covering organ failure.

Human organ trade - a necessary evil?...fait accompli...

So my information was correct. (see report in today's Channel News Asia)

Despite Minister Khaw proclaiming that "... there was no possibility of legalizing organ trading any time soon.", their legal eagles have already drawn up the amendments to HOTA (Human Oragan Transplantation Act) to allow "reimbursements"to living donors!

I have no problem with the idea of reimbursing living donors per se. They should be reimbursed in some way for the risks they take and discomforts they endure. This must extend beyond just a one time exchange of $$$...and must include some sort of longer term insurance coverage of a delayed form of risk should the remaining organ subsequently fail.

The idea of reimbursements is therefore not wrong. But the devil is always in the implementation. The Minister is right to point out that there is a scale of differences between
reimbursement, compensation and inducement. How they intend to differentiate these, is the big devil in the works. Clearly what is one man's meat (pardon the expression!) is another man's poison. A scale of reimbursements for a middle income worker in Singapore may be ethical and appropriate, and something he can easily walk away from....yet the same sum to a struggling Indonesian farmer, may be one that can support his family for a few lifetimes, and will be an extreme inducement.

I understand from my colleagues in the clinical trial 'industry', a similar problem exists. Normal volunteers are 'reimbursed' for their time and effort in participating as clinical trials subjects...yet the scale of reimbursements can sometime be so lucrative as to be highly inducive. The ethics committees so far have not been very stringent in examining these issues, and have willy nilly allowed the scales of reimbursements to escalate upwards so that a whole corp of volunteers have been induced to become professional trial subjects. How can we be assured that this does not happen with organ trading? Who polices this? One might question if Ethics Committees, often appointed by the institutions themselves are as objective and independent as they make out to be. How often would they be biased towards saying yes than no, because they want to see the transplant proceed.

We certainly need to discuss this a lot more. It would have been better if if weren't so obvious that the decision has already been made to proceed with the HOTA amendments. It is really a fait accompli.

But might ask...what better way to make Singapore a medical hub? ...sigh...