Tuesday, March 31, 2009

The Medical School and the external economy - at what price?

The discussions about the medical schools and the training of doctors need to be viewed from another perspective - the need to service the external economy. This is an unfortunate reality of Singapore life,....and possibly existence. MM Lee KY has been very blunt about this. Back in 1992 he already made very clear, 'Today's peace and plenty would come to a halt if Singaporeans do not venture overseas to build up an external economy .... Singaporeans should not be distracted by domestic issues to the extent that they ignore the danger of being left behind in the economic race.'

That the medical schools in Singapore are being positioned for the external economy is without doubt. That we are recruiting and staffing the hospitals with so many doctors, is without doubt for the needs of our external economy. The training of physician scientists is not for our domestic patients but to meet the needs of another aspect of our external economy.

Is it wrong? I don't think so. MM Lee is right that our small island state will be swept aside by the tsunami of globalization if we do not find a way to expand our external economy.

The fundamental question is - what is the price we are prepared to pay as a society?

Therein, I believe, lies the problem. I am not so confident that our decision makers at the present, have a good appreciation of what the price is that we are paying to achieve certain numerical targets. It's the curse of a management approach that is based primarily on 'metrics'.

Our medical schools (no matter what their PR machinery tells us) are poorly resourced to produce the numbers of doctors required. Whatever resources that have been allocated to the educational mission tends to get 'stolen' by more high profile and eye-catching needs of academic research staff and facilities. You do not need to go very far to verify my comments. Speak to any of the medical teachers on the ground (not the policy makers obviously, lah!) and you pretty much get the same sense of pessimism and discouragement, and the perception that education has not only been devalued, but the product has already been severely degraded. All this despite soaring school rankings etc.

Why the discordance? Simply because management focuses on delivering according to a demand set by certain 'metrics'. Staff-student ratio? Looks good on paper, but no one needs know a substantial number of these staff numbers are no-intention-to-teach high profile researchers. No support or recognition for educators? Who says? Look at the number of medical pedagogical activities that have been organized!! (A little bird across on the ridge intimated with a bit of eye ball rolling that the school there is setting up a 'Teaching Academy'. Why? Mainly I believe, as a very public demonstration of how they recognize their educators. Another feather in the cap for the metrics champions.)

So here is a bit of a hint for our Ministers of Health and Education - please go ahead and build our capabilities to meet the globalized challenges, and our external economy, but please don't ignore the substance of what we need to try and do for our own people. It is not all about meeting the 'metrics' for an external demand. Many aspects of the product quality cannot be readily codified into check boxes. Many people on the ground will be ready to give you evidence of how the environment is being rapidly and alarmingly degraded, to the point where they are genuinely concerned for the future.

Do we need a third medical school? Of course we do. We desperately need a third school, because we need a school that will bring us back to basics. We already have two high profile schools for the external economy. We need one to look after domestic needs. It's not too much to ask for a school that will train good local doctors for our own domestic health care needs. The Tan Tock Seng Hospital is an excellent campus for this effort. If this third school were to follow the same 'educational' mission that has become the rallying cry of the first two schools, then I think we would have totally lost the point.

Monday, March 30, 2009

A third medical school - a prayerful plea to the powers that be

So here's my humble plea to Minister Khaw as he ponders about the third medical school.

Please give us a third school and not squeeze more demand into the already over stretched NUS medical school.

Please give us a third medical school; one that can concentrate on good down to earth training of doctors. We do not need them to become great scientists. Just good down to earth, compassionate, caring doctors.

Please give us a third medical school; one that is unconcerned about establishing phenomenal global rankings based on academic research. One that is concerned primarily with being good at what it is supposed to do, i.e. train good doctors.

Please give us a third medical school; one that is cheap and good. We do not need to pay expensive salaries for top researchers who do not teach. Or expenseive research labs that do cutting edge research. The only lab we need is the lab that is the lab of life experiences.

Please return to the community the medical school that it once had.

Sunday, March 29, 2009

Too few doctors? Yep, most definitely... and the giraffe's neck is too short.

A letter writer in today's ST posed the question "Why didn't we see it earlier?".

I'm afraid we won't readily get an answer, I don't think. But let me tell you a story. A story that is just that, a story. And one that is definitely not based on any insider information.

Once upon a time, doctors were pretty much regarded as the scum of the earth. Temperamental, self serving, greedy prima donnas who were difficult to manage and kinda messing up the pristine pretty health care system, and in the process escalating health care costs. So the response was pretty predictable. Cap the number of doctors. Control the supply of services, and the demand for services will be bottle necked. QED.

This kinda coincided with the sudden flurry of excitement about life sciences and biotech, and the lure of fame and fortune through patents and drug discoveries etc. It was such a waste that talented high achievers were all queuing up to enter medical school. Unpatriotic lot!! No reason at all to produce more doctors.

A little bit down the road the life sciences initiatives morphed into biomedical sciences and a recognition of the need for yet another catch phrase - "translational research". Multiple and repeated visits to US great halls of learning taught us that the great medical research institutes were all populated by clinician researchers. All of a sudden doctors came back into vogue. Plus, the ideas for a biomedical hub and commercialized medicine suddenly began to assume well-definable shapes. How are we going to have a bustling medical service reaping megabucks off the medical tourist industry when we don't have enough doctors? How are we going to get those top-notch clinical scientists if we don't have enough doctors in research? Train them!! But our medical schools are obsolete traditional structures merely teaching students all the unexciting mundane stuff about being good practitioners and concerned health care givers. What a waste! They should all be trained to be translational, clinical researchers. What an unpatriotic lot!

Solution? Increase the intake of medical students! A second medical school - make that a graduate one to train physician scientists! Why stop there ..? Have a third school! Bring in those top tiered research oriented US medical schools to challenge our own home grown one. Dukes, Cleveland...etc...

