Thursday, October 30, 2008

Melamine hysteria #6 - ... an open secret for 18 months?

TODAY newspaper carried a news report about the practice of melamine spiking being an open secret.

I mean duuuhhhhh.....

This has been an open secret for 18 months since the infamous US pet food recall. So why has the regulatory authorities, not just in China, but worldwide (including our Agri-Food and Vet authority), not been proactive in monitoring the situation? Why the persistence with an outdated protein assay when it was an 'open secret' that melamine was being used to cheat the old protein assays?

AVA, are you listening?

Adding melamine to animal feed an ‘open secret’

BEIJING — Animal feed producers in China routinely add the industrial chemical melamine to their products to make them appear higher in protein, state media reported yesterday — an indication that the scope of the country’s latest food safety scandal could extend beyond milk and eggs.
The practice of mixing melamine into animal feed is an “open secret” in the industry, the Nanfang Daily newspaper reported in an article that was republished on the websites of the official Xinhua News Agency and the Communist Party mouthpiece People’s Daily. For more...

Wednesday, October 29, 2008

Human organ trade - a necessary evil? Here's a thought....

The principal arguments in favour of organ trade centre upon the noble and virtuous saving of lives. There is no doubting the benefits that organ transplation bring to suffering patients with end organ failures. Doctors managing such terminal patients are understandably motivated to provide for this life saving option. Balanced against the saving of a life, the potential risks of exploitation of the seller can seem trivial.

There is however, another perspective that is often neglected. In fact I have not come across any readings which have pointed this out...perhaps the truth is too uncomfortably close.

To some extent this resonates with an earlier post on the 'commodification of health care'. I can't help noticing that the proponents of organ trade are either patients/relatives of patients, or doctors/surgeons involved with managing such patients.....and (dare I say it...the Ministry of Health (although it is giving the impression of moving slowly on the issue, there is little doubt it is moving determinedly towards the eventuality).

The question that bugs me is this....' what extent is this move towards legalizing organ trade related to our national strategy of developing health care as an engine of economic growth?'

I would like not to believe they are related, but the cynical part of me suggests that there are clear economic benefits to being recognized globally as a medical centre of excellence engaged in responsible and highly regulatable organ trade and transplant. I hope I am wrong. But here's a challenge to those in the medical profession and the MoH who argue for organ trading as an essentially altruistic life-saving activity..... 'how about removing the profit element from the whole organ trade and transplantation scene?'.

I am not talking about the appropriate reimbursements for the organ seller, but to the enormous profits made by the hospital, surgeons, physicians...and whole chain of health care providers in the wake of any legalization of the organ trade. If this is such an essential, noble and altruistic act, the organ owner shouldn't be the only one to carry the burden of the transaction. Society must do its part...i.e. society must pay the price in the form of an increased MoH health care budget, and doctors their fees. Subsidies for the transplants should be provided, and hospitals and surgeons should forego revenues associated with these and related procedures.

Do it....and see if the proponents are still quite so willing to be 'noble and altruistic'.

Human organ trade - a necessary evil? The real deal.

What do I really feel?

I think there should never be a situation when a person, no matter how rich and powerful can induce a fellow human being to take risks and sell him an organ.

I imagine if I were ever in a crisis situation, a massive flood perhaps, or Titanic moment, I would never, could never expect someone else to risk his/her life to save me. If he/she did so, it would have been a wonderful act of grace, for which I would then owe an eternal debt of gratitude. But I could never expect that act of selflessness, nor even pay to induce such a wonderful act of self sacrifice.

Therefore I feel that no decent human being, should expect a fellow traveller through this life to part with a vital bodily part to save him/her. While I can understand the desperation to cling on to life, I cannot see that anybody's life is so vital that another's is deemed sacrificeable.

If you have to die, please die with grace, honour and peace.

Tuesday, October 28, 2008

Human Organ Trade - a necessary evil?

Another round of public venting of views is going round the press circles.

Inside information is that the HOTA (Human Organ Transplantation Act) [see here also for more readings on HOTA] is being further tweaked. I'm not sure what the amendments are going to look like, but it seems like the legal eagles in the Ministry of Health are going through the process of preparing a draft amendment. This despite Salma Khalik reporting in Oct 6 Straits Times that "Health Minister Khaw Boon Wan said that there was no possibility of legalizing organ trading any time soon.".

So we'll wait and see.

It seems like the issues around which the organ trading controversy revolves are,

a] sanctity of the human body...that somehow it is degrading to trade in human spare parts.

b] the problem of exploitation.

Quite frankly, I am personally not so convinced about [a]. The biologist in me says it's just a lump of flesh. If someone wants to sell his kilogram of flesh...what's the big deal? The human body (the whole and parts of...) has been bartered and traded since the beginning history. We've had slavery (of various degrees), prostitution, menial labourers (no minimum wages), paid volunteers for human experimentation (sanctioned as ethical by institutional review boards), etc. Hospitals and research centres hoard spare parts for their research efforts which bring fame and fortune (and patents) to the researchers and institutions....this seems to be pretty acceptable! All in the name of altruism and science!

It is true that the christian in me balks a little since our bodies are supposed to be the 'temple of the Holy Spirit'. But I think this idea has been over represented. No where in the Bible does it say that our physical bodies are worth very much. In fact the Bible tends to be rather deprecative about our physical bodies.

"In the sweat of thy face shalt thou eat bread, till thou return unto the ground; for out of it wast thou taken: for dust thou art, and unto dust shalt thou return." Genesis 3:19

Issue [b] is a much weightier problem. How can one allow such a way as to prevent exploitation. I am not sure it can ever be done in a perfect way. Exploitation occurs in all forms of trading. One buys, and another sells...Is there ever a fair deal where both parties truly 'wins'. Trading is always a matching pair of trade-offs. Some one is always 'exploited' in some way. Who will ever voluntarily sell his/her organ? Obviously the poor. Who will engage in high risk work, if not for the lure of money? Who will prostitute her body, unless she so desperately needs the money? We've accepted all these unfair trades in our society without a blink, haven't we?

