Friday, July 31, 2009

Mall car park problems? How about schools??!!

Reading about the car park congestion at malls etc in today's Straits Times (, I can't help wondering who the bright sparks were who thought it was a great idea to pack many schools into residential areas with small roads. Would this be the MOE or the LTA or both?

Whoever they are, they should be given a proper National Day Award this year for help to make the start of every day such a wonderful exhilarating experience!

Thursday, July 30, 2009

The problem with organic foods - need for objectivity

The Straits Times has followed up on this controversy by publishing an editorial comment about it.

The problem that plagues controversies such as these is that one is often unsure about the credibility of the scientific data out there. Nowadays we cannot even put our full confidence in academic studies because these studies can be funded by commercial interests. Sometimes these interests are reported, but often they are not revealed. The possible involvement of the agri-food industry is also highlighted in the ST editorial.

But my previous post references comments made by the UK FSA (Food Safety Agency). The FSA is "an independent Government department set up by an Act of Parliament in 2000 to protect the public's health and consumer interests in relation to food". One hopes that their governance allows them to be objective about the issue.

Thinking about the FSA also triggered some thinking on my part about our own food agency, the AVA (Agri-Food & Veterinary Authority). Unlike the FSA, the AVA's mission is to "..ensure a resilient supply of safe food, safeguard the health of animals and plants and facilitate agri-trade for Singapore". Like many of our regulatory agencies in Singapore, the AVA's mission carries some inherent conflict of interests. It does not just regulate food safety, but must also ensure food supply and promote agri-trade. How do they do they manage this conflicted mission?

One other thing I've also wondered about is why the separation between food safety, environment safety and pharmaceutical safety? Whether they deal with pesticides, environmental pollutants or pharmaceutical safety, these are all different parts of the same spectrum of safety concerns. Should they not reside in the same regulatory agency? Can environmental toxicology be artificially separated from health and medical toxicology?

Wednesday, July 29, 2009

Is organic food better for you? The answer is.........

Here is a comment from the UK watchdog Food Standards Agency that kinda confirms what I have felt for a long time. That this organic food nonsense is just that....nonsense. Its just people taking money off gullible consumers.

Oh, people will say it tastes better but I seriously doubt they will pass any taste test. Better nutritional value? Apparently not. Pesticides? Not an issue.

If you want to pay more for your food, that is of course your prerogative, do but bear in mind that organic food actually does come with an increased cost to the environment.

Tuesday, July 28, 2009

Singapore Medical Council's ongoing battles

The Straits Times reports today on the ongoing battles of the Singapore Medical Council against the Ministry of Health's continuing efforts to enable a non-medical Chairs for the disciplinary tribunal.

I personally don't have have any objections to it although many of my colleagues are resistant to the idea. I don't really subscribe to the argument that issues are so complex difficult for non-medical people to grasp. I think that's a lot of bull. It might have been true in the past when the level of education was low, and when medical issues were seldom discussed in public. This is no longer the case. Medical issues are now widely discussed and there is a fairly good understanding of medicine and bio-medicine outside of the profession. In fact the converse might be true, that many medical issues are now so inter-disciplinary and technologically complex that even doctors themselves have difficulty grasping all the implications of the cases.

One additional issue for some of my colleagues to consider is the Physician's Pledge which compels each physician to "respect my colleagues as my professional brothers and sisters". Although well meaning, the pledge effectively signals a closing of ranks around professional colleagues who are effectively 'in the family' as professional brothers and sisters.

But having said that, a number of problems plague this discussion. The chief one for me is, why single out the medical profession? I think the medical profession has been the most transparent and open with regards to the working of its disciplinary tribunal. It has probably been the most scrutinized and commented upon. Regardless of any perceived deficiencies, it has functioned 'well' so far. So why the sudden, almost urgent need to reform the system? Does the Ministry of Health know something it is not telling us? Has there been any evidence that the system is not working? And on a more Machiavellian note, are there any other forces at play that are perhaps driving this relentless drive to change the status quo?

Perhaps it might be better all round if this reform was undertaken as a cross-professional effort, so that the reforms at the SMC can be seen as only the first step in reforming all the professional guilds.

HSA, cell therapies and conflicts of interests...

As if providing an example on cue, for what I had recently been posting on the potential conflicts of interests in our regulatory agencies, the HSA announces the setting up of a S$9 million facility for cell processing.

Now, I am not arguing against the need for such a facility....just the appropriateness of parking such a facility in the HSA.

HSA is our regulatory authority for health sciences and health services. By owning such a large service facility, does it not create conflicts of interests within the organization? How will it view commercial units who may intend to offer similar services? How will it ensure, that the services offered are at the best value for MOH hospitals? What would be fair value for patients? How would it regulate supply to non-MOH entities? How about best practices? Will it be able to ensure, its own facility operates according to best practices? Who will audit them?

Wouldn't it be wiser (but perhaps not as expedient) to have it operate as a stand alone unit, perhaps with the entire hived-off Blood Services Group, so that they will be more independently accountable.

Monday, July 27, 2009

Ethics, professionalism and the medical school(s)

We wade back into the issue of doctors' ethics with two letters to the Straits Times today - one by Bob Kamei from Duke-NUS and another by retired surgeon SC Ong. These letters confirm the growing concern about the standards of ethics and professionalism in our doctors.

Two issues come to mind.

Firstly, there appears to be an elitist attitude fostered in our school system that starts from a pretty young age, carries all the way to medical school, and through into the working life of doctors. The medical school need to do more to correct this aberration, even though they are essentially the inheritors of a problem that began quite a few years earlier. Parents need to do more...because generally elitist parental attitudes beget elitist expectations in their children.

