Saturday, October 24, 2009
I remain horrified that we insist on regulating drugs to the nth level. Preclinical studies, clinical trials.... and what not. Pretty much about 10 years of generating data on safety and efficacy before we allow them into the market place. But when it comes to cell based products, whether of animal or human origins, there is this huge blindfold on. The Bioethics Advisory Committee is only concerned about the ethics of doing such research. But if it is for clinical use, there are no regulations in place, and it's pretty much a hands off approach.
I am particularly surprised that when the Health Products Acts was passed in 2007, it only applied to First Schedule items such as Medical Devices and Cosmetics. Wasn't it considered then that cell based products were something to be concerned about? Or for that matter, any biological products that were not technically 'medicines'.
Oh yes, we can argue that such experimental practices fall under the scrutiny of the Singapore Medical Council, who have a Ethical Code and Ethical Guidelines to hit people on the head with. Para 4.1.4 particularly. But this is too ambiguous and subjective to have any real meaning. I mean, what are unproven therapies? If I have 20 anecdotal reports, does that mean it is proven? How about 50? 5000? or 5?
So why aren't cell-based products registrable? Where are the legislative powers for HSA to do this work? Why is there such a big blindspot in our regulatory environment?
Friday, October 23, 2009
A couple of things bother me though. There's been a lot of talk about a second wave emerging. The reason for the vaccinations are to mitigate against this second wave. But I never quite bought into this second wave thing for Singapore. If indeed there is a second wave, given there will be more herd immunity, it would be a lesser wave than the first, would it not? Unless of course, the virus mutates. But it hasn't as yet, and it looks like we are dealing with the same, not so virulent, not so lethal , not so pandemic virus.
Also seasonal flu? That applies to temperate countries with summer/winter type seasons. Since the only winter we have in Singapore is the styrofoam/soap variety in Orchard Road, there isn't going to be much in terms of seasonal change in flu transmission. In fact, a scan of the MOH epidemiological stats over 2004-2008 confirm that the incidence of acute respiratory infections were pretty flat throughout each year. The only interruption to this flatness was the rather short-lived H1N1 pandemic earlier this year. So the only seasonal change we may expect in H1N1 would be due to increased seeding by travelers from temperate zones who carry the virus to us. And given the increased herd immunity, such seeds may not transmit that well.
Actually, I wonder why the MOH does not survey the level of herd immunity in our population beefore embarking on any immunization programmes? This developing herd immunity would certainly be one of the reasons why the earlier first wave pandemic fizzled out. After representing more than 60% of samples at the peak fo the pandemic, it is now hovering at about 24% of cases surveyed.
So is there a rush to get vaccination? Apparently not if the health care workers are polled. But these are still early days.
Wednesday, October 21, 2009
Other types of xenotransplants would be - sticking an animal (e.g.pig) organ (heart, liver, kidney etc) into a human recipient, or putting animal (again usually pig) cells into people (e.g. pancreatic islet cells).
Strangely xenotransplants seem to be a relatively unregulated medical procedure. The HSA regulates medicines, complementary medicines, cosmetics and medical devices but apparently not animal cells. It would seem that xenotransplants would be regulated under transplantation laws, but not so. The Human Organ Transplant Act doesn't cover animal cells into humans, just the use of human organs.
So doctors seems to be pretty unregulated with respect to their sticking animal bits and pieces into people. Possibly it may be considered an experimental surgical technique, but one could argue that sticking sheep fetal cells into someone isn't really surgery. It could possibly be regarded as an experimental procedure or a clinical trial; in which case it should be approved by the ethics committee. But this would assume the doctor would classify it as an experiment. If he maintains that the procedure is not experimental he need not subject it to ethics review.
It then becomes the responsibility of the Singapore Medical Council to consider it under Para 4.1.4 of the ethical guidelines. Unproven therapies. And that seems to be pretty inconsistently interpreted at the moment.
It would seem that Singapore is quite backward and confused where this is concerned.
Here is a list of site where you can read about regulations elsewhere:
Tuesday, October 20, 2009
Monday, October 19, 2009
But the question must also be raised as to what actual law did he break, and what crime did he commit? Apparently he done the unconscionable and had injected sheep foetal cells into patients to slow aging. The Medical Council screamed that this was offering unproven therapy, and not allowed. Such unproven therapy violate the SMC Code of Ethics :
The SMC Ethical Code and Ethical Guidelines para 4.1.4 state very explicitly: "A doctor shall treat patients according to generally accepted methods and use only licensed drugs for appropriate indications. A doctor shall not offer to patients, management plans or remedies that are not generally accepted by the profession, except in the context of a formal and approved clinical trial."