This I guess is the ultimate challenge in dealing with the organ trading issue. I can't see any way to prevent it from happening. If a wealthy s.o.b. wants to purchase an organ to save his own wretched life, he will do it some way or other...if not in Singapore, then it will be elsewhere. Much as it may sound unpalatable to some, it may be the lesser of two evils to legalize it, and manage it rationally so that we can ensure, a reasonably fair deal for the seller....and ensure the buyer takes on his/her legal and moral responsibilities for the transaction.

A necessary evil, for an imperfect world. sigh...

Monday, October 27, 2008

Black Swan? The financial meltdown...

No, this is not a post about any more birds. The black swan has become some sort of a metaphor of unpredictable, catastrophic events, ever since Nassim Taleb's bestselling book. He draws his inspiration from the notion that prior to the discovery of black swans in Australia, all swans were thought to have been white.

The latest financial crisis has been touted as an example of Taleb's black swan.
Yesterday the Hang Seng Index crashed out 12%. The Straits Times Index has been wobbling around a negative 5-6% this morning. The way the market has been unraveling is nothing like what I have experienced before. I don't dabble in the market, rather preferring to see my assets grow slowly each month. So far, I have more than enough to feed my family, so it's been a workable strategy for me. Still.....I can see it's going to be a tough time for many of the middle and low income earners. Layoffs are going to wreak havoc in people's lives. I feel sorry for them, but don't know what I can do...maybe to be extra kind when they come to the clinics.

But is this a black swan upon us? I somewhat disagree with the pundits who have proclaimed it so. According to Taleb, a black swan is something that has occurred out of the one swould have seen it coming. This is certainly not the case here. It seems like the writing has been on the wall for a long time already. People just didn't want to see it. An obvious case of not being able to assess risks. Analysts were shouting buy calls up to the very last moment. Some are still trying to persuade others of the bargains out there.

You cannot blame folly and bad judgment on the black swan.

Now don't anyone dare to call the melamine fiasco a black swan event....!

Red-breasted Parakeet (Psittacula alexandri)

I had one of these wonderful, unexpected moments of plain joy this last weekend, when sitting under the shade of the angsana trees lining the Changi Village boulevard, I 'discovered' this large flock of noisy parakeets. I had previously come across some random sightings of these birds before, and I have never gone looking for them,....but here they were ....noisily screeching and making their presence felt in the otherwise quiet balmy evening of the village. I was surprised at how many there were....must have been several flocks there totalling at least 50 birds.

These are the Red-breasted parakeets, (or sometimes called the moustached parakeet) identified usually as
Psittacula alexandri, although some have suggested some admixture with a fasciata strain. At close inspection, they are actually quite beautiful birds, ... their colourful plumage making them quite striking even from a distance.

I was just so pleased to have encountered them. Apparently that stretch of angsana trees are home to the Tanimbar Cockatoo (Cacatua goffini) as well, but I didn't see them that evening.

A nice report of these birds in Changi Village can be found here.

Friday, October 24, 2008

Melamine hysteria #5 - AVA why the delay?

The AVA (Agri-Food and Vet Authorities) yesterday recalled a whole bunch of Khong Guan and Julie biscuits. It's about time too. Malaysia had already incriminated them all a week ago.

I can't imagine what took the AVA so long. Couldn't they have acted on the basis of information sharing with our Malaysian counterparts? Meanwhile, the stuff remains on our shelves??

Don't like saying this but I am increasingly losing faith in their ability to protect our food safety.

Alan Greenspan - ''Savant Idiot''?

The title of the post is taken from Michael Thomas' op-ed in about the iconic former US Federal Reserve Chairman Alan Greenspan, who yesterday admitted before the House Oversight Committee to having made mistakes in regulating the financial markets. [ A savant idiot, according to Thomas, is unlike the idiot savant, "... one who is festooned with credentials, diplomas, laurels and prizes both professional and academic, who pontificates and expounds impressive-sounding "truths" and explanations--what a friend of mine used to call "chinstrokers"--that in the fullness of time and markets prove to be utter b.s. The idiot savant produces substance out of apparent ignorance; the savant idiot produces ignorance from apparent substance.]. His 'mistakes' benefited many during the boom past years, but have led to the 'worst financial crisis in living memory'. Once regarded as the 'greatest central banker' of this generation, Mr Greenspan has fallen from grace, and has increasingly come under attack as the financial crisis unfolds on a daily basis, revealing its roots to his flawed policies of deregulation. Clearly, all this was due to US fiscal imprudence.

But Mr Greenspan's folly is related to something much more insidious. For many years the world has very much admired the US's freewheeling spirit which has led to the development of the world's largest economy. It's dynamism and spirit of entrepreneurial adventurism, has been the envy of many a developing country, including Singapore. Mr Greenspan's philosophies with respect to the economy and financial regulation, although drawn from Ayn Rand's views of laissez faire capitalism, should be seen in this larger socio-political context. While this free-wheeling individualistic culture has inspired and led the world for many years, its negative consequences have become more apparent in recent years as US self-centredness repeatedly lead us into crisis after crisis.

What lessons for Singapore? Apart from having to deal with this engulfing financial tsunami (interesting article here from across the causeway, NST), Mr Greenspan's follies should perhaps give us something to think about. Perhaps the US model is not necessarily the best model to so blindly emulate. The US, for the moment the world's largest economy and much envied epitome of wealth and capitalism, does not clearly hold a monopoly on common sense, ability and wisdom. Otherwise, Greenspan's folly will be Singapore's.

We have too easily and comfortably just followed the US model, imagining it would lead us into roads paved with gold. Perhaps the time has come for us to re-evaluate that strategy. In this tsunami, some Asian paternalism and clear regulatory leadership, seems much more comforting than the free-wheeling, everyman-for-himself culture the US has tried to foist on the world.