Nothing wrong with the strategy. Who cares about over-servicing anymore, especially since the more you service the global community the more we can tax, and the more the ancillary services can also make money? How about the escalation of cost of health care? Tricky problem, but our population's pretty docile and we can still manage public expectations pretty well.

Do we need more doctors? Duuhhh....how can you even ask that question? Of course we do. Meanwhile the giraffe's neck gets longer. Hmmm...on the other hand, perhaps its his legs that are getting shorter.

Saturday, March 28, 2009

The Third Medical School

So we need a third medical school to produce enough doctors for our health care system.

Well, we certainly will need more doctors if we are ever going to be able to adequately service our commercialized medicine hub and still have enough doctors to look after our own people. And we will definitely need a third medical school to produce the number of doctors that are required.

The problem in our midst is that the existing medical school's missions (and I am not refering to those motherhood statements that pass off as institutional missions) are geared primarily towards research and academic excellence. Global ranking exercises are heavily biased towards academic parameters and reputations of their scientists. The problem we have in Singapore is that the medical schools seem to have forgotten that their main mission should be to produce good caring practitioners who will look after their patients and their families.

So here's hoping any ideas of a third medical school will take this mission into consideration during their planning. Otherwise, it will be just more of the same...... self gratifying pursuits of fame and glory.

Human Organ Trade - Rationalizing the problem

The starting point is the easiest part. Noble intentions.

We all have sympathy for and want to find ways to help the patient with end stage renal failure, whose life can be extended (not somehow made immortal, by the way) by a timely renal transplant. The problem is there is a shortage of donors. The solution would seem pretty straightforward - encourage more living donors to come forward by making sure they don't suffer financial or personal losses by being a donor. QED.

The question is how do we reimburse the donor? The fact is no matter what scheme we come up with, it will always carry some element of exploitation. Invariably, it will be the poor and desperate who will sell their organs. Quite frankly, who else will do it? Apart from the obvious ethical difficulties here, this is a particular problem for us as Singapore is likely to be a wealthy net importer, in a socio-political hinterland of poor desperate donors. Accepting that we can never ever free ourselves from the reality of the burden of somehow being exploitative, if we go ahead with it, the question is how to do this in the least exploitative way, i.e., let's face the reality that we are being exploitative, but let's do it in a way that is as fair and reasonable as we can be. We will pay the social and ethical costs of being exploiters for the sake of our patients who are dying of renal failure, but let's try and be as fair as we can be.

Can this be done? Perhaps, ... with a complex regulatory system in place, and with difficult mathematics of computing payouts (or the more palatable term, 'reimbursements'). Can it be regulated? Clearly only with great difficulty. The Ministry of Health has been vary vague about all this, and the lack of clarity clearly troubles many people. The Ministry of Health's position essentially is ... "Trust us...."....

OK , lor.

What worries many is that once legalized, the Ministry of Health will no matter what it says now, quickly forego it's role as a regulator, and default this responsibility to local hospital review boards with different bottom lines. The payouts will be simplified to a lump sum cash payment ($50-100,000? or more?), with the possibility of variable ang pow sweeteners from grateful recipients. What about the problem of exploitation? By this time, who in pragmatic Singapore cares?

How about the recipients? We started this thinking with the noble intention to help our local Singaporean kidney failures. But by not restricting the recipients to Singaporeans, the Ministry of Health is suggesting that its real purpose, is to develop Singapore into a transplantation hub. A centre of excellence for human organ trade even. We can pay the social and ethical cost of being an organ importer and an exploiter of the poor for the sake of our renal failures, but by opening the system up to foreign recipients, the dynamics of this process will become completely changed.

The organ to the highest bidder. It will become unabashedly, a free trade in organs. How else can it be? Almost predictably, if the system works, the actual number of Singaporeans benefitting from this trade will eventually only constitute a small percentage of the overall human organ entrepot trade.

This will be the logical outcome. Good for Singapore? Yeah...but only from a commercial sense. Someone joked recently that we now at least have a dollar value for our bodily parts....

But what value, our souls?

Thursday, March 26, 2009

Human Organ Trade - The ethics of 'inducements'

Since so much in the debate revolve around the problem of inducements, I wondered if we are all on the same page with respect to what 'inducements' really are.

The problem of inducement is fundamental in the consideration of its ability to compromise the 'volunteer''s (be this donating organs, tissues or participating in clinical research) independence to make an autonomous, free will decision. This is a very clear inviolable ethical position that has been internationally accepted. See Belmont Report.

The difficulty lies in the interpretation what constitutes an 'inducement'.

Our Bioethics Advisory Committee (BAC), while proudly trumpeting its Consultation Paper on egg donation, curiously surfacing just before the Organ Transplant discussion began, waffles a bit about the issue of inducements.

It says:

Para 48
"In Singapore, the general ethical framework relating to the donation of tissue (which includes eggs) for research was established by the BAC in 2002. Such donation should be outright gifts and there should be no financial incentives, although reasonable reimbursement of expenses incurred should be allowed.

This ethical requirement in relation to the donation of gametes and embryos was taken up in legislation. Under Section 13 of the Human Cloning and Other Prohibited Practices Act (Cap 131B, 2005 Rev Ed), a person is prohibited from giving or receiving valuable consideration for the supply of human eggs, or to otherwise make an offer to that effect. Valuable consideration has been defined as including “any inducement, discount or priority in the provision of a service to the person, but does not include the payment of reasonable expenses incurred by the person in connection with the supply.” Reasonable expenses include expenses relating to the collection, storage or transport of the eggs. However, the possibility of compensation for time, risk and inconvenience has not been addressed. Based on the general ethical principle of fairness, it appears that there could be circumstances where allowing reasonable compensation for time, risk and inconvenience is consistent with the existing ethical framework."

After all that, the paper concludes:

"Compensation for contributing eggs for research in an amount and manner that is fair and without inducement is likely to require the attention of ethicists, policy makers and regulators in the foreseeable future."