Secondly, medical schools need to disabuse these students of the notion that they have 'earned' their place in society, and that somehow it is society that 'owes' them, rather than the converse. These students believe that as they have fought so hard to get into medical school, they should early on reap the rewards of their struggle. Medical schools should do more to correct this malignant attitude and to foster a greater sense of servanthood in the doctors we produce. This is not easy because of the very materialistic self-serving culture that pervades our society, but the medical school must not shirk from this responsibility.

On this latter point, I am continually disappointed in the medical school for her nominal efforts to discipline students' bad attitude and behaviour even when it is recognized. Why do you think the student's grow up into doctors who are quite happy to overlook each other's bad behaviour? I am quite sure the medical schools will protest their innocence, but we should ask these schools just how many students have they ever 'failed' from the course after they have entered the school? Almost none. Are there no students with demonstrable bad attitudes? No disciplinary problems? Were they all so correctable that almost all students who enter the school graduate as upright citizens who will go out to make exemplary doctors? Surely this has not been the case because otherwise we will not be having these discussions about falling standards of ethics and professionalism.

Unfortunately in recent times the student-teacher relationship has been subverted by populist measures to position the student as a consumer and the teacher, a service provider. This is unhealthy and untenable. Often careers of young medical teachers have been held to ransom by student's 'feedback scores etc. Such an environment does not make it easy, nor even possible to teach discipline and ethics.

I have said it before....if we want better doctors, we desperately need to reboot the system.

We claim it is a noble profession. We make graduands pledge to honor the profession and make it noble. But we lack the courage and fortitude to make it so.

White hibiscus

White hibiscus

An unusual view of a common flower. Things aren't always what they appear to be.

For more of my amateur attempts at capturing and interpreting the floral world, go to "Tears of an angel".

Saturday, July 25, 2009

The foolish young man at the NTU commencement

Can't help commenting on the incident at the recent NTU (Nanyang Technological University) commencement when the valedictorian speech became a protest speech. Hooray, some people cheered.

But all I could see was a brash arrogant young ingrate without manners. And I can't help feeling that this is so symptomatic of the discussions we've had in recent posts about doctor's loss of ethics and professionalism.

Here's a product of our society and educational system. A smart young man so full of himself, that he cannot see beyond his own 'hurt' of being 'censored'. Oh wow....big crocodile tears. Did he not feel any sense of gratitude for the institution that had nurtured him, that had given him the opportunities, that had selected him and had given him the honour of representing his school. And all that he could contemplate during his 'moment of glory' was to bite the hand that had fed and nurtured him?

His mother should hang her head in shame.

Where is the sense that he 'owed' something to his alma mater? Where is the sense that he had some responsibility to represent his peers? Where is the sense that the moment meant something more to others than his over-glorified poster?

So do we wonder why some of our doctors only think of themselves?

Friday, July 24, 2009

Singapore's doctor bashing continues - and is a test of our medical ethics

The spate of doctor bashing that started with the publication of the Tan Tock Seng Hospital study continues in today's Straits Times.

While I have some reservations about the methodology of the study and conclusions drawn, I don't necessarily disagree with the overall impression that ethics and professionalism has become somewhat lax. Nevertheless, I do feel the doctor bashing is somewhat unfortunate and unfair because I think this phenomenon is really a function of the general decline in ethics and professionalism across much of Singapore society. It is quite unfair to just single out the medical profession. I mean, the lawyers, engineers, accountants, businessmen are probably as bad, if not worse. But perhaps this is only because the issues of ethics and professionalism is most visible for the medical profession. And it is easy to bash doctors.

The degeneration in our value systems, is a societal one, and which begins in early development - at homes and in schools. To finger the medical school as being responsible somehow for this decline is probably quite misguided.

There is also a facile and wrong perspective that this can be corrected by giving 'x' numbers of ethics lectures in the school. This does nothing but comfort the educators that they are doing something....or at least can appear to the public to be doing something. In the Singapore culture, we have become quite good at 'talking ethics'. Oh yes, we have ethics committees and we publish guidelines, and can satisfy all the accrediting authorities that we are an ethical nation. But I seriously question if we are truly an ethical people, or just a simulate of an ethical people.

This is not an unimportant issue because we have many medical challenges on the horizon that will test the very core of our ethics. And we need to be ready. Human experimentation is already upon us. And so is experimentation on the embryo. The balloons for organ trading and euthanasia have already been floated by the Minister of Health. Is our ethics environment ready for these? Or will we be apathetically lulled into thinking everything is ok because all we need is to simulate being ethical?

We need our society to start practicing ethics, and stop being so pragmatic. I was going to say we should stop just discussing ethics as if it were an academic subject, but the truth is that we aren't even doing that. Where are all our wonderful ethicists? Why aren't they in the public domain, discussing and educating us? Why do they just hide in the comfort of committees, only to periodically issue politically correct position papers?

We desperately need a serious cultural reboot.

See previous post: 'Are we an ethical society?'

Thursday, July 23, 2009

Doctor's ethics in Singapore - the Tan Tock Seng Hospital study

Salma Khalik reported on the Tan Tock Seng Hospital survey of doctor's ethics recently.

I think the TTSH study is to be commended because I think we need to keep examining this issue and to keep a close watch of our local attitudes towards medical ethics. Having said that, I think there are a number of methodical difficulties in the way the study was conducted. One primary problem is that the sampling of local and foreign trained doctors immediately creates a bias. Most of the doctors who were trained overseas could have had a very different starting point as compared to those who had been selected into the NUS Medical School. Thus the difference in ethical attitudes may have been primarily due to the survey sampling biases.