Secondly, despite the supposed openness of the democratic system the US is so proud of, there was far too much invested in the wisdom and authority of just one man, the Federal Reserve Chairman. Because he had assumed such a elevated stature and reputation, few had the academic strength to challenge his assumptions or to overrule his decisions. As a result, his assumptions and ideas about the superiority of the free market system held sway even as the bubble grew. None had the temerity to deflate a bubble that was on the verge of bursting.

We should therefore be cautious about investing too much power in the personality and/or the intellectual strength of one man, or
some small exclusive group of insiders. No one person knows everything. While a narrow power pyramid may make for swifter decision making, it also predisposes to tsunamis of a different sort, if the narrowly perceived wisdom proves wrong.

Wednesday, October 22, 2008

Rev Henry Khoo - Requiescat In Pace

Rev Henry Khoo, retired Chaplain at the Changi Prison has passed away at the age of 76, after a long battle with cancer.

I never really knew the man, but our paths crossed many years ago. I knew of his work with the inmates. A saintly man, whose life has always been a source of inspiration to me. In today's crass commercial world, so corrupted with calculative, mercenary selfishness, Rev Khoo's life of selfless devotion to his charges in prison, must remind us of a life beyond this world, and values higher than what the world offers.

The Straits Times today carried a wonderful obituary of the man, written by KC Vijayan.

Rev Khoo, May God bless you. Thank you for showing us the face of God. Rest well in the Father's arms.

Managed risks????

Managed Risk Approach

Dr Maliki Osman, Parliamentary Secretary for the Ministry of National Development, was yesterday reported by TODAY newspaper as defending AVA (Agri-Food and Vet Authority) 's position... "....that Singapore takes a managed risk approach to food safety. To test for all kinds of chemicals and contaminants would require “many more laboratories and personnel”, and cause food prices to escalate."

errrr.....Dear Dr Maliki, ensuring safety of our food, should cause food prices to escalate?? Isn't that like saying, "...if we want safe streets, our taxes will go up." Surely safety monitoring of foods must be the government's role? Dr Maliki's idea of a "managed risk approach" seems a bit like neglect to me. A bit like saying, " ... don't tell us about the shit that's about to hit the fan. We'll manage the shit, when it does hit the fan!" I don't think we will need highly paid talented civil servants if that's the kind of approach to risk management. I mean the melamine issue (read 'shit') was already known 18 months ago after the US pet food recall. Now the AVA is scrambling for credibility after the melamine hit the fans,....simply because no one wanted to put in place a melamine assay. This is the consequence of the famous "managed risk approach"!!

DNA tests for talent...? BULLSHIT!!

My Paper this morning carried this report of a lab in Singapore offering genetic services to do genetic testing for talent. Ifd it were April1st, I would have passed it off as a joke. But this is pure bullshit!!

Apparently brought in by brought in by local health-marketing services DNA Dynasty, its contracted laboratory is Shanghai Biochip in Pudong, China. I tried to Google DNA Dynasty and cannot locate it anywhere. Only an anonymous blogsite soliciting testimonies....and a CEO blogsite with no identity.

Apparently..."Dr Y.M Wong, who runs an anti-ageing management practice at Paragon Medical Centre, is a doctor who recommends his patients to DNA Dynasty to complement his treatment." C'mon Dr YM Wong....! This is pure BS and you know it!

Monday, October 20, 2008

Euthanasia - what price, life?

Minister of Health, Mr Khaw Boon Wan was reported by Salma Khalik of the Straits Times as having raised the controversial issue of euthanasia at a recent speech he gave to a bunch of engineers. I respect the Minister for facing some of these difficult issues head on. It is uncommon for a politician to confront problems like these without preconceived notions as to what a 'government solution' might be. It's certainly a refreshing level of honesty to hear a politician call for more public debate on what was a 'complicated issue'.

This, plus issues of organ trading, are indeed complex and ethically challenging issues. I find myself personally very conflicted about what might be my approriate response to these questions. I will try and marshall my thoughts and try and articulate them in future posts. But for now it seems like there are a number of ethical 'sacred cows' which might need to be slaughtered. I know I may come under attack for raising these ideas, but....what the heck? These cows include the following:

a] What is the meaning of sanctity of human life? To what extent are we obliged to preserve all life at all costs? Which faith/ideology peaches this idea that we should save life at all costs? Seems to me all faiths teach the temporality of our physical life and that the true eternal value of life lie in the spiritual domain.

b] To what extent is the human body, and parts of the body...sanctified, that its 'dignity' should be defended at all costs? What is meant by the dignity of the human body? In today's biological world, these ideas seem somewhat anachronistic.

More on these thoughts later.....when I get a longer coffee break.

Sunday, October 19, 2008

Seasons of the heart - bradycardia, arrhythmias and sudden death

A younger colleague stopped me over the weekend and asked my opinion of an young otherwise healthy individual with a resting heart rate of 40/min. I had to admit to pausing for while before answering. The normal range for a normal heart rate is probably about 60-100/min. Quite often we do see individuals with heart rates between 50-60, especially if they are aerobically quite fit. But 40/min is a bit of a stretch below the normal range especially considering that the atrial and nodal pacemakers start to kick in. Marathon runners can drop their heart rates down to 40. But here the individual wasn't quite a marathon runner...merely borderline fitness. He had a heart rate of 40, no escape rhythms (ECG done), and otherwise cardiovascularly normal.

I passed him as normal.

But it made me think a bit more about the heart. Amazing organ. At an average heart rate of 72/min, with a lifespan of 80 years, the heart would have beaten over 3 billion times. Isn't that incredible?
And all this while, the complex movement of Na+, K+ and Ca++, through intricately regulated ion channel activities, maintain appropriate heart rhythms that allow us to function normally through extreme ranges of physical activities. It's just such a miracle that we don't all seize up and die. When you think about it, we wouldn't really require a myocardial infarct to die of ventricular fibrillation. Yet most of us will live through this uncertainty.