Yes....we all know it requires the attention of ethicists, policy makers and regulators....in the foreseeable future. And all this time I thought the ethicists were in the BAC.

The shadowy National Medical Ethics Committee, an organ of the Ministry of Health (you still can't find any information about the NMEC in MOH website!), while happily supporting the BAC, hasn't published its own comments about the problem of inducements. To find out what they think I had to korek out this information from their 2007 recommendations on Phase 1 (normal volunteers) clinical trials.

In that paper they say:

Executive Summary

"Payments for participation in Phase I trials should be commensurate with the burden of participation. However, excessive remuneration or other forms of benefit are improper if they are such as to persuade people to volunteer against their better judgment."

Yet in their recommendations they say:

"The remuneration and other benefits offered should not be such as to induce people to volunteer against their initial judgment."

I am not a person of words, and not a 'semantologist', but it seems like there is a difference between initial judgement and better judgement.

This is what I think I can understand from what our local ethics groups have been saying. I am not sure I am very clear. I guess, maybe I am a bit dense. But I will leave readers to draw their own conclusion if the ethics people are themselves are very clear about the issue. And if they are prepared to deal with the issues now that the Act has been passed. Or just look the other way?

Dr.Huang Shoou Chyuan's letter to the Straits Times

I have deep reservations about the latest legislation which allows for payment for living kidney donors.

Although Health Minister Khaw Boon Wan had categorically assured parliament that the new law did not seek to legalise organ trading, many including myself remain unconvinced.

If we truly only wanted to reimburse donors for their altruistic acts, and not let this become a backdoor for organ trading, the following safeguards should have been present:

1. Foreigners should have been excluded
Only local donors should be allowed onto this scheme as we can then monitor them within our system and either reimburse them for healthcare expenses related to the organ donation through direct payment or through lifelong medical insurance coverage. Compensation for loss of earnings and other more difficult computations can also be decided by a neutral committee.

To allow foreigners into the scheme opens a Pandora’s box as it is impossible to know what a foreign donor does with the money back home. He could literally put the whole lump sum down on some gamble and have nothing left when he needs it most.

To include foreigners is also a tacit admission that transplant medicine is big business that Singapore cannot afford to ignore.

2. Compensation details should be available before parliament vote

The details about mechanisms for quantifying fair compensation should be present before MP’s were asked to vote on what must have been a tough moral choice. These details must surely be the difference between the money being “compensation” rather than “profit” for the donor.

To be asked to vote for something which lacked any specifics at all might cause our parliament to be misconstrued as a “rubber-stamp” as many may consider voting for this legislation in such a way to be irresponsible and akin to writing a “blank cheque”.

I fear that Singapore’s reputation as a medical hub with a “high ethical standard” has been seriously eroded by the passing of this legislation.

Dr.Huang Shoou Chyuan

Human Organ Trade- Inconsistencies

Today's letter to Forum by Ms Boey Shee Lai, pointed to the ethical inconsistencies between Minister Khaw's approach to reimbursement and Professor Lee Wei Ling's approach to pay the poor out of their poverty. She is right. Such inconsistencies run through a large part of the discussions on this issue. The definitive distinction between reimbursement for expenses incurred and compensation/payments is extremely difficult to make in people's minds and impossible to legislate. Yet Minister Khaw seems to think it can be done. I hope he is right.

Minister also seems to think that our ethical reputation is so strong that somehow that will protect us. I am not so sure. I think perhaps he confuses lawfulness with ethics. I think we are widely regarded as being a very law abiding people. Ethical? hmmm...I am not so sure ( see 'Are we an ethical society?'). I get the feeling that our brand of ethics is a somewhat ends-justify-the-means type.

Are we able to enforce the laws against 'trading'. I seriously doubt it. The will is not there. Neither the tools. Take the recent Tang Wee Sung case. I got nothing against Mr Tang and I am happy for him that he got his kidney. But the truth is that there is a considerable amount of disquiet about how he obtained his kidney. Almost everyone I talk to felt there had been some off-the-table payment to the donor family. This cannot be proven and I am not saying this is true. But many people view it that way. The point is, if there is some truth in it, can the police act? Do they want to investigate? Did they investigate? Did the MOH investigate? Did they want to? If they did not want to, cannot investigate before the Act was passed, what assurances do we have that they will do a better job now that it has been legalized?

I am keeping all my toes and fingers crossed that Minister Khaw can do what he has promised to do, and that eventually he will do the right thing. The ball now is entirely in his court, and I hope he will keep his eye on that ball.

Medication errors - no one wants to find out...

News report today of a medication error that came to light only because the patient's family made it public. Honest mistake by a sincere, decent doctor. But potentially tragic.

Medication errors occur much more commonly than the public is aware of. (I personally heard of recent incident in a local major hospital.) A recent report (2006) by the National Academies of Science highlighted this problem and estimated that medication errors harm at least 1.5 million people every year in the US. The medical costs in managing these errors amount to some US$3.5 billion. Awareness and simple solutions can prevent many of these problems.

Unfortunately no one locally seems to be interested. The hospitals don't want to know. And obviously do not have any means to track this problem. The Ministry of Health show no interest in auditing this problem and is quite content to let the hospitals manage the problem by sweeping everything under the carpet.

See no evil, hear no evil - and no evil shall be spoken, seems to be the motto.

Wednesday, March 25, 2009

Are we an ethical society?

This is a difficult question. The answer will I guess be a hesitant qualified yes.

I mean, we do have all the instruments in place to be ethical. On paper we would be fully compliant with international best practices. Our institutions, hospitals and universities have duly constituted ethical review boards who sit and approve all our research and clinical practices. And we certainly know the jargon.

But don't you get this niggling feeling that we are not that ethical a society? We have the form, but don't you often get the feeling that despite the form, we are really not a very ethically concerned society?