At a personal level, however, I have witnessed myself the degeneration of professional attitudes in successive generations of students and doctors coming through. I have posted indirectly on some of these changes :

So I am really not surprised by the findings.

But even as I am not enamored with the medical school curriculum locally, I think it is more than a bit unfair to lay the blame on the medical school training.

Students who make it to the medical school have largely been forced fed by a drivel of elitist attitudes towards life by the time they come to medical school. But I must be careful not to over-generalize. Many students and doctors I see still have exceptional qualities and will make exemplary doctors. But an increasing number just show themselves to be self serving, egotistical monsters in the making. For these, their basic attitude is that society 'owes' them. I can't help feeling that this malignant life view had been created by the journey through some of the elitist schools that we have. By the time they reach medical school, their basic attitudes have already been formed.

The data produced by the TTSH study may simply reflect the proportion of students from 'elitist' schools who go to NUS as compared to those who have to go overseas. I would highly recommend that the authors re-look their data and see what the secondary and JC education background of their respondents were.

Sadly incorporating ethics teaching in medical school may not be as successful as some would hope.

Wednesday, July 22, 2009

Three things that p***ed me off this morning

a] Drivers who speed up to close the gap the moment you signal that your intention to change lanes;

b] People who charge into lifts without allowing passengers to exit first;

c] People who chair meetings without controlling the discussions and agenda.

Tuesday, July 21, 2009

HIV in Singapore

This plot was generated from data on the Singapore Ministry of Health website. It shows the rising number of HIV cases since 2002. As pointed out in the earlier post, HIV testing moved to an opt-out process in 2008.

Clearly as the graphs show, despite HIV being most common among heterosexuals, the incidence is rising most rapidly for homosexuals and bisexuals.

Monday, July 20, 2009

Are our regulatory agencies adequately china-walled against conflicts of interests?

The recent Auditor General's audit thrashing of the MDA (Media Development Authority) and today's report on the MAS's (Monetary Authority of Singapore) management of the financial institutions re-awoke that niggling feeling in me that there is something not quite right about the way our regulatory agencies are structured.

You see, most of our regulatory agencies serve at least two masters - one that is promoting the industry and the other protecting the public. Some agencies are more of one than the other. This duality of mission creates an immediate conflict of interest within the agency's decision making process. If it single-mindedly protects the public, it may over-restrict the activities of the industry, and possibly destroy it. On the other hand if it is over-friendly to industry, it will clearly compromise its role in protecting public interests.

One common refrain heard is that Singapore is very small and we have limited expertise, and therefore often the same bigwigs sit on committees serving regulatory as well as promotional roles.

The question therefore is how do we ensure that public interests are actually being looked after, and not held to ransom by big industrial interests.

In MAS's situation, how does the agency balance public interest against the interests of the the big financial insitutions? How does MDA balance the consumer needs with the mission to please the industry? How does the AVA protect us with respect to industrial poisons, without compromising big business' interests and possibly losing industrial investors?

Closer to home, how does the HSA protect medical consumers without losing big pharma investments for our biomedical initiatives?

In short, what has never been very clear is if the decision making processes in our regulatory agencies are adequately china-walled against all these conflicts of interests?

Sunday, July 19, 2009

Why the difference between HIV and H1N1? Exceptionalism?

The coincidence of the reports on our first H1N1 related death and the guy who came out with respect to his HIV, gave me cause to think about how the world treats these two pandemics.

It is becoming increasingly clear that the mortality related to H1N1 is nowhere as high as was initially estimated. A recent article in Eurosurveillance by two New Zealand public heath experts reviewed the methods for estimating the case fatality ratios (CFRs) for the H1N1 flu and concluded that the current methods overestimated the CFRs. They present possible alternative methods, which despite their limitations, all produce much lower CFRs (0.06% - 0.0004%) compared to the original estimates of 0.4%.

By contrast also, the HIV CFR has an almost surreal air to it. Nobody talks about HIV related deaths in the same way as for H1N1. For example, a heart attack patient with positive H1N1 would be an H1N1 related death, but an HIV patient dying of a heart attack would not be a HIV related death. Even so, the very crude estimates of HIV CFR is in a totally different ball park from H1N1. In 2007 WHO reported a global incidence of 33 million cases of HIV. Over the same period 2 million AIDS deaths were reported. This allows us to make a very rough estimate that HIV related deaths could be at least 6%, 10 x the worst estimated CFR for H1N1.

Yet we run around panic stricken, whacking at the H1N1 flu with fancy words like containment, mitigation - quarantines, contact tracing etc etc.....while treating HIV almost with kid gloves.

The word that epidemiologists use for this is - 'exceptionalism'.

HIV is probably one of the most destructive pandemics in human history. Since 1981 when it was first discovered it has been estimated to have killed 25 million world wide. Yet we are afraid to manage it in the same scientifically rational way we manage all other epidemics. Activists and lobbyists have managed to persuade the global community that to do otherwise is a human rights offense.

So we have been powerless to deal with this pandemic in the correct way.

But things seem to be swinging away from that falsehood as people come to terms with the destructive nature of the pandemic. In 2007, the US CDC and and WHO/UNAIDS finally got the courage to recommend that testing for HIV be part of routine clinical testing. This is 26 years too late if you ask me.....but at least it is now being done.

Singapore followed suit with Changi General Hospital taking the lead. Senior Minister of State Ministry of Foreign Affairs, Dr Balaji, reported (Nov 2008), "... Changi General Hospital was the first hospital in Singapore to pilot voluntary opt-out HIV screening for inpatients just under a year ago. They have shown that it can be done. More than 3,000 of their patients have been screened so far, and around 50 have been found to be HIV-positive. The Ministry of Health has asked other acute hospitals to implement a similar opt-out HIV screening programme for their adult inpatients, and it should be in place in all public sector hospitals by the end of the year. Private hospitals should also study how they can implement opt out testing as this becomes the standard of care."