What Martin Huang did was offering a therapy that was uproven, and which was not part of a formal clinical trial. Bad guy.
But then again ( and I have posted on this conundrum before) so many of our doctors are clearly in breach of this. Unproven therapies? All off label use of medications are unproven therapies. Furthermore, their use are often not in the context of a formal clinical trial. How about off-label stent operations? The recent media reports on inappropriate slimming pill prescriptions fall into this category of offense. Yet the SMC did not act.
Not that I am a supporter of Martin Huang. I totally disagree with what he did and fully support the SMC's actions in his case, but the SMC's actions now look horrendously inconsistent. How did the SMC arrive at the conclusion that the offering of sheep fetal cells was so wrong compared to surgeons sticking all kinds of un-trialed appliances into our bodies, and physicians offering all kinds on drugs for un-trialed and unproven indications?
One last bit of ranting before I go for my teh-see....
Were the sheep cells licensed to be imported for cosmetic therapy? Here is where HSA has to explain their position. There apear to be regulations for medicines, for biosimilar products, for some medical devices and for cosmetics (external applications)..... but for cell based therapies?? Silence.
So were the cells allowed into Singapore for such use. If they were licensed imports, would this license represent tacit approval by HSA for their use? If they were not licensed, was Martin Huang guilty of breaking an import law? If so, he should be hit with the full weight of the law, as would any merchant intending to trade in an illegal product. Or does this indicate there is a legal loop hole for doctors to violate patients' safety? If so, why is there such a loophole and what are we doing about it?
What are the conflicts of interests within HSA, as they themselves begin to offer cell based therapies? How do they regulate themselves, in the absence of proper legislation for this, and as they come into competition with commercial providers of cell-based therapies?
We need to know.
Friday, October 16, 2009
Deepavalli's roots are shrouded in mystery, but most believe it has its origins as a harvest festival.
Autumn is a significant time of year in the agricultural calendar of the northern hemisphere. Crops planted in Spring ripen and are collected in the harvest. Agricultural communities celebrate this gathering of the harvest through various thanksgiving feasts. Often lights are featured, as in Deepavalli, perhaps as a recognition of the lengthening nights as Winter approaches. Even the Jewish communities celebrate a Festival of the Ingathering. This subsequently became the Feast of the Tabernacles which they use to commemorate the exodus out of Egyptian slavery.
But what of the harvest in Singapore? We have left our agricultural roots long ago.
We need to remember that our plenty of today is a harvest of the seeds sown by the previous generation. As we continue to reap the harvest despite the economic downturn, we should remember those who had planted seeds with foresight and diligence. Some thanksgiving in due.
But going forward, we should also be very mindful of what we are sowing for the next crop. So here's my plea to the leaders of today. Do not look just at the short term gains as indicated by superficial metrics. This has tended too much to be the management norm of today. While there is little doubting the longer term mission spelt out by our senior political leaders, the middle management levels have tended too much to just focus on short term metric indicators of performance. It's tempting to do so because individual performance looks good, but too much preoccupation with short term goals may ultimately undermine our very existence.
So where medical education and practice is concerned, let us please look at look the ultimate future of our health care system. Let's not screw it up or (as frighteningly overheard coming from a very senior person in YLL), cause it to implode.
Happy Deepavalli, all. And have a great weekend.
Well said, Sir!
I hope Prof Satku's public comments on topics pertaining doctor's professionalism and ethics will not be a one-off event. There is much out there that requires a re-boot. Ethics and professionalism has been fast tracking down the wrong road as the medical market place develops. Sometimes legislation is required. But often it is just the regular and consistent articulation of what is acceptable and what not that puts peer pressures on doctors to 'conform' to best practices. I believe most doctors want to do their best, but if things are left unsaid, errancy can fast become the norm.
I firmly urge our medical professional leaders to take up more visible, clear and vocal positions about medical ethics and professionalism. Not just generic statements, but targeted specific comments about issues. This includes not just the Ministry of Health but also the Medical Council and the Medical Association.
It's time to stop the rot.
Thursday, October 15, 2009
In Singapore, more and more gahment type organizations are now holding 'town hall meetings'. I suspect the management teams have all attended some similar senior management courses, and have been told that it was good management practice to do so.