You see, we don't really discuss ethical issues. Any discussions go on behind closed doors and we don't get to hear of the discussion points. In the end there is a very palatable consensus document which doesn't really tell us what the contrarian views might be, if there are any. The ethicists in our midst tend not to want to let us know what they think.

The ethics committees tend to be rather politically correct, and in the absence of any real public discussions by our ethicists you can't help wondering if the final consensus documents have been massaged to fit the intended outcome. It's all very discomforting.

Plus, as a society, we tend to be pragmatic to a fault. This pragmatism works in our favour sometimes, and allows us often to be able to cut the Gordian Knot when problems appear insoluble. But with ethical issues this overly pragmatic approach often leads us to consider that the ends can be used to justify the means. Which makes for a rather uncomfortable kind of ethics.

Tuesday, March 24, 2009

Human Organs - The new entrepot trade?

Singapore made it's reputation in the past upon being an entrepot trader. Buy from the region... sell to the world.

Now that we have legislated (and there was never really any doubt the Act would be passed) it is really all up to the Ministry of Health to determine how this whole thing about organ trade will develop. Yep, organ trade. Because no matter how you choose to define it, when you provide money in exchange for goods, that's trade.

I am not against appropriate compensation for organ donors. This would be fair and just. But it was never discussed if there was some other way to ensure fairness to donors. Was a 'purchase' the only way to do this? The Minister has opened a can of worms. The challenge is how to prevent it from degenerating into a free trade. By opening the system to foreign donors and foreign recipients, no matter how we want to camouflage the process, this will become an entrepot trade.

Sadly, once we go through this door, there is really no way to backtrack. I wish we had spent more time discussing this. As a society I think we will regret rushing into this.

Monday, March 23, 2009

A Time To Die

A time to die

By Anthony Yeo, Life Lines

I was one of the speakers at a forum on euthanasia held by the Medical Directorate of the National University of Singapore recently.

The controversy surrounding this issue raises various dilemmas, mostly of a moral nature. When one considers the reasons of those who prefer to be assisted in their death, we must appreciate the complexity of the matter.

More than two years ago, I had an intense conversation with a colleague and friend who was suffering from nose cancer.

She was expecting to die in November of the year of her diagnosis. When November came, she was in excruciating pain while expecting her impending death.

That did not happen as she battled her pain and discomfort, wondering when her suffering would end. She even prayed to God for relief from this life so she could join her Maker.

Our conversation covered many aspects of her life, including the legacy she thought she was leaving behind and her readiness to depart from this earth. Somehow she decided she was more than ready to die.

But providence seemed to decide otherwise and she continued in her agony, struggling to make sense of a life that she had released psychologically and spiritually.

One day she peered out the door of her eight-storey apartment and said: 'I wish I have the strength to get over the ledge and end my life. If only you could help me with it.'

We then sat in sombre silence, she placid and composed, I reeling in pain that I could not relieve her suffering that lasted for another five months before she finally breathed her last.

As I pondered over her extended time on earth, filled with nothing but pain and agony, I thought she was feeling a grievous loss of control over her predicament.

There was nothing she could do except be attended to by her maid, get shuttled to and from hospital, and wake each day to contend with what seemed to be meaningless suffering for her.

She must have decided that a possible way to assert control was to find a way to hasten her death. If only she could have someone who could help her to make that happen.

I suppose there might be others who think like her. They must be wishing that they could be given the freedom to do so.

Her situation has challenged my thinking about euthanasia and to consider the possibility that life need not continue if there is no more reason to do so.

If I were to be in a similar predicament as my friend, I would like to go rather than wait for a painful and inevitable death.

Meanwhile, I want to live each day meaningfully and learn not to wish for undue extension of life.

I want to be at peace and grateful for the life that I have had. May I learn to live so that I may learn to die.

Human Organ Trade in Singapore - at last, some discussions?

The issue has come up for discussions in Parliament. It's clear now the timing of Dr Lee Wei Ling's bemused rants. But I seriously hope that this will lead to some serious discussions about a critically important issue. The last wayang by Ministry of Health was such a rushed job, you seriously had to question what they were doing it for?

What I would like to see, and hope our Parliamentarians will raise are:

a] In depth presentation of pros and cons. Let's just not talk about the number of kidney failures and how many people will benefit. Let's have a really hard look at the ethical issues and the downsides and social impact to having a flourishing organ trade in Singapore.

b] A more honest discussions by our ethicists about the issues about to be breached by having an organ trade. Please don't hide behind august committees and issue bland politically correct, consensus documents. Let's discuss the issues openly. I must say I have been sorely disappointed by our ethicists who privately express reservations but who strive so hard to be politically correct.

c] Let the issue be clearly separated from issues of commercialized medicine. Why can't the Ministry of Health make it plain that this is not about establishing ourselves as a medical hub par excellence? If we have to do it, why open it to foreign recipients... unless we want to make their money? Society pays an ethical price in order to provide a service for our own citizens. Let's do it properly for our own citizenry, and let this not be a business/trade.

d] Let's have a clear plan on how we are actually going to implement a reimbursement/support scheme for donors. Call it whatever you want. The rose will smell the same whatever sweet name you want to call it. This is critical to the acceptability of the programme. It is not adequate to say let's approve first...and work out details later. This is just not acceptable.

The ends never justify the means. If we want to mature into a responsible civilized society, we need to give serious consideration to the hows and whys of what we are doing, and not capitulate to expedience.

Sunday, March 22, 2009

Dr Lee Wei Ling's bemused ranting about living kidney donors

Dr Lee Wei Ling is back in the news with a letter to the Forum page essentially attacking doctors who are uncomfortable with the organ trade. She accused wary doctors of being afraid of being labelled professional pariahs in the international community. "....groan"

Not a very fair attack I must say. Somewhat childish, I might add. I mean, to resort to name calling just to make your point. Tsk Tsk, she should know better.