Perhaps the sudden death cases that we read about in young people ...or crib deaths in infants....are nothing more than the random occurrences of electrical convulsions of the heart? Intrinsic risks of life.
Food for thought.

Commodification of health care

Over the weekend, the Sunday Times reproduced Dr Lee Wei Ling's earlier letter to the Straits Times (15 Oct) about the commodification of medical care. The letter is reproduced below.

I have always had the highest regard for the good doctor. Despite the open road for her to jump into high political office, she has instead opted to align herself with the less 'rewarding' mission of championing the needs of the common man. Here she has been able to put her finger on the nub of the problem. In various ways, each of us has been struggling with issues related to the commodification of medicine, and the commercialization of patient care. In today's world, I guess some degree of commercialization cannot be avoided. But Singapore is already paying the price of being overly pragmatic in wholeheartedly submitting to these crass values of commercialization, and there are clearly worse consequences than what we already see happening to the medical profession. Things will get worse. Medicine is a noble profession, but it will not stay that way if we do not fight to hold on to her noble values. The Singapore Medical Association has been greatly weakened and has but a little voice in this struggle. That is why Dr Lee's voice is so invaluable. There are few individuals with the kind of stature and 'protectedness' (she will hate my saying this, but it's true) who can articulate this to the powers that be. Her diagnosis is correct. I am not sure what she can achieve, but her's is a voice that must be heard.

Interestingly, this route that the medical profession is taking, unless I am mistaken, was actually begun many years ago by her own brother who proposed the development of Health Care as one of the pillars of Singapore's economic growth. The lifting of the GOF is merely a logical step in this process.

Medical care is not a commodity

By Lee Wei Ling

MOST developed countries believe that the free market is the best system for allocating scarce commodities. The right price for such commodities, they believe, is best determined by allowing the forces of supply and demand to operate freely.

But a free market can work efficiently only if sellers and buyers have roughly equal knowledge about the commodities changing hands. Such a condition does not always exist. Medical care, especially, cannot be priced like any other commodity because the seller (the doctor) has much more information than the buyer (the patient).

The patient is therefore at the mercy of the doctor, not only in terms of what he is charged but also in terms of what he needs to 'buy'. For example, procedures that may be unnecessary, such as blood tests and radiological examinations, may be ordered by a doctor, and the patient would be in no position to refuse.

One could argue, of course, that patients can shop around to find doctors who would offer them the cheapest package. But this is impractical: Patients with urgent medical problems do not have time to shop around. Patients from foreign countries would want to get their medical problems attended to quickly so that they can return home. Moreover, patients are usually informed of the medical procedures they require only after consultation with a doctor. They do not know beforehand what they would require in order to shop around effectively. This, together with the time constraint, makes it impossible for most patients to make an informed choice among doctors.

Prior to 2006, the Singapore Medical Association (SMA) had a 'Guidelines on Fees' (GOF) for doctors in private practice. The GOF recommended a range of fees for various medical procedures. It was only a guideline, so doctors could deviate from the quoted fees if they wished. However, if they did so, they were expected to inform patients in advance.

This enabled patients to know what was the 'premium' they were expected to pay for the exceptionally superior treatment their doctors were promising, and they could decide for themselves whether they wished to pay that premium.

Sometimes, patients discovered they were charged much more than what was recommended in the GOF only after they received their bills. Some complained to the SMA as a result.

In such cases, the SMA would request the relevant doctor to justify the extra charge, and if there was no reasonable explanation, it would advise the doctor to refund the difference. This advice was also transmitted to the patient who complained. Most doctors who overcharged without good reason followed the SMA's advice and refunded the money. The guideline worked, functioning both as a moral and practical rubric.

In 2006, the SMA abandoned the GOF because it was encouraged to believe that the guidelines might contravene the Competition Act. Ironically, the purpose of the Competition Act was to protect consumers from being overcharged by allowing free-market forces to determine prices. And the GOF was designed precisely to protect patients from being overcharged by private medical specialists - always a possibility given the asymmetry of information between doctors and patients.

To abandon the GOF on the grounds that it is anti-competitive is so illogical that I wonder whether anyone in the Competition Commission of Singapore understood that medical fees cannot be determined by free-market forces. The abandonment of the GOF has made patients the easy prey of unscrupulous private specialists.

They can now charge as much as they think they can squeeze out of patients. Charges tend to vary, depending on the patients' addresses, whether they have medical insurance policies or are dressed expensively or wear jewellery. Foreign patients are more likely to be overcharged because they have no time to shop around. I know first-hand of an Indonesian patient who was charged $100,000 for a simple laparoscopic removal of a gall bladder, a procedure that usually costs $10,000 in the private sector. There have been enough cases of shameless profiteering to earn some private hospitals here a bad reputation.

Public-sector doctors cannot overcharge because their fees are fixed by the Ministry of Health. Many of us in the public sector have had friends, both local and foreign, ask us for advice about which doctors in the private sector they should consult. They know that without medical information, they are unable to tell which are the good doctors, professionally as well as ethically.

The current situation, with some specialists in the private sector overcharging, is bad for Singapore. The Government hopes to promote medical tourism. But news of overcharging spreads very quickly abroad. Unless action is taken soon, greed will kill the goose of medical tourism before it has had a chance to lay any egg, let alone golden ones.

Overcharging is also bad for Singapore's medical fraternity. Young doctors watch what their seniors do and will overcharge too when they enter private practice. As it is, there is already an erosion of medical ethics here - not only because of overcharging, but also because of superfluous referrals to other specialists who are one's personal friends, unnecessary and expensive investigations and even some unnecessary procedures that carry risk of harm to patients.

Medicine as a profession is a calling, and medical care cannot be treated as a mere commodity. If the medical fraternity does not act soon to cajole or coerce the black sheep among us to stop taking advantage of patients, Singapore's reputation will suffer and all its doctors will be tarred by the same brush. If we delay reforming the system, its faults will become more difficult to reverse.