Let's do away with exceptionalism once and for all, and deal with a pandemic the way pandemics ought to be dealt with. Scientifically, rationally and truthfully.

Read "Changing the Paradigm for HIV Testing — The End of Exceptionalism" in the New England Journal of Medicine.

Friday, July 17, 2009

Wrightia religiosa - the humble 'shui mei'

Wrightia religiosa 'shui mei' 水梅

Here is a photograph I took of the shui mei 水梅 in my garden. When it was recently in bloom the garden was just so delightfully fragrant. These flowers I photographed were from the tail end of their blooming cycle. But they are just as lovely.

I have started a blog to share my photographic efforts, called "Tears of an angel". Do drop in and have a look.

Wednesday, July 15, 2009

Auditor General's Report - How did our MOH do?

The publication of the recent AG (Auditor General)'s report created quite a bit of stir. What has been refreshing has been the increasing transparency of the process and findings. What had in the past been pretty much swept under the carpet is now (since 2007) finding it's way out into the public domain. And it is fantastic improvement, I must say.

This year the MDA (Media Development Authority) got a bit of thrashing ... deservedly so I thought. And what about SPRING's fiasco with respect to Phillip Yeo's Office? That was kinda indecent the way they handled it. I hope there will be some concrete response to the report. Who will the scapegoat I wonder?

I wonder if there have been other irregularites that have been found but not made public?

Why can't the report be more substantive and complete? For example, the report on our MOH kinda fudges around the use of inadequate KPIs without telling us any details, and cites MOH's rather fuzzy remarks about internal KPIs without telling us what these KPIs are. And since we don't know what the MOH KPIs are....the whole thing is meaningless to us.

One gets the feeling that the AG Office is somehow skirting the issues and 'afraid' to point the finger at where the problems lie.

Lastly as the 'My Sketchbook' cartoon above mocks.... Where is the follow up? Is someone keeping track of remedial actions? The AG's report doesn't mention compliance and follow up actions from previous audits.

So how? I say more needs to be done.

Meanwhile malaria.......

Meanwhile malaria doesn't seem to want to go away despite all attempts to eradicate the anopheles from within our midst. Stubborn little fellas.

Last week we crossed our century mark (104 cases) and had 8 fresh cases, at least one of which is a locally transmitted case. Over the first half of 2009 we chalked up 96 cases of which 22 were local.

Meanwhile, the other nuisance infection seems firmly entrenched as an endemic disease.... the chikungunya has also refused to go away and has maintained a steadfast presence in our midst. Last week we had 4 cases, 2 of which were locally transmitted.

Tuesday, July 14, 2009

Water, water everywhere..... PUB's success.

While we are on the subject of water, I just want to share my thoughts on Singapore's water management.

I think of all our agencies here in Singapore, PUB clearly takes the prize. Once merely a utilities manager, PUB has become a world class standard bearer for water management.

I have travelled round the world and I can confidently state that I know of no other place in the world where I can happily drink straight from the tap. Not just safe drinkable water, but actually clean pleasant tasting water. And all this considering we have little ready natural water resource.

In just a few decades, PUB has not only made us water sufficient, and has put Singapore on the map as a global leader in water management.

PUB, you've done us real proud.

Which makes it all the more ironic that we have so many bizarre practices that seem to deny the reality of our access to clean drinking water from taps. Why do people buy bottled water, and pollute the environment with more plastic bottles? Why do restaurants not serve tap water, or make it seem so expensive to turn on the tap for a glass of tap water?

It's time we changed our mindset.

Keep it up Sparklette!!

Sparklette Veron, peeved by restaurants who do not serve water, has published a list of such restaurants. I must admit I did not know of her list until the Sunday Times made it known. And my response? Hoooray for the gutsy gal!

If you want to view her list, go here.

I have to confess to being one of those ‘cheapskates’ who get really irate when restaurants don’t serve water. To me it’s just lack of common courtesy, and the restaurant that cannot even extend that courtesy to its customers, are really signalling what they think of their patrons, and do not deserve my business.

I have actually walked out of restaurants before on being told they cannot serve plain tap water.

Just plain no manners.

I would really encourage as many people as possible to do the same….and to make a big issue of it before they leave.

Veron, you go girl!!

And to that restaurant mentioned in the Sunday Times.... you are just a forkettable eating place.

Sunday, July 12, 2009

Managing and Reducing Uncertainty in an Emerging Influenza Pandemic

Interesting comments from the recent copy of the New England Journal of Medicine.

I excerpt some paras for your reading. Can go to the original by Marc Lipsitch from Harvard School of Public Health above if you want to read full article.

"Crudely speaking, the (H1N1) case fatality ratio thus appeared to be 0.2%, near the upper end of the range for seasonal influenza, and superficially, this statistically uncertain estimate seems remarkably accurate given the data available on May 27, by which point there were 11 deaths and 7927 confirmed cases (a case fatality ratio of 0.14%)."

"Public communication of risk and uncertainty will be critical. It has been suggested that the existing criteria for moving to World Health Organization pandemic phase 6 (sustained transmission in multiple geographic regions) should be modified to incorporate a judgment that the world's population is at increased risk. We would argue against conflating assessments of transmissibility and severity in this subjective way, which risks adding to the confusion faced by decision makers and the public. Rather, the global extent of a pandemic should be described objectively and should be just one factor in decisions about how to respond."