The resistance to the organ trade isn't about providing reimbursements. It is about designing and implementing a system whereby there can be appropriate and just compensations without allowing the system to degenerate into a crass free for all, cash for organ trade where the rich sick can exploit the poor and defenseless. Because that would be a system where wealth justifies any manner of abuse.

Think again, Dr Lee.

Tuberculosis in Singapore

My earlier post was based on the abbreviated online report. Today's ST carries a more detailed report where indeed some of the points I raised was covered. At least we are all on the same page!

But the point remains that we need to make a distinction between fresh TB infections (which mean catching the stuff because someone is coughing in your face) and the reinfected cases where, you actually have the bug but is gets out of control because of stress, reduced immunity or just age etc. The former is the real problem to worry about if that is indeed rising. The latter is something we need to investigate more to find out why.

But like I pointed out before, the incidence really isn't rising alarmingly. The following graph is reproduced from past MOH data, and is something I posted before. See for yourself.

Tuberculosis in Singapore

Lee Hui Chieh reports in Straits Times that TB figures for Singapore are up from 35.1/100,000 in 2007 to 39.8/100,000 in 2008. The Health Ministry (MOH) released the update ahead of World Tuberculosis Day on Monday.

There needs to be some perspective with respect to this alarmist type of reporting.

The incidence of TB in Singapore is low and has drifted from (per 100,000 Singaporeans and PRs) 54.9 (1997) to 37.0 (2005), 34.8 (2006), 35.1 (2007) and now 39.8 (2008). It remains to be seen if this is a sustained increasing rate or just a yearly fluctuation. Fact is most of these cases are reactivation of old infections. Even if the rates are really increasing, the MOH should try and ascertain why the reactivation rates are increasing? Is it a function of our aging population? Or is it related to the increase in immigrants and PRs who harbour old infected foci?

The MOH needs to get better data.

Saturday, March 21, 2009

Dengue in Singapore - Why no progress in labour?

"Rare dengue type on the rise" proclaimed Jessica Jaganathan in the Straits Times on Friday. And today's ST reported on Ms Yong Ying-I, permanent sec for health, commenting on the dengue epidemic in her speech at the conference on the genetics and genomics of infectious diseases.

Somehow I think perhaps most people are missing the point here. Sure, it is important to track the disease, particularly the dengue serotypes. Sure, it is important that we do all we can to control the vectors that transmit the disease. Sure, it is very important for us to have in place programmes and processes to control future epidemics (this was somewhat deficient during SARS).

But the point here is really not about the usual dengue infections. This while troubling and produces some degree of morbidity is part and parcel of life, and living with microbes in the world. What is the real problem in dengue is that a small number of patients get a fatal haemorrhagic disease. Dengue haemorrhagic fever (DHF) is really quite diferent from the run of the mill dengue fever (DF). This is not necessarily related to the serotypes of the virus. The immunologists have postulates about this. Prof Halsteadt writing in 1981, proposed the idea of sequential infections as being behind the fatal haemorrhagic manifestations of dengue. But this is does not explain the haemrrhagic fatalities in children who catch the disease for the very first time (naivetes). Vaccinations are not necessarily the answer to the dengue problem, and may even predispose to the haemorrhagic manifestations.

There remains a lot we do not understand about the disease. For example, why does the disease predominantly affect an older population in theAmericas than compared to South East Asia? Or why are the haemorrhagic manifestations more common in South East Asia? The DHF variety is seen in only about 0.3% of the total dengue infections, while in Singapore, the DHF variety can be as common as almost 3% of total dengue infections? Why??? Do Asians have a genetic predisposition?

Why did the Straits Times miss the opportunity to interview Prof Halsteadt who has researched many of these questions? Instead, they concentrated on reporting on meaningless numbers, and talk of producing vaccines etc etc.

More research money should be directed to answering some of these questions. Let me say again....the question is not about preventing dengue infections, but really about preventing DHF and the fatalities associated with dengue.

The difficulty, I believe in addressing many of these questions is that too much research money is going into empty and false promises of vaccine breakthroughs. The lure of quick megabuck patents is far too tempting for scientists to refocus their minds on less eye catching epidemiological and genetic studies (not on the virus but on our local population). All backroom stuff....plodding detective work...but essential backroom stuff that helps us understand and hopefully prevent deaths in the future.

Wednesday, March 18, 2009

Prof Kesavan's letter on Organ Trade:

Well said. Well done Prof Kesavan!! Thanks for bring this back online. We should not allow this organ trade nonsense to just willy nilly drift into becoming a fait acompli. I was worried you guys didn't care.

Concerns over proposal to reimburse organ donors
(ST 19/3)

THE Singapore Urological Association is a professional society representing specialist surgeons. Many of our members are directly involved in renal transplantation and the care of kidney failure and kidney transplant patients.

We commend the Ministry of Health's efforts to amend the Human Organ Transplant Act, with the intention of increasing the number of transplants.

Our association fully endorses the proposed amendments to lift the upper age limit for cadaveric donors and to allow donor-recipient paired matching as these are medically justified.

The amendment to support the welfare of living donors by allowing them to be compensated seeks to reimburse donors for expenses incurred through their altruistic act, including loss of earnings, transport costs and possible future medical expenses.

But this amendment raises the following concerns:

  • The proposed amendment currently before Parliament would allow for monetary payment of the donor for such costs. There is a real risk of manipulation by the indirect inclusion of financial inducements for the donor, in the guise of loss of earnings and potential medical costs, to inflate the amounts payable.

  • The provision for 'lump sum' compensation for potential medical expenses is problematic. The amounts of such expenses are, at best, uncertain; calculations of future health insurance premiums for the donors will be difficult.

    It may be preferable to provide for such costs within Singapore's health-care framework. An example would be to issue donors with a medical benefits card that would cover related medical issues.

    The ministry may also wish to consider wider medical coverage, given the potential problem of future insurability of the donor.