Reviving the GOF would provide one solution to the problem of overcharging. It is not a perfect solution but, as with many other problems in life, there is no perfect solution. We know that the GOF will work - because it did.

The writer is Director of the National Neuroscience Institute. Think-Tank is a weekly column rotated among eight leading

figures in Singapore's research and tertiary institutions.

This story was first published in The Straits Times on Oct 15, 2008.

Friday, October 17, 2008

Why did the sparrow die...?

Javan Myna

Lovable as the sparrows (Eurasian Tree Sparrows) are...they are not a very intelligent bird, nor a very competitive species. The disappearance of sparrows from our gardens has been noticed by many, who have also claimed that this was evidence of trend towards an eventual extinction of the species.

I think this disappearance of the sparrow is largely because of their failure to compete against some very aggressive and intelligent bird species who have inserted themselves over the last few decades. First there were the Common Mynas who invaded the same ecological niches the sparrows had occupied for years. More recently, the Common Mynas themselves have been displaced by the Javan Mynas. So now these dark brown birds are ubiquitous.

I am not sure what the differences are between the Common Mynas (Indian Mynas; Acridotheres tristis) and the Javan Mynas (Buffalo Mynas; Acridotheres javanicus). Apparently the Common Mynas have got a more striking yellow beak and markings around the they can mimic the human voice.

It's just sad that the sparrows lost out. I am not sure what we can do about it. The mynas are clearly here to stay. I have nothing against them. They are smart and social birds who unfortunately are also very aggressive and brutal in brutal in decimating the sparrows. I suppose biologically they deserve to succeed. But I just wish they can succeed without wiping out the sparrows.

But such is life.....:(. So tragic!

Other readings about the Javan Mynas:
Bird Ecology Study Group:

Thursday, October 16, 2008

Melamine hysteria #4

As of 9/10, another 3 products have been incriminated in the melamine scandal. The lowest melamine of the 3 products was 21.4 ppm in Cadbury's Choclairs. So far, we still have no idea how many have been tested and passed. The lowest melamine in all the incriminated products (so far 13 such products) still stands at 8.1 ppm (Silang - House of Steamed Potato - Potato & Tomato Cracker). So far we also have no idea what level of melamine is deemed acceptable by the AVA (Agri-Food and Veterinary Authority). They have been gloriously and majestically silent.

Meanwhile Vietnam has said (today's TODAY) some Pokka products made in Singapore are contaminated, but AVA says "test products manufactured by Pokka in Singapore....have been found to be satisfatory."

....sigh....why can't AVA just come clean and be a bit more transparent about what they are doing...??

For the uninitiated, 1 ppm = 1 mg/kg. Generally accepted minimum levels tolerated in food products is 2.5 ppm.

Another funny survey....

Young people nowadays consume too much alcohol. Or so a survey by the Dept of Sociology, at NUS says (reported in today's TODAY).

Err...another funny survey here.

Survey sponsored by the Asia Pacific Breweries? Conducted on patrons at disco/pubs? 73 respondents out of the 531 youths said they binge drink at least once a month.


Tuesday, October 14, 2008

Care for the dying...

Caught a glimpse of Minister of Health Mr Khaw Boon Wan's comments on the front page of the Straits Times about how the State has come round to recognizing that it needed to play a bigger role in caring for the aging population and the terminally ill. It's about time. He is a good man, if he truly believes in this, and will truly allocate adequate resources to make it work. But this is not a small problem. It is also a burgeoning problem. His declaration that the MoH will increase the 125 hospice spaces by 20% is a grand gesture of intent. But it is a minuscule effort given the size of the problem. Care for the dying, is not just about bed space. It is not only about medical care. It is about providing for a whole range of services that will look after the dying's social and emotional needs. It is about the writing of wills, and reconciliations between family members. Is the MoH really serious about this? I really sincerely hope so.

Minister Khaw, thank you. I don't mean to sound ungrateful, but we really need much much more.

Monday, October 13, 2008

Science, Religion and Politics

from Bob Englehart, The Hartford Courant

Greed, ignorance and appreciation of risks....

TODAY had a opinion piece by a financial consultant entitled "Ignorance and Greed", essentially discussing the people who got burnt exposing themselves to high risk investment products. This kinda resonated with my previous post on how we are all biologically designed (condemned) to be incapable of accurately appreciating risks. It's fine for people who didn't get burnt to patronize those who did, but truth be told, many savvy investors (read gamblers) who should know better also got burnt. Were they ignorant? I mean couldn't they see the risks?

But beyond kinda struck me that there is probably a massive amount of commerce and wealth generation that exists in the world, that systematically exploits this biological deficiency we have in risk appreciation. Think insurance managers.....preventive health screenings (wealthy cardiologists in big Mercedes!)! Are the premiums invested in these activities appropriate for the size of the risks...? Who knows. Actuarists and epidemiologists give us numbers that no one can understand.

In this regard, the concern of the NMRC in surveying attitudes of trial volunteers fall smack in the middle of this discussion. Clinical trial subjects (no matter how educated) are singularly incapable of appreciating risks in participating in clinical trials, no matter how much we kid ourselves. Gross and irresponsible oversimplification of the process, such as the statements put out by the Straits Times yesterday complicate matters. How can anyone dismiss the risks by saying that "clinical trials are as safe as they can be"? The whole idea of clinical trials to to find out what you do not know. This surely must include the discovery of risks....

What a way to do a survey!

I read the review in today's Straits Times about the NMRC 's (National Medical Research Council) plans to survey patients' and potential subjects' attitudes towards participating in clinical trials. This is the second bit of information that has come out about this survey. I remember reading something in the papers a couple of days ago as well. No doubt it will be a useful and time survey. But it just struck me as odd that just before the survey is conducted, the NMRC should flood the public domain with reasons for conducting the survey, and information that will clearly affect prevailing attitudes. I guess it doesn't matter to them as long as the survey is conducted. No one can say they didn't try!