"As we adjust our mitigation policies, there will be a continuing need to make decisions without definitive estimates of severity. For example, the decision to move from production of vaccine for seasonal influenza to that for pandemic influenza will need to be made in the next month or two. Similarly, the United States will need to decide soon whether to use adjuvanted vaccines to protect more people with a given amount of antigen, although such vaccines are not currently licensed in the United States. As always, however, the main losers from delays in such decisions are likely to be developing countries, which will have less access to vaccine while probably suffering the greatest clinical impact from this new pandemic virus."

Infection Control Authority for Singapore?

Singapore has an Infectious Diseases Act. This was enacted by Parliament in 1976 and came into force on 1 Aug 1977. This essential piece of legislation is jointly administered by the Ministry of Health and the National Environment Agency (NEA) and deals with the prevention and control of infectious diseases in Singapore.

I remember hearing talk some time ago about the establishment of a regulatory agency that can more specifically deal with infections - a kind of Infection Control Authority. Currently it seems to straddle two Ministries, which may or may not be a good thing.

I think having a fully dedicated Authority to deal with infection control in Singapore is long overdue, and in fact seems to be looking more and more urgent. I hope the government will not delay too long in setting this up.

Saturday, July 11, 2009

H1N1 (aka American flu) - dying embers of a spurious fire

So Minister Khaw reckons the battle for H1N1 is almost over.

I think everyone is just kinda hoping that everything will blow over quite quietly with as little egg on people's faces as possible.

I do agree though, it's true that we should be looking to learn whatever lessons we can from this global event. And I really hope they will do it honestly and not sweep stuff under the carpet, in the interest of looking good.

Some lessons worth learning, I think:

a] How did the world get it so wrong?

Quite clearly the virus is nowhere is virulent as was initially made out to be. No, Minister Khaw.... the virus isn't getting weaker. It wasn't that 'strong' in the first place. Somehow data collected in those early days just massively inflated fatality risks of the novel flu.

We need to seriously look at how global flu data is collected, and have a better idea of credibility of data when they do appear.

b] How do we manage public health information in the context of a pandemic?

I don't agree with Minister that the whole thing was managed well and that the public has done well in managing the pandemic. I think the public did try their best in dealing with the very confused signals appearing. But the whole thing could have been managed much better. All those messages about how serious this whole thing was, just wasn't very convincing to much of the public, and very early became viewed as a massive nuisance that people had to bear when few were at all convinced it was a serious flu pandemic. Now that it is blowing over without much of a fanfare, is just confirming in everyone's minds, that this has been a complete overreaction.

I know that this is being said with the wisdom of hindsight, but I think the uneventful outcome wouldn't have been very different even if nothing much had been done in the first place. So I don't think there is any credit due anyone, that not much damage had been done by the novel virus.

I am not making these comments flippantly, because I think it is very important to be honest about these deficiencies because the next pandemic might well be a real one....and a bad one at that. We need to have more confidence in the data collected, and have a proper and accurate diagnosis of risks as early as possible. And we need real decisive leadership to know when to turn off the alarm, when we recognize that it is false. It goes without saying that in the management of a real pandemic, a very strong and clear buy in by the public is critical in order to make pandemic management effective. This did not happen.

c] Resourcing for the pandemic management was woefully inadequate.

Surprising especially as we had struggled so much through the SARS experience. So it is strike two, ...but we are not quite up to scratch.

BMI (Body Mass Index) for Asians

So, the Brits are finally coming round to the realization that Asians are not Caucasians and should not measured by the same yardstick. At least where the BMI (Body Mass Index) is concerned.

I mean, duhhh........ we have known this for a long time already, haven't we? What took them so long?

Four years ago, the WHO Expert Consultation in Singapore already recommended new and more appropriate guideline for Asians.

BMI (kg/m2) for Adults...Health Risk
27.5 and above...High Risk
23 – 27.4...Moderate Risk
18.5 – 22.9...Low Risk (healthy range)
Below 18.5...Risk of nutritional deficiency diseases and osteoporosis

You can use the Health Promotion Board calculator to calculate your BMI.

:( Mine is 24.8.
Got to stay off that tiramisu.

Thursday, July 9, 2009

The Physician's Pledge

The recent discussions about whether a doctor is morally compelled to put his life on the line in dealing with pandemics and such, if nothing else, did highlight the level of ambiguity that exists in doctor's minds with regards to their moral obligations under such circumstances.

One comment in Angry Doc's blog pointed out: "I don't remember ever making any oaths to say I would die for my work."

That made me sit up a bit....

The Singapore Medical Council implemented a Physician's Pledge for graduating doctors in 1995. This was kinda inspired by the Hippocratic Oath, but is actually very similar to the Physician's Oath (adopted by the General Assembly of the World Medical Association, 1948 and amended by the 22nd World Medical Assembly, 1968).

The SMC Physician's Pledge reads:

"I solemnly pledge to:

dedicate my life to the service of humanity;
give due respect and gratitude to my teachers;
practise my profession with conscience and dignity;
make the health of my patient my first consideration;
respect the secrets which are confided in me;
uphold the honour and noble traditions of the medical profession;
respect my colleagues as my professional brothers and sisters;
not allow the considerations of race, religion, nationality or social
standing to intervene between my duty and my patient;
maintain due respect for human life;
use my medical knowledge in accordance with the laws of humanity;
comply with the provisions of the Ethical Code; and
constantly strive to add to my knowledge and skill.
I make these promises solemnly, freely and upon my honour."

I suppose the interpretation of that pledge will revolve around what we understand to be meant by "dedicate my life to the service of humanity" and "make the health of my patient my first consideration". What do they mean to graduands, and do those statements actually compel doctors to put their life on the line?

I know this pledge may be just words mechanically uttered by some graduands, but it is a solemn pledge and meant to be taken seriously.