  • Having 'lump sum' compensation would be inappropriate for donors from foreign countries, as they will have no access to the Singapore health and legal systems once they return to their countries of origin. There will be little guarantee that any money paid will be used for its intended purpose. It will also negatively affect Singapore's international standing as a medical hub with high ethical standards.

    We therefore recommend that the above amendment be restricted to Singaporeans and Singapore permanent residents.

    The question of financial compensation for the donor remains a difficult ethical and practical issue, and should be tailored to the specific situation in Singapore. We hope these concerns are taken into consideration in the implementation of the proposed legislation.

    Professor E Kesavan
    Singapore Urological Association

  • Saturday, March 14, 2009

    Invisible Disease - Medication errors

    Just as we had been discussing the invisible diseases in hospitals, here is a recent report (hot off the press!) of an Austrian study on medication errors across 113 intensive care units in 27 countries. Participants were 1328 adult patients in ICUs. This was an observational, prospective, 24 hour cross sectional study with self reporting by staff.

    The results?

    "861 errors affecting 441 patients were reported: 74.5 (95% confidence interval 69.5 to 79.4) events per 100 patient days. Three quarters of the errors were classified as errors of omission. Twelve patients (0.9% of the study population) experienced permanent harm or died because of medication errors at the administration stage." (Cited from the original paper BMJ 2000 320: 745-749)

    Their conclusions?

    "Parenteral medication errors at the administration stage are common and a serious safety problem in intensive care units. With the increasing complexity of care in critically ill patients, organizational factors such as error reporting systems and routine checks can reduce the risk for such errors."

    We will not likely ever, to find out what the situation is in Singapore. It's an invisible disease. No one wants to know. Neither the hospitals nor the MOH wants to find out.

    But the public has a right to know.

    Latest on Bisphenol A - the ball is back in AVA's court

    The BBC carried a report yesterday that US baby bottle manufacturers are removing the controversial chemical Bisphenol A, but they will continue selling Bisphenol A bottles in the UK.The Food Standards Agency insists BPA in UK plastic products is "well below the levels considered harmful".

    The UK will come under increasing pressure to follow suit. What will our AVA do?

    See previous posts on this issue:

    Dengue in Singapore

    There was a series of reports through Channelnewsasia about the dengue situation in Singapore arising from the recent Asia Pacific Dengue Workshop. Somewhat confusing I must say.

    First on 10/3, they reported the alarming 26% year-on-year increase in dengue cases in the first 9 weeks of 2009. Then, on 14/9 they reported that the number of dengue cases in Singapore were down in the last few weeks. Duhhh..... such mindless reporting, just regurgitating information without processing it!

    Fact is the apparent surge in 2009 was due to an unusually large spike of cases over the new year. Here are the actual numbers. Past the first week it has been actually same as 2008. Business as usual. Practically smack on the dot.Actually Singapore has done extremely well in managing the dengue problem. The Cairns Post in Australia carried commendations from medical entomologist Scott Ritchie. "The Far North must follow the lead of Singapore to drastically cut the chance of another large dengue fever outbreak, medical entomologist Scott Ritchie says. He
    said a house index, measuring the percentage of houses breeding dengue fever mosquitoes was often used to determine the level of risk an area was at of a major outbreak. Cairns' house index was currently about 25 per cent, compared with 0.5 per cent in Singapore."

    That's good stuff. Singapore has done extremely in managing the mozzie problem. We can certainly try to do better, but I seriously don't think we can ever be 100% free of the Aedes mosquito. That bug is an urban warrior. A smart one at that. He is comfortable in and completely adapted to his environment. So the reality is that we need to co-exist with the mosquito much as we loathe him and will likely have to live with a certain degree of baseline risk of dengue ... and chikungunya.

    The other thing reporters often forget is to see that picture of dengue in greater totality. The usual dengue infections shouldn't worry us. It carries a certain morbidity no doubt, but it is self limiting and other than making you feel miserable, accounts for little. What is of concern is really the haemorrhagic form. This is the one that kills you....very quickly. How you differentiate one from another is what puzzles scientists. They talk of serotypes and superinfections, but in reality these are only guesses. Reasonable, educated guesses, but still just guesses.

    The dengue infection rates fluctuate apparently in 5 year cycles. Don't ask me why, but they seem to do that. Here is a yearly plot of the dengue strike rates from 2007. As you can see we are way off the 2007 peak. Business as usual.

    But what this graph doesn't tell you is that the haemorrhagic variety doesn't just follow the overall dengue strike rates. Here is my plot of the ratio of the haemorrhagic form to the non-haemorrhagic form over the last 8 years. As you can see, it also gyrates violently, and even that seems to be coming off a recent peak in 2005.The dengue problem is here to stay unfortunately. We shouldn't be complacent about it because 1-2 out of 100 cases will succumb to the infection and die. But we shouldn't need to be alarmed. Singapore is doing as best as can possibly be done globally. We would be at far greater risk when we travel to any city in tropical Asia.

    Sunday, March 8, 2009

    Hospital infections

    Not so long ago a friend of mine, an active young lady who tore her meniscus during some games was operated on in one of our major hospitals. What started as a simple surgical procedure, turned out to be a painfully distressing, protracted and expensive journey because she picked up a septic arthritis following the operation. What was worst for her was the callous way the hospital shrugged off the incident as part of the risks of surgery.

    Really? Should it be part of the accepted risks of surgery?

    I was bemused by the letter that appeared in today's Straits Times from Drs Lee and Hsu from the Society of Infectious Diseases, Singapore vigorously defending the hospitals' efforts in this direction. I was curious about the society because I didn't know of it's existence, so I looked them up online. (BTW, The SID ought to know that their website hasn't been updated since 2007). The membership of the SID really comprises the Infectious Disease consultants I know in the hospitals. :)

    Anyway, I am glad they responded. They are right of course in pointing out that Denmark took 10 years and UK took 4 years. They are also right in that we can't expect to turn this around overnight.