Cynically one can say that it's very much a Singaporean approach towards these telling people, " Now guys, look here....we are going to survey your attitudes about this thing ...but first let me tell you what your attitudes ought to be!"

It's quite funny.

Sunday, October 12, 2008

What a splash...!

Some alarmist thoughts. I wonder what the risks are...
Here is a site that lists possible steroids hitting earth. The next one is Near-Earth Asteroid (99942) Apophis [2004 MN4]which will have a very close approach to earth in 2029.

Oooops.....I think I should go take in the laundry!!

Saturday, October 11, 2008

Regulatory independance ?? FSA (UK), FSANZ, FDA, AVA...

I had a nice time googling all the food regulatory agencies....having had a bit of time on my hands this weekend.

Did you know that in the UK and Australia-NZ, food regulation is carried out by agencies which are stand alone independent agencies?

In the UK, it's called the Food Standards Agency, an independent Government department which was set up by an Act of Parliament in 2000 to protect the public's health and consumer interests in relation to food. The FSA functions independently and does not report to any Minster. Rather, it reports directly to Parliament. It is free to publish any advice it issues.

Australia and New Zealand have a joint agency called Food Standards Australia New Zealand. The FSANZ is an independent statutory agency established by the Food Standards Australia New Zealand Act 1991. It reports to a 12 member Board, and the Parliamentary Secretary takes executive responsibility of the agency. The policy and guidelines are set by a joint Ministerial Council. Once the Ministerial Council has decided on policy guidelines, these will be published and the FSANZ will automatically implement them.

The US FDA (Food and Drug Administration) has had a much longer history and developed originally as a regulatory agency concerned about food adulteration and contamination. It was brought into existence in 1906 with the passage of the Federal Food and Drugs Act. Ironically, the problems that gave birth to the FDA are the very same kind of problems that are afflicting China at the moment. The FDA is an agency within the Public Health Service, which in turn is a part of the Department of Health and Human Services.

In contrast to these agencies, our own AVA (Agri-Food and Veterinary Authority) comes from a backdrop of being a Primary Production Department, with responsibilities for developing and regulating the local farming and fishing industry. Then in 2002, the Food Control Division of the Ministry of Environment moved over into the AVA.

Food regulation in Singapore, historically,...and strangely, has always been handled as an environmental as compared to a health concern. I cannot help but wonder if this is the correct or optimal situation. Unlike other developed countries where food regulation is an independent agency, food regulation in Singapore, is part of the AVA, an agency concerned not only with food safety, but also health and safety of plants and animals as well as with agricultural trade. I am always worried about situations where human health and safety concerns and tempered by concerns about trade and commerce. In this instance, can regulatory decisions by AVA about food safety be made objectively and transparently? Are there enough safe guards to ensure officers can act without conflicts of interest?

I don't mean to be targeting our AVA in my posts, but the unfolding melamine scandal has put the AVA under some limelight, and maybe it's about time we had a closer look had how regulatory decisions are made in Singapore.

Friday, October 10, 2008

What a mountain..!

Melamine hysteria #3 - a missed opportunity, or negligence...?

Apparently the melamine story goes back 18 months to early 2007, when it was first recognized that precious pets in the US were dying of renal failure. The problem was soon traced to the presence of very high levels of melamine in the incriminated pet food. Since melamine does not occur naturally in food, the source was quickly traced to intentional spiking of wheat gluten so as to fool chemical assays for N2 that there was more protein in the gluten than there actually was in the pet food. The amount of melamine in the pet food was more than 1000 ppm (1 ppm = 1 mg/kg). This led to the largest pet food recall in US history.

The scandal prompted the FDA to pay greater attention to produce from China, particularly those that depended on the chemical assay of N2 (Kjeldahl and Dumas methods) as an indicator of protein content.

It is now recognized that melamine has found its way into the food chain, possibly through the use of the common pesticide cyromazine. Small amounts of melamine in food is acceptable as it is not a particularly toxic chemical. But it is thought now that melamine may act synergistically with a co-contaminant cyanuric acid to produce the renal toxicity.

The story is better reviewed here:

After the 2008 Olympics, the scandal with respect to infant toxicity hit the front page. A detailed account can be found here:

According to a CNN report, ... "Levels of melamine discovered in batches tested varied widely, from as much as 6,196 milligrams per kilogram to as little 1.3 milligrams per kilogram.".

The question I have is this:
Why did it take so long for the regulatory authorities to begin policing melamine content in food products?

For one thing, it should have been very clear 18 months ago that the old chemical assays for N2 were inadequate, and those should have been replaced by a good LC-MS/MS assay for melamine. For some strange reason this was never done. Complacency or negligence? Was it a case of everyone waiting for something to happen? Could it not have been expected, that what happened to small furry animals could also happen to babies, and other members of the human species?

To be fair to the AVA, they were just following the idiocy of other regulatory agencies, now having a lot of egg on the face. But I feel they have not been as professional about this as they should have been. The implications following the pet food scandal should have been obvious (although much better now of course with hindsight) back in 2007. A better assay, and more careful scrutiny would have been appropriate. Now they, like many other food regulators are scrambling to manage this mess, which should not have been allowed to deteriorate to this stage anyway.

Now, nobody really knows what the AVA is doing. Information from the authority trickles out almost grudgingly...and in confused fashion. My sources tell me they have pulled all products from China. No one has any idea what products have been tested, and what have not. A short list of products that fail testing have been put out, but we have no idea what assay the AVA uses and what the implemented concentration limits of melamine are.