So we hear of town hall meetings from time to time. Sadly most of these town hall meetings are very contrived and generally very poorly attended. I think the reason for this seemingly apathetic response from these corporate communities are because our management teams don't quite get the idea of what a town hall meeting is supposed to be. Instead of having a meeting to discuss and solicit opinions from the community (which means they actually must want to listen to the opinions raised). Most often, our Singapore styled town hall meetings are poorly disguised top down briefing sessions that are little more than for management to tell you more of the same thing. Typically in such town hall meetings, management's voice represents perhaps 90% or more of the proceedings. A poor simulate of a democratic process.
The MOH apparently wants to have a dialogue session, a town hall meeting about the coming residency programme. Great. But I am really hoping they will be more prepared to hear and listen than to just make presentations.
Tuesday, October 13, 2009
I had previously reported that at Giants:
Giant brand normal white Thai Fragrant Rice was retailing at $1.83/kg
They had a hermetically sealed brown rice 5kg @ 11.95 ($2.39/kg)
At Cold Storage:
Song He "Healthy Rice" 2.5kg @ $7.30 ($2.92/kg)
New Moon Red Cargo Rice 2kg @ $4.95 ($2.47/kg)
Paddy King Red Cargo Rice 1kg @ $3.30 ($3.30/kg)
Paddy King Mixed rice (20% red/brown rice) 2.5kg @ 7.75 ($3.10/kg)
NTUC Thai Red Unpolished Rice 2.5kg @ $5.65 ($2.26/kg)
NTUC Thai Brown Unpolished Rice 2.5kg @ $5.15 ($2.06/kg)
NTUC Thai Healthy Rice (20% red/brown rice) 2.5kg @ $5.65 ($2.26/kg)
One thing to note is the amount of mislabelling that occured for the rice on the shelves. Whole grain does not refer to whole grain as we understand it to be, i.e. the unmilled hulled rice grains. What is labelled as whole grain rice apparently means the polished rice grains are unbroken and therefore 'whole'. The biggest culprits for this mislabelling is actually the NTUC brand. The hulled rice is called at NTUC, unpolished rice.
Oh yes, while looking I also scoured the shelves for hulled barley, being the whole grain equivalent for barley. They do not exist on the shelves.
"The HDB owes affected residents a duty to thoroughly evaluate the impact of such change of use on the character and quality of life in the community in question. Although not legally obliged to do so, the HDB should consider polling the views of affected residents now that it has become clear that this issue is certainly no storm in a teacup.
The authorities should be mindful of an important factor not usually captured in land use consideration: Our collective memory. Buildings and other physical structures are an important anchor for a young people like us; to many Singaporeans, the humble wet market is an important part of that memory."
This is in contrast to the recent Straits Times editorial which argued for letting market forces determine the fate of wet markets.
Wet markets are part of the life of the community, and they cannot be allowed to live or die purely through market forces. They are really no different from considerations of whether the HDB estate requires a park, or a playing field/swimming pool. If these are forced to meet bottom line considerations we would not have any parks or sports facilities.
Likewise, the wet market.
So my plea to the HDB and the Town Councils is, "Please Sir, let them be!".
And to the residents, please go to your respective Town Councils and let them know your sentiments about the impending doom of the wet markets.
Monday, October 12, 2009
I want to go further and suggest that medical ethics is not just limited to what is being discussed within the profession. Medical ethics, like all other kind of ethic practice and concepts belong to the community and has to be shaped by community values. It is therefore vital that the discussion of medical ethics, whether it be related to organ trading, euthanasia or the over-prescriptions of slimming pills, must occur in the public domain and not restricted to hallowed hallways, and hospital meet rooms.
Here's my plea to the medical community, and to those involved in some way or other in the deliberations about contentious issues.... come out into the public space. Let your discussions be public so that the community can learn and therefore contribute to this process. There is nothing to be afraid of, because public discussions can only enrich the process.
Singaporeans are "used to" working in an environment where the goalposts keep changing. Progress, she is called. After all we live in a rapidly changing environment where targets are non-static. Change or stagnate. In Singapore, any change is implemented so that targets are achieved yesterday.
At about this time last year, the NTU embarked on a large scale review of her staff contracts. Many saw it as a culling exercise. The university's mission had morphed from a teaching heavy one to a focus on leading edge research. So the goal posts moved. And in the process, a large cohort of academics who had given the best years of their lives, and had served the teaching mission faithfully were unceremoniously booted out.
More recently there was the problem about the maths paper in PSLE. A last minute change to allow calculators resulted in a flurry of complaints from concerned parents. Not a real problem here except that Gigamole couldn't see why the goalposts had to be moved. Was it not something that could have been implemented the following year so that the students would not be surprised by the changed location of their goalposts? Was it so urgent a mission that one could callously disregard students' anxieties? Apparently so.