    My question to SID is: So why are we waiting? We were aware of this problem 10 years ago. When did we actually make this 'commendable start', and this 'move to share data and knowledge'? How do we actually share data when we are tip toeing around hospital sensitivities about who is doing better and who's worse, and case-mix ratios and what not?

    Can we move a bit faster please, and take some definitive concrete action? We don't really want to wait another 10 years to actually start.

    Resarch vs Education - The curse of Janus

    The Greek God Janus was supposed to be the God of doorways, and is often used to represent a transition between two states - from old to new etc. He is often visualized as a guy with a head having two faces in opposite directions.

    For me he kinda represents the current tension between research and education in the universities. My recent comments about the universities may have led some to think that I am somewhat anti-research. Far from it. I think research is critical, not just from our national development point of view, but also because it is vital part of our global scientific and academic contributions. I think it is really wonderful that the research $$ are flowing in Singapore.

    But the other face of Janus says that the universities have made serious errors in judgment in too eagerly jumping onto the research bandwagon, and have seriously neglected their responsibilities towards the educational mission. By all means progress the academic mission, and reward good research. But a research mission that is primarily directed towards commercial endpoints, and devoid of a strong educational ethos is sterile, mercenary and dishonest. Worse, it essentially steals from our future, because it will eventually hollow out and kill whatever is noble and truly worthy in our educational system. And I am not just talking about an educational system that just drives students towards academic endpoints.

    Janus is not very happy.

    Friday, March 6, 2009

    Hospital infections - the saga continues

    I am glad that following Salma Khalik's report that there have been a flurry of hospital and MOH responses appearing in today's Straits Times. If nothing else it would appear that they have taken cognizance of the groundswell of public concern.

    It would appear that some sort of 'awareness' had arisen at their level back in 2007, and that there were some (albeit kinda half-hearted) attempts then to deal with the problem. That was back then. Hopefully this display of public angst may provoke them to adopt more concrete and enduring solutions.

    So far, they seem only to be playing with numbers. Sure, there is a problem with definitions. But to sit back and wring their hands for 2 years knowing the stats are not meaningful because of a non-harmonised approach towards data collection smacks of a fairly large dose of a 'boh chap' attitude. I mean, if you are really interested in the data, it doesn't take too much effort to standardize the definition regardless of the limitations. And why not provide the public with a tracking of this problem over the years? Don't just tell us the comparisons between the worst year and the best. Don't fudge by playing with the denominator to make the numbers look miniscule (per patient days? errmmm...why not per patient seconds?). Is the situation really getting better as every hospital seem to suggest? If really so we shouldn't need to worry and these discussions would be totally unnecessary. But I suspect not, so give us the real news.

    The MOH provides weekly stats of the reporting of of all kinds of infectious diseases. Why can't the MOH tell us the yearly-hospital incidences and let us judge for ourselves if the situation is really under control, and which hospital is really biting the bullet where this is concerned?

    Thursday, March 5, 2009

    Invisible diseases...

    Used that term, and need to explain abit more...

    Invisible diseases??

    They are just stuff that occurs in clinical practice that adversely affects the patients without their realizing it, and that doctors and hospitals like to pretend don't exist. They are just invisible. Until someone points them out.

    What are some of these?

    For one thing, diseases caused by doctors. These are called in our jargon, iatrogenic diseases. Often just unsavoury outcome of a reasonable practice. But sometimes can be bad outcome of unsavoury practice. Side effects of drugs, for example.

    Medication errors.

    Bad surgery. How many of these surface? Do hospitals track poor/bad outcome?

    Stuff like that. They remain largely invisible, because people wear blinkers and pretend they don't exist. Why? simply because they cost money to prevent, even though they will eventually save health care costs because preventing them decreases overall morbidity. And reduced morbidity will eventually save health care $$. But hospitals and doctors tend not to want to deal with this because their accounting is too simplistic to take into consideration health $$ savings of this nature. As long as the patient/consumer is prepared to pay for the increased morbidity, why bother spending money from your own coffers for good preventive medicine. You can't bill the patient/consumer for preventive measures.

    Blogs' reach limited: Study

    The recent study and comments by the Institute of Policy Studies is another one of these pointless meaningless exercises. I mean what's the point of comparing apples and oranges. The mainstream media is a mass media, heavily resourced and professional outfits whose mission is to generate revenue out of news as a commodity. Blogs are very different entities. Admittedly some blogs do deceive themselves into believing they are news outfits, but they seldom get close to competing with the traditional mass media on that platform

    The innate strength of blogs is their nimbleness and cost effectiveness in maintaining a cyberspace community through which news and views can circulate in an unrestricted fashion. They cannot be evaluated as if they are a single business unit, not can they be benchmarked in terms of parameters more suitable for newsprint and other mass media. There is no comparison to the power of the blog, when you consider that it allows a single, otherwise powerless voice, to communicate ideas to the world and/or to the powers that be. Free and freely. Does it work? Depends on the ideas being floated. Many will die as soon as it is articulated. Some will reach the intended ears...and maybe effect a small change. Some ideas will assume a power beyond expectations, and perhaps even change the world.

    All this for the cost of a computer, and an internet subscription.

    Keep the faith!

    Wednesday, March 4, 2009

    Hospital (nosocomial) infections - an 'invisible' disease

    Salma Khalik, Health Correspondent for the Straits Times had a good write up today (pg 2 ST) on stamping out hospital infections. Her comments resonated with what I had posted earlier, and points the finger at bottom line issues affecting the hospitals. She suggested an interesting solution. Make the hospitals liable for hospital (nosocomial) infections. She's right, of course. They should be. Why should patients have to pay extra if hospitals are responsible for infections inflicted upon the patients. It's like asking patients to pay for the extra surgery required if surgeons botch up their routine surgery (oooops...that happens too doesn't it?). Problem is hospitals will just pass on the costs of litigation, and of insurance back to the patients. And then up go health care costs.