The SMC's Ethical Code and Ethical Guidelines makes a more explicit statement in Para

"A doctor shall be prepared to treat patients on an emergency or humanitarian basis unless circumstances prevent him from doing so."

But I suppose that still requires us to interpret what it means by being prevented from doing so.

Wednesday, July 8, 2009

Did Paris Jackson actually cry?

Like many other people on this pathetic planet, I was compelled to sit through Michael Jackson's memorial event. It was a bit of a circus - but this was an American production was it not? I didn't really mind because after all, despite the poor guys flaws, he was an enormous talent, and as many had attested was probably the most influential and talented performer in our lifetime, and possibly ever, .... especially since MTV.

What was really bizarre though was when his daughter Paris actually came forward to speak, and when she cried.

Now, please don't flame me for what I want to point out. I just ask you to be objective about this.

The first thing that struck me, and did so with the force of a hurricane was that she made all the appropriate noises and sounds like she was crying, but I didn't really see her cry. Now, I am not saying this to take away or belittle the grief of the little girl, but it was so blatantly obvious that there was not a single tear drop. And neither were her eyes red. Was there any snot? No.

Essentially, I didn't see Paris Jackson cry.

Here's the funny thing. Everyone was primed to cry. Everyone was primed to see people cry. And when she spoke, the tears were already welling up. It didn't really take very much for Paris Jackson to move everyone to cry in sympathy.

But in honesty I didn't really see her cry.

Again, I ask you to be objective. Go and watch the video again and again. Do you actually see her cry? Now, again I am not suggesting she was insincere or exploitative, or was being manipulated etc....she may have had a gazillion valid reasons, and she was entitled to all those reasons..... but fact of the matter is I don't think she was crying.

And I wasn't the only one to notice this. See here.

The 19C Italian poet, Antonio Porchia wrote: "More grievous than tears is the sight of them."

Perhaps, in this case, even more so, when you don't see them.

Tuesday, July 7, 2009

Who is a Han Chinese?

Cheong Suk-Wai of the Straits Times wrote a review of Anthony Milner's book "The Malays". In it she cites the Basham Professor of Asian History at ANU as saying ' the struggle for Malay identity through the ages has been such that it is as hard to say for sure who is Malay as it is to say who is not.'

It just made me wonder if that is not true for any other ethnic definition?

After all....who the hell are the Han Chinese?

Wikipedia says:

Han Chinese (simplified Chinese: 汉族 or 汉人; traditional Chinese: 漢族 or 漢人; pinyin: hànzú or hànrén) are an ethnic group native to China and, by most modern definitions, the largest single ethnic group in the world.

Han Chinese constitute about 92 percent of the population of the People's Republic of ChinaRepublic of China (Taiwan), 75 percent of the population of Singapore, and about 20 percent of the entire global human population. There is substantial genetic, linguistic, cultural and social diversity among the subgroups of the Han, mainly due to thousands of years of immigration and assimilation of various regional ethnicities and tribes within China. The Han Chinese are a subset of the Chinese nation (Zhonghua minzu). An alternate name that many Chinese peoples use to refer to themselves is "Descendants of the Dragon" (Chinese: 龍的傳人 or 龙的传人). Many Han and other Chinese also call themselves "Descendants of the Yan Di (Yan Emperor) and Huang Di (Yellow Emperor)" (Chinese: 炎黃子孫 or 炎黄子孙).

Locally we usualy don't even use the term but refer to Chinese as "Tang Ren 唐人".

Wikipedia further points to the fluidity of the Han concept:

'The definition of the Han identity has varied throughout history. Prior to the 20th century, some Chinese-speaking ethnic groups like the Hakka and the Tanka were not universally accepted as Han Chinese, while some non-Chinese speaking peoples, like the Zhuang, were sometimes considered Han. Today, Hui are considered a separate ethnic group, but aside from their practice of Islam, little distinguishes them from the Han; two Han from different regions might differ more in language, customs, and culture than a neighboring Han and Hui. During the Qing Dynasty, Han Chinese who had entered the Eight Banners military system were considered Manchu, while Chinese nationalists seeking to overthrow the monarchy stressed Han Chinese identity in contrast to the Manchu rulers.

Whether the idea of Han Chinese is recent or not is a debated topic in China studies. Many Chinese scholars such as Ho Ping-Ti believe that the concept of a Han ethnicity is an ancient one, dating from the Han Dynasty itself.

So let me ask you..... how do you know you are Chinese?

Something that made my day....!

In a corridor, deep in the bowels of the hospital, I saw a Chinese woman heartily greet a Sikh woman. The obvious warmth expressed between these two women of different ethnicities just made me feel so grateful that I live in a society where there is so much freedom from ethnic discrimination and strife.

Something we shouldn't take for granted.

The race for the H1N1 vaccine

Major producers are now in the race to produce the H1N1 vaccine. Obviously the dollar stakes are extremely high. Getting a contract to supply any country will represent enormous revenues for the manufacturer.

Recently the China company Sinovac claimed to be able to produce the vaccine by the end of the month and to have it out into the market by September after a 2 month clinical trial.

Novartis and Baxter using cell culture techniques, both made claims to be ready for clinical trials this month.

GSK, Sanofi and Australia's CSL are somewhat slower with the egg based methods and are projecting perhaps availability for trials in about September.

Efficacy and toxicity data for any of these vaccines will depend on clinical trials that are all yet to be conducted.

I am curious though, in a situation like this how does one decide who to contract the vaccine supply to? Would the MOH follow the usual GEBIZ open tender process? Or would they go down the road of a preferred supplier?

To what extent would this decision be coloured by the fact that of these companies, Novartis and GSK are huge investors here in Singapore, and are significant industrial partners in the manufacture of biologics and pharmaceuticals? Both Novartis and GSK have invested in excess of S$1 billion in Singapore.