Then today, the new residency programme for the training of medical specialists was outed. Nothing new here, as this has been the hot topic in medical blogs, and has caused immeasurable angst among medical students. But this was really a problem of moving goalposts. Students shouldn't be so upset. This is Singapore. And goalposts change here. Frequently. We know it was done as a last minute scramble to match the graduating class from Dukes-NUS. The question was 'wasn't this anticipated?' Didn't management figure out Dukes-NUS was about to graduate and usher in the residency programme? I figure they had about 4 years heads-up on this. But the goalposts changed at the 11th hour as if the problem developed overnight. One must question, why? Why?
Please don't get me wrong. I am all for change, for dynamism. No problem for me if management wants to move their targets. After all the world is not sitting still. But what is good for management is not necessarily good for staff or students. I believe management is getting away with much of this because, the management style is very much top down. Can staff complain? Not really. Can students protest? Not really? What happens usually? Management issues some bland unsatisfactory statement to gloss over the issue, citing how we need to remain top of ranking, or how we are on the way to performance excellence and everyone quietly swallows the bitter pill. But the bitterness remains.
Effective. Progressive. And scores a lot of points with the man upstairs looking at metrics. But cold, uncaring and soul-less.
Management should be aware that there is a limit to how much of this shifting goalposts angst people can absorb. At some point in time, a price will have to be paid in worker's satisfaction, or student's loyalties. There is a limit to how much one can continue to depend on imported talent to replace disenfranchised citizens. At some point in time management will need to count on its own citizenry to staff the hospitals, and to look after our own. Then by that time, there might be no one left.
Friday, October 9, 2009
I see a paediatrician I know, and some old contacts from the university. He is waiting for his wife, so I know she has been in much earlier than me. Then there's that couple from church, who are trying to get their marketing done before morning service.
The fishmonger yells something at me, but I ignore him. The stalls round the back are much better. I avoid the vegetable stall I used to frequent. I stopped going there when the brother took over the stall after their mother passed away from diabetes. They had a falling out and he brutally pushed her out of the business. I go to the other stall now. Also they have a wider range of vegetables. I used to buy some breakfast soya bean for the vegetable lady because she once told me she didn't have a chance to grab breakfast. The pork lady greets me but I tell her I don't need any this week. Once I used to call them auntie. Now the seniority is reversed. It used to irk me, but I kinda enjoy it now.
The wet market is a strange thing. I think it is our equivalent of the village square. The community meets, says hello and move on with their lives. It's a reference point for their week.
I don't believe the wet market produce is necessarily cheaper than the supermarkets. They may provide a better freshness for the money spent. But for me, those are not the issues. For me, it's the life of the community it represents. I don't begrudge the extra dollar the fruit woman makes, nor that I can get cheaper prawns at Giant's down the road. These are ordinary folks making an honest living. They work hard, and like us, they do need to put their children through schools, and pay their hospital bills.
I feel privileged to intersect my life with theirs on that precious occasion when I wander down to the wet market. I get to know of their pains and struggles. Their domestic politics. Their joy when one of their sons graduate from university. Their anxieties when one gets called up to national service. Or fails an exam.
We lose our wet markets at a cost to our soul. This is not something the supermarket can replace.
The gahment would be wise to heed the concerns of the people on this particular issue.
And I am asking myself if the Ministry of Education's expectations for this examination for Primary 6 students are realistic, or not? For goodness' sake, these are barely 12 year old kids.
An example of a question that stumped many was something like this:
"Jim bought some chocolates and gave half of it to Ken. Ken bought some sweets and gave half of it to Jim. Jim ate 12 sweets and Ken ate 18 chocolates. The ratio of Jim's sweets to chocolates became 1:7 and the ratio of Ken's sweets to chocolates became 1:4. How many sweets did Ken buy?"
I didn't even bother to try it....certainly not before my morning 'teh see'. Not sure if the question was correctly reproduced, but it seemed to me that someone couldn't make the distinction between buying, possessing and eating.
Wednesday, October 7, 2009
Methinks this is not a food borne disease. Because if it were, the clusters would have been obvious by now, and the AVA would be running all over the place making a great show of catching rats. But everything's quiet at the moment. So to my reckoning this must a diarrhoeal disease caused by some other pathogen....an airborne virus perhaps?