The AVA website is full of general motherhood statements with no real information. We are told that "AVA adopts a risk-based approach towards ensuring food safety. Food products identified through trend studies to be of high potential health risk, or have a history of poor food safety record are placed under strict import control (high risk). These products require pre-market assessment such as the requisition of health certificates or laboratory analytical reports to certify the safety of the products, or inspections and/or sampling, at the points of import."
In other words, AVA only does sampling checks (how frequent, how representative these sampling is, we have no idea) and requires nothing more than the importer to provide documents from the Chinese factory certifying quality of the product (ho hum....). Clearly, the AVA wants us to just trust them implicitly, and blindly...i.e. like little blind mice! *sigh*

For infant formulas, these are the published AVA requirements:

Microbiological Tests:

  • Total colony count
  • E. coli
  • Staph enterotoxins
  • Salmonella
  • Bacillus enterotoxins#
  • Clostridium botulinum#
  • Enterobacter sakazakii
  • Sterility test for food in hermetically sealed containers

Chemical Tests:

  • Aflatoxins M1
  • Heavy metals#
  • Pesticides residues#
  • Polychlorinated biphenyls (PCBs)#

# Upon request by AVA

duuuhhhhhh...............! Anyone there heard of melamine?

I think AVA owes us an explanation, big time...really big time!!

"...poetic adventure and sensual ecstasy.."

Jean-Marie Gustave Le Clezio

A French writer Jean-Marie Gustave Le Clezio has won the 2008 Nobel Prize for literature. I must confess I have not read any of his books. I should ... maybe on my next long haul flight. The Swedish Academy awarding the prize refer to him as being an "author of new departures, poetic adventure and sensual ecstasy, explorer of a humanity beyond and below the reigning civilization." I don't know if is just the way I am wired....(does anyone feel the same way?) but I have no idea what 'poetic adventure' means...nor 'sensual ecstasy'. Is there a form of ecstasy that is non-sensual?

dip in fortunes...

So the latest THE (Times Higher Education) ranking is out. The overall ranking for NUS climbed ever so slightly from 33 to 30, while that of NTU took a bit of a dip from 69 to 77. The gap between Singapore's two top universities continue to widen.

I need to explain that I am not a believer of the ranking, nor do I follow the perverse fixation of our leaders on pursuing these ranking numbers. Some have likened this process to a bunch of people sewing on buttons onto the emperor's new clothes, and everyone crowing about how beautiful the various emperor's new clothes look. But given Singapore's fixation with metrics and astute skills in playing global ranking numbers for almost every sphere of government and quasi-governmental activities, the falling ranking of the school must be of concern to all.

But these numbers do to some extent reflect the commitment of the various institutions to their mission. We can of course, debate the appropriateness of their mission, or strategies taken, but the maintenance of a good global ranking should theoretically reflect on the quality and commitment of the management of the institution. That being the case, the falling ranking of NTU should give their leaders some reason to do some self examination. The Straits Times reported Prof Su Guan Ning, NTU's President as being "...optimistic that NTU's ranking will improve in a few years when work by new top faculty members will start to have an impact". But that sounds somewhat lame because the school's ranking should not be so dependent on the publications of a couple of recruited top scientists.

NTU has not had very good press lately. They have had problems with staff morale...and they have had run ins with their students. Not so long ago they struggled with their mission, torn between being a full university, or a limited technological one. Perhaps their indecisiveness and somewhat confused corporate mission may have had a part to play in degrading the university's overall performance. The corridor talk is that morale in the university is low.

I hope for Singapore and NTU's sake the situation will improve soon.

How to cook an egg with your handphone...or, why did the sparrow die?

The Eurasian Tree Sparrow (Passer montanus)

A strange article caught my eye in today's My Paper (10/10/08, A10). This was a reference to some rather bogus sounding research in India on the cooking of an egg using radiation from handphones. Curious, I googled the thing and found that it apprarently wasn't such a new idea, and that some Russian journalists had not only latched on to it before, but had actually demonstrated it in a rather neat experiment. I still find it hard to believe, but it's kinda a scary especially if you are a handphone wielding egghead!

But what actually caught my eye wasn't really the hard-boiled egg, but a stray comment that these electromagnetic radiations were the cause of the extinction of the house sparrow. Now that really worried me. I had never thought about it. But you know, the common sparrow has somehow disappeared.

When I was growing up, the sparrow was the commonest bird around. Back then you pretty much wake to the sound of sparrow chirps and the sight of these sprightly little birds dancing on your window sill. But now, you can't even find one. A Nature Watch report on a 2000 bird census, showed that the the sparrow had dropped to the 7th most common position, from being the commonest according to FN Chasen's observations in 1920. Now this is really alarming....and so sad.

But apparently this is a worldwide phenomenon. The reasons for this decline in population is unknown and there are several speculations (one of which being electromagnetic radiations).

There's something really heartbreaking when some icon from your childhood disappears. And it's doubly so, when it involves a species of bird going extinct. So I was further intrigued, when I read a bit more and learnt about the efforts of some activists in Mumbai, to setup 'sparrow shelters'. Curiouser and curiouser, ...especially when I read the reference to previous pioneering work on 'sparrow shelters' in Singapore and UK, which saved the sparrows from extinction!!

Anyone know anything about this unheralded heroic pioneering work in Singapore, that saved our sparrows from extinction? Maybe we should resurrect this effort and save our sparrows once again? Come on, Singapore!

Thursday, October 9, 2008

"It's the risk,......stupid!!"

Wrong time to find out about Parkinson's disease

So the Dow crashed out about 7% last night to its lowest since 2003. This, the Nikkei fell ins response. Who knows what will happen to STI?

This is shaping up to be a bigger financial crisis than many people had expected.

Which made me wonder a bit about how people assessed risks. This sub-prime mess was clearly about greed, but I can't help thinking that behind it all was really the complete inability of people to assess risks. The writing had been on the wall for a long time, but people kept wishing it away, and generally ignoring all the warning signs. I must confess that I myself had been tempted on more than one occasion to take a punt or two.