Who would we eventually award the contract to?

If I were a betting person I would probably place my bets on the GSK vaccine. But I am your guess is as good as mine.

Monday, July 6, 2009

Bisphenol-A (BPA) - What are we to make of it?

I have posted on bisphenol-A before, back at in the beginning of 2009 in response to a letter writer in the Straits Times. Then, I commented that it was probably just hysteria because we probably consume greater amounts of estrogenic substances than whatever can be found as a result of BPA.

[Bisphenol-A (BPA) is a chemical found in hard plastic bottles.]

But recent presentations at the recent Endocrine Society ENDO09 meeting are threatening to rewrite this thinking.

Dr VandeVoort and his co-workers from the University of California, Davies reported that if female rhesus monkeys are treated with a single oral dose of BPA that is 8 times higher than the estimated 'safe' human dose, the serum concentrations of BPA are less than what has been ordinarily found in humans. In addition, when Frederick vom Saal of the University of Missouri-Columbia and colleagues administered 4,000 times estimated typical daily human consumption to 11 rhesus monkeys, BPA blood residues in the spiked monkeys ended up only one-eighth as high as seen in a German study of pregnant women. Both these studies implied that human consumtion of BPA is higher than what has previously been estimated. Dr vom Saal estimates that typical human daily consumption may be as high as 1000 micrograms per kg body weight per day.

In yet another study (in press) Dr Michels reports that students drinking from plastic bottles over a one week period showed 69% higher BPA levels in the urine compared to if they drank from steel containers. (FDA safe upper limit is only 50 micrograms per kg body weight per day

So what do we make of it?

I must admit that the data is making me change my mind about the safety of BPA. What is particuarly worrying is that the plastic industry isn't taking this lying down and appears to be poised with some rather aggressive and scary counter-intelligence efforts.

The AVA is supposed to regulate the chemicals in our environment. I hope it has been following some of these developments. It has to constantly review its position about BPA.

A particular difficulty for us I think is the fact that one of our major long term industrial partners here in Singapore is Mitsui Chemicals. Through its local subsidiary Mitsui Bisphenol Singapore Pte Ltd (MBS), it is a major producer of BPA.

I hope the AVA is adequately china-walled against industrial/economic considerations to be able to do the right thing by us.

Sunday, July 5, 2009

So we won't repeal Section 377A?

Is it a cause for celebration? Not really.

The inconsistency in the law is not something we can be proud of. And I am saying this even though I do not agree with the homosexuality arguments.

But Minister Shanmugam's position is a pragmatic one. And for that I respect him, and the government he represents, that they can be mature enough in his/their thinking not to be too fixated on a course of action that is inflexibly bound with ideological correctness. He is right in stating the obvious, that ..."We, sometimes in these things, have to accept a bit of messiness."

Yep. Applies to both sides of the argument.

Friday, July 3, 2009

Flu: Docs need not swallow bitter pill

Andy Ho's review under the Straits Times Daedalus column touched on the interesting topic of a doctor's moral responsibility to put his life on the line for the patient, for example in the mamagement of pandemics etc.

His review entitled "Flu: Docs need not swallow bitter pill" contains the usual dispensing of confused ramblings. But it is an interesting topic....and it made me think about it for more than a while.

In a past generation this would not perhaps have been an issue. In fact it even have been scandalous to suggest that doctors would not be self sacrificial in dealing with patients' problems. Admittedly the level of self sacrifice and altruism would vary between doctors .... but it would have been scandalous to suggest that a doctor would not consider it his duty to put his life on the line to save a patient's life.

A doctor's lot, to my mind, is not very much unlike that of a soldier's calling to protect his country. One doesn't sign up to be a soldier unless one is prepared to be on the front line to be sacrificed in the line of duty. Likewise, one shouldn't contemplate being a doctor unless one is prepared to put his life on the line in the performance of his/her duty. To me there are no two ways about this. Medicine is a noble calling, and one which requires nobility of character and self sacrifice.

But it seems we live in a different world now. A world characterized by law suits, professional insurances and work contracts.

The British social commentator John Ruskin wrote (Unto This Last, 1860):

"Five great intellectual professions, relating to daily necessities of life, have hitherto existed – three exist necessarily, in every civilized nation:

The Soldier’s profession is to defend it.
The Pastor’s to teach it.
The Physician’s to keep it in health.
The Lawyer’s to enforce justice in it.
The Merchant’s to provide for it.
And the duty of all these men is, on due occasion, to die for it.
‘On due occasion,’ namely: -
The Soldier, rather than leave his post in a battle.
The Physician, rather than leave his post in a plague.
The Pastor, rather than teach falsehood.
The Lawyer, rather than countenance Injustice.
The Merchant – what is his ‘due occasion’ of death?
It is the main question for the merchant, as for us all. For, truly, the man who does not know when to die, does not know how to live. "

Suicide at Fusionopolis?

Something interesting happened yesterday. Someone launched himself off the 23rd floor of Fusionopolis and fused his brain with the pavement below. Apparently someone from Institute of Infocomm Research (but this remains to be confirmed).

Tragic. And I don't mean to be sensationalizing something like this.

Just struck me as interesting that the apparent suicide occured at about 2pm yesterday, and reported all over on the internet chat rooms, but the incident never made an appearance in the newspapers today. Meanwhile a soldier who got run over by a vehicle was widely reported in the newspapers.

Just made me wonder if there is a media policy against reporting on apparent suicide incidents, and what the basis is for such a policy? Isn't news news?

Thursday, July 2, 2009

104 years old today - an heritage forgotten?