Once we start thinking along those lines, one of the likely candidates, especially of recent importance, is the H1N1 virus. The novel H1N1 virus has been reported to be capable, more so than seasonal flu, of causing diarrhoea, and I can't help wondering if perhaps this 'epidemic' of diarrhoea is somehow related to the H1N1 virus. Perhaps it has somehow attentuated to just produce gastrointestinal symptoms.
Just some speculations, but I think, may be worth considering. I wonder if anyone has bothered to assay the virus in these doarrhoea cases.
Tuesday, October 6, 2009
Now there's no disputing the healthiness of eating whole grain, but where on earth do you find it? I went searching for it in Giant supermarket... and found red unpolished rice hanging pathetically where the small packets of barley hung. At $0.83 for a 300gm pack. That works out approximately $2.80 per kilo. And if I were going to feed my family for a month I would have to carry home about 20 packs.
Next went to where the sacked rice were. And among the piles of rice (huge range!!) there, I found only one variety of hermetically sealed brown rice retailing at $11.95 for a 5kg bag. Hermetically sealed?? My calculator went click-click-click and I figured that worked out to approximately $2.40 per kilo. Not too far from it, the housebrand perfumed Thai rice was on offer at 18.30 for a 10kg sack. Only 2 clicks this time....and I worked it out to be $1.83 per kilo.
Not easy to find this brown rice! And it seems that wretched rule of market place was working.... you know, the one that says the less you process the food stuff, the more expensive it gets. So unpolished rice costs approximately 60 cents per kilo more than the conventional white rice.
Then another thing I discovered.... ( I did wonder why the rice was hermetically sealed)... and that is unpolished rice has a short shelf life as it tends to go rancid. Some suggest that the rice be stored in the freezer. Duhhhh.....there is no way I was going to stuff a 5 kg sack of rice into my freezer!!
I guess it's down to buying small packs of unpolished rice ... no more 10kg sacks!
So eat healthy is going to cost ... both in times of $$ and time.
I must say that the letters, while trying to defend doctors against the perceived injustice, really themselves presented a very negative image of doctors. I think their crocodile tears have done more to hurt doctors than the article themselves.
How can I say that?
Well, in neither of the letters do the authors deny that over prescribing of slimming pills were a common practice. They referred to Subutex and benzodiazepines, but these were not the slimming pills in question. Ms Khalik in her article had reported that her svelte colleague did not have difficulty in finding doctors who readily prescribed her slimming pills. Although anecdotal, this would suggest that it was a common practice. Why would a doctor prescribe slimming pills to a svelte young lady other then to make money? Unethical? Most definitely. Such unprofessional practice should be regulated by the profession itself.... why insist that legislation is required?
Yet neither Presidents offered a solution to this problem. Neither would acknowledge that it is a problem.
I would rather the medical profession self regulates such bad practices, but the tone of the letters disappointingly suggests that neither the Association not the College of FM (and likely the Medical Council as well) will proactively deal with the problem. So what can one make of the profession?
It is of course unfair to tarnish the reputation of the profession because of a few black sheep, but here are indications that this is a more wide spread problem than just involving a few melanotic herbivores. The apathy of the professional bodies is quite telling. Perhaps the solution is not about decoupling consultations and dispensing, but their nexus in GP clinics does create the setting for a major conflict of interest that does not acting in the patient/consumer's favor. Pretending the problem does not exist doesn't make it go away. Doctors should know better.
My plea to my professional sibs is this: Do something about it and swallow the bitter pill before something more unpleasant gets forced down our throats.
Monday, October 5, 2009
The speed at which. time just whizzes by never ceases to amaze me. Kinda depressing actually. But it's been a year since Gigamole took the first tentative steps to becoming a blogger.
I never really thought I'd last a year. But here I am, 1 year old, and with 297 posts under my belt. How did find so many things to yak about? Who would have thought that my ramblings and rants would drag in 35,000 visitors in the first year.
So happy birthday Gigs. And many thanks to all my supporters out there.
Friday, October 2, 2009
Bright moon, when was your birth?
Wine cup in hand, I ask the deep blue sky;
not knowing what year it is tonight
in those celestial palaces on high.
I long to fly back on the wind,
yet dread those crystal towers, those courts of jade,
Freezing to death among those icy heights!
Instead I rise to dance with my pale shadow;
better off, after all, in the world of men.
Rounding the red pavilion,
stooping to look through gauze windows,
she shines on the sleepless.
The moon should know no sadness;
why, then, is she always full when dear ones are parted?
For men the grief of parting, joy of reunion,
just as the moon wanes and waxes, is bright or dim:
Always some flaw - and so it has been since of old.
My one wish for you, is long life
And a share in this loveliness far, far away!