People really have no ability to assess risks. I think this is something very biological. Our entire physiology is calibrated to either flee or fight...i.e. we operate on the basis of a predetermined threshold of danger. The first response is to run...if not, then to stay and fight it out for survival. In both situations, the adrenaline gushes. We are simply not designed to respond in a rational way to graded levels of risk. We simply cannot make the distinction between 0.03%, 30% or even 300%. We simply decide if enough is already too much. Is it time yet to panic? By which time it is usually too late.

A few days ago, a colleague was commenting to be that it was simply impossible to convey to patients the risk of a certain medical procedure, or medication. How true...and I wondered if anyone thinks about the risk of the doctor sticking his scope through the walls of his gut, and his chances of dying from that as compared to the remote risk of his getting colonic cancer and dying from that. Or how about trying to impress upon people that smoking carries a risk of lung cancer? What was that risk, by the way, if one smoked 20 fags a day? If one smoked 2 stick a day? Or your real reduction in risk of dying from breast cancer if you went for the new fangelled breast scan?

Yet we keep bombarding people with numbers reflecting risks of this and if anyone was able to make sense of the information. "Caveat emptor!" We cry. Yet can anyone reasonably emptor the caveats?

Interestingly My Paper today carried a front page report on the recent Nielsen study about Singaporean's bad health attitudes. Need I say more?

Wednesday, October 8, 2008

My Wi-Fi...

Nobel laureate

Dr. Harald zur Hausen

So this year's Nobel Prize for Medicine has gone to 3 scientists working with viruses. Two for the discovery of the HIV virus and one for the discovery of human papilloma virus as a cause of cervical carcinoma.

To my thinking, the one that stood out in this award was really the physician-scientist Dr. Harald zur Hausen of the German Cancer Research Center in Heidelberg for his work on the human papilloma virus. What impressed me most was his dogged perseverance, believing in his cause even when no one else would (a 2005 review of his struggles can be found here). How he eventually succeeded despite being largely out of alignment with much of the thinking of his peers, should be an inspiration to all budding biomedical scientists. So here's to you, Dr Hausen!! Congratulations, and thank you for teaching us how to believe in ourselves.

Tuesday, October 7, 2008

Melamine hysteria #2

So the saga continues with a report in My Paper (8/10/2008, p A3, A8) on barcodes and countries of origins of food products. Groan.....! Why are they missing the point?? I mean, nobody produces things, including food products, using raw materials from only one country! It's really naive to incriminate only food produce that originates from China. For one thing I can imagine any other other country resorting to the same melamine cheating if they are trying to sell their milk substitutes globally. They just never got found out. Correspondingly food industries all over the world source for the cheapest milk substitutes for their factories. China got into trouble because it is arguably the world's cheapest and biggest supplier of these contaminated milk substitutes. They got found out because their own children consumed the most of these contaminated milk products. The point is no one can be certain, just by looking at the country of manufacture of milk and related products, that what they are consuming is free from contamination. What is critically important though, is for our AVA to screen all such products on the shelves to ensure the levels of melamine/analogues do not exceed tolerable limits. We won't even ask why this screening was not preemptive, but only undertaken in reaction to the scandal.

Which brings me to the next point. In TODAY (8/10/2008, p 27) a reader wrote to ask if AVA assays cyanuric acid as well as melamine. She has a good point. This is one of the reasons why FDA uses measures for melamine + analogues rather than just melamine, because it is not just melamine causing the problems. She shares my view that the AVA has been rather tardy in providing information that the public needs.

C'mon AVA, stop treating us like children!! You are otherwise doing a good job, but why this shroud of secrecy? Come clean and tell us what is happening. What products have you screened so far (TODAY (4/10/2008, p 27) ?...and what have you found? What are your benchmarks for acceptability with respect to melamine + analogues/cyanuric acid. I think we deserve better.

Melamine hysteria - or ...why is AVA not forthcoming?


Today's press carried a report that Malaysia was going ahead to test their vegetables for melamine. I guess being an agricultural country, they have to...but it's probably going to be a waste of time and money. Melamine isn't all that toxic, and so far only appears to be problematic for infants who consume disproportionately large amounts through tainted milk formulae. The main problems are related to formation of renal stones and consequent renal failure. There is no apparent association with cancers.

Melamine generally finds it's way into synthetic milk products where producers try and cheat the protein assays by spiking melamine into the raw materials. Where vegetables are concerned, melamine is apparently a breakdown product of the approved pesticide cyromazine. Recent screening in China identified as much as 17mg/kg of melamine in batches of Chinese mushrooms. Apparently small amounts of melamine are already in our food chain, as a result of contaminated animal feeds etc.

It has been difficult for the regulatory authorities to pin down an acceptable concentration of melamine in food products. The FDA appear to have kind settled on 2.5mg/kg (not applicable to infant food products). Taiwan and Hong Kong use this benchmark as well, although some products have been voluntarily recalled even though levels were less than this arbitrary cut-off.

It is not clear what Singapore's standards are. A visit to the AVA website reveals little about what the permissable levels are. The prohibited products listed contain a minimum of 8.1 ppm (8.1mg/kg).

It is unfortunate that our AVA has not been as forthcoming as they ought to be about this matter. Press releases are few and far between. Important information is squirreled away on their obscure website. I tried, for example, to find out what products have been tested (I really want to know if my 3:1 coffee mix is safe or not!!)...but found no such listing. Does this mean that all other products are safe or that we actually don't know?

There are also some problems with respect to the information they provide....for example the cited TDI (Tolerable Daily Intake) published by the FDA is wrong. The AVA report cites a value of 0.63mg/kg melamine, or a total intake for a 60kg man of 37.8mg, whereas the FDA uses a value 0f 0.063 mg/kg of melamine plus analgues, or 3.78 mg for a 60kg man. This is 10x lower.

Also the measured amounts of melamine in the banned items are listed in ppm units....While this may be technically correct, it really makes no sense to the general public, particularly as acceptable limits etc are published as mg/kg?