As I drove past the College of Medicine Building (COMB) at Sepoy Lines today for the umpteenth time in my professional life I couldn't help feeling very nostalgic. So much of our student life was spent at that quirky campus. So many of us grew up there, became adults, became doctors - learnt about life and death, married. Even died. Once the King Edward VII College of Medicine, it now houses the Ministry of Health.

But it didn't all begin at the COMB.

In the 19th century, there was no medical school in Singapore. Doctors were either British, or were local eurasians and Indian nationals posted to Singapore. There were few local doctors, and if one qualified to be trained the nearest medical school was in Madras.

A local entrepreneur Tan Jiak Kim, in 1904 led a petition to the British Governor Sir John Anderson to establish a medical school in Singapore.

"... your petitioners feel that no measure can so successfully diffuse this understanding as the provision of a proper supply of trained medical men who are in racial sympathy with those whom they attend..."

Together with the the Straits Chinese British Association and other local community leaders he raised a total of $87,000 to start the school.

Then on this day, 3rd July, 104 years ago (1905), the Straits and Federated Malay States Government Medical School came into being. In 1912, this became the King Edward VII Medical School. And in 1926, the College of Medicine.

This very original building for the Straits and Federated Malay States Medical School was a disused female asylum. It used to stand round the back of the COMB. In the mid 1980's it was callously, insensitively...and I believe, criminally.... bulldozed over, and replaced by a car park.

Sadly, this heritage is all but forgotten. The medical school, 104 years old today, is only celebrated in the hearts of those who remember. Tragically, the fancy glass and steel of facades of the modern medical school does not seem to care.

A very happy 104th to a very grand old lady.

Wednesday, July 1, 2009

Vaccine safety - preparing for the eventuality

I have posted on the topic of vaccines and vaccine safety before.

Here I want to highlight 2 recent scientific reviews on this topic which I think are important for us to consider as we hurtle down this road towards H1N1 mass vaccination programmes.

The first is a review in 2008, by Dr Fineberg in the Journal of Infectious Diseases (if you want the pdf of the original paper, just email me). This review was done when avian flu was a hot topic, and it draws upon lesson from the 1976 US mass vaccination programme for swine flu which resulted in a national fiasco where 25% of the poulation was vaccinated and no evidence of any pandemic. In the review, Dr Fineberg recalls the 7 features of the swine flu :

1. Overconfidence in theory spun from meager evidence.
2. Conviction fueled by preexisting agendas.
3. Zeal by health professionals to make lay superiors “do the right thing.”
4. Premature commitment.
5. Failure to address uncertainties.
6. Insufficient questioning of implementation prospects.
7. Insensitivity to media relations and to long-term credibility.

....and identifies 7 lessons today that we can learn from that fiasco:

1. Beware of overconfidence in models drawn from meager evidence.
2. Invest in a balanced portfolio of research and contemporary preparedness.
3. Clarify operational responsibilities in the federal government.
4. Refrain from overstatement of objectives and misrepresentation of risk.
5. Strengthen local capacity for implementation.
6. Communicate strategically.
7. Lay the basis for program review.

The second review is just hot off the press in the same august journal, entitled ""Prepandemic" Immunization for Novel Influenza Viruses, "Swine Flu" Vaccine, Guillain-Barré Syndrome, and the Detection of Rare Severe Adverse Events", by Dr Evans and his co-workers. (conclusions abstracted below)

"In summary, the risk of SAEs (serious adverse events) will remain important considerations in developing immunization policies for interpandemic use of novel influenza vaccines and implementing mass immunization programs. These issues are particularly challenging when the risks of severe illness or of a future pandemic are uncertain and, therefore, safety concerns more acute, as is the case in interpandemic vaccination. However, even if an association between SAEs and interpandemic vaccination could be discounted with confidence, the reality is that public perception of a link has the potential to undermine amass vaccination strategy over and above the scientific evidence, as clearly evidenced in the 1976 experience."

I will leave it to you to form your own impressions about our current approaches towards the H1N1 vis a vis the comments contained in these reviews. I would certainly recommend these as compulsory reading for those interested in vaccine safety, and also for our decision makers in MOH who may be contemplating a mass vaccination strategy.

H1N1 (aka American flu) - Making it clear

The MOH has made a significant attempt in clarifying the situation with regards this 'pandemic'. So thank you, MOH.

For those who are still confused, I have tried to summarize the current understanding and to give a simplified common sense layman approach if you get any 'flu-like symptoms' below:

a] This is a new strain of an old 'flu' virus. It spreads pretty easily but at the moment does not seem to be 'dangerous' other than to some 'high risk people. These high risk people are:
- pregnant women
- patients who have immunological deficiences such as on steroids, on cancer treatments etc
- patients on dialysis
- very young children less than 1 year old

b] If you have runny nose, sore throat and even a cough, but no fever, just stay away from people and wear a mask. Take the usual cough/cold medications. If you need and MC, go see any GP.

c] If you have runny nose, sore throat, cough plus fever and or body aches etc, these would be considered a flu-like disease (what the MOH calls 'influenza like illness') and you are not in the high risk groups of people, this would probably not progress more than the usual seasonal flu. Stay away from people wear a mask, go to your GP and get an MC until you are better (probably 5-7 days).

d] If you have flu-like disease(as in [c]) and are very sick, as in weak, breathlessless etc... best you call 993 or just go to one of those PPC (Pandemic Preparedness Clinics). They have Tamiflu to issue, and if you need to be hospitalized, they will know what to do.

e] If you or your relatives are in the high risk group and who have flu-like disease, it is best you go to one of the PPCs where the doctor there can assess if treatment with Tamiflu is required. You can call 993, if you are very ill.