    This really underlies the difficulty in implementing solutions which we all know are required. Hospitals don't want to track nosocomial infections
    and don't really want to know about it no matter what they profess. And MOH also doesn't really want to track the problem, nor seriously deal with it. Ministry of Health needs to keep health care costs down, or else pay the political price.

    It's all lip service at the moment, because the numbers are still manageable. Many patients are not even aware they have picked up nosocomial infections, or that their hospital costs are high because they needed that expensive special antibiotic, or that extra long stay to deal with an unnecessary superinfection by a resistant bug. It is really one of several 'invisible diseases'....ailments that doctors pretend not to see, and for which patients willy nilly accept as part of their hospital experience. And pay for it. What choice do they have?

    So as long as patients happily pay the cost of their superinfections, its really "hush everyone...don't tell anyone the problem exists".

    Ultimately it is a problem that Ministry and hospitals have to take responsibility for. No doubt health care costs will go up because of it, but someone has to pay for it...and someone other than the patient who was really an innocent victim of dirty facilities.

    Tuesday, March 3, 2009

    Universities - a stressful environment? Increasingly so...

    After the recent tragic stabbing - suicide incident at the Nanyang Technological University (NTU), schools and universities have come out with a flurry of reassuring statements, highlighting the extent to which they have been equipped to deal with student stress etc. The NTU's support services kicked it commendably as soon as they were aware of the tragedy. But NTU President Su Guan Ning pointed out in TODAY, that "We need to reach out a bit more, because sometimes (students) don't reach out at all." Quite obviously.

    My take on this is that many of such services are largely cosmetic and are good only after the fact. They are really important as in this case, after the incident and when staff and students, plus their families need support. Unfortunately though, they are pretty useless as a preventive measure. Few students will spontaneously approach a counselling centre, or a counsellor to seek help. Worse, if it is to do with problems associated with their course, or the university itself. But there isn't much anyone can do to induce troubled students to come forward to seek help.

    Universities have become simmering cauldrons of unresolved stresses. And it is getting worse. The student intake has screamed upwards to stretch current university resources. Coupled to this is the universities' relentless push towards academic excellence. High grade expectations, high rankings, high impact publications...all contribute to the pressure cooker environment that the students are placed in.

    Underpinning this deteriorating situation is the universities' diversion of much needed student educational resources towards meeting its research/academic agenda. (I understand only a fraction of the education subsidy and student fees go to educational needs ... a significant portion go to high salaries of researchers and research infrastrcture). No one wants to admit this but it seems to be a formenting problem in the universities. Staff are recruited primarily to meet research missions (not teaching). Many high performing new staff have no interest in teaching, and are often 'excused' from teaching because of their research track record.

    A final year NTU student I encountered volunteered that she has to complete an FYP (final year project) to graduate well. She was allocated a staff to supervise the project but her repeated attempts to meet the supervisor had been rebuffed or ignored. Time is running out for her, and now fraught with anxiety, she is forced to undertake the project without supervision. Woe betide her should her 'absent' supervisor fail her project. But what can she do?

    Unless the universities become accountable to the public for the proper use of educational budget, to meet proper educational needs (not the public relations ranking nonsense....not the high visbility research nonsense), this problem will not go away, and will predictably, just get worse.

    Monday, March 2, 2009

    Scrubbing out the superbug? Yeah...sure....

    Today's Straits Times also carried a report entitled "Scrubbing out the superbug". It's no easy task, and we are dealing with a smart bug (Staphylococcus aureus) that's able to develop resistance as fast as we are able to produce drugs against it.

    The problem is set to get worse, with no real end in sight. I am not so hopeful it can be scrubbed out.

    Reading the report I was particularly struck by the apparent reality that we actually know what needs to be done, and yet mysteriously are not able to do what needs to be done to "scrub out" this bug. NUH says it wants to have more MRSA (methicillin resistant Staphylococcus aureus)-free wards but are constrained by a "tight bed situation". Good hand hygiene of health care providers is paramount, yet compliance is low, and there is no process in place to check compliance. Doctors drape stethoscopes around their necks like ornaments to be brought to public areas. NUH's Prof Tambyah says MRSA infections should be notifiable. But it is not.

    It struck as me as odd that hospitals 'try' to tackle this community problem at their level while keeping a half-cocked eye on their bottom lines. The Ministry of Health knows what needs to be done, yet seems to by pussyfooting around with 'guidelines' to the hospitals they 'regulate' - guidelines which nobody reads and nobody enforces. It seems to me more than a bit odd.... a bit like asking Jurong Town Corporation to 'regulate' worker's safety in the factories of their tenants. I was wondering of MOH's apparent softness arise from this 'conflict of interest'.

    Perhaps it is time for an external regulator to be overseeing this process. Control of infectious diseases (not only this superbug, but others that affect the community such as SARS and the dreaded and anticipated avain flu) should perhaps be delegated to an authority external and independent of the Ministry of Health. Perhaps then we can see hard decisions being taken without being affected by bottom line issues.

    It's a question of our national health and safety.

    See other conflicts of interest posts:


    Sunday, March 1, 2009

    PM Lee HL and the Rohingyas

    I was most proud when I read today that our PM Lee Hsien Loong brought up the issue about the Rohingyas at the ASEAN Summit. This at a time when the other leaders would rather look the other way. "Illegal migrants from the Indian Ocean" they have apparently been labeled. Oh yeah...sure... kinda like 'Men from Atlantis'.

    PM Lee said:
    "As a very small country ourselves, Singapore understands why countries cannot simply take in everyone who lands on their shores. But we still have a responsibility to treat the Rohingya people humanely and try to alleviate their plight."

    Well said, Sir.

    [See previous post on Rohingyas.]