Saturday, May 30, 2009
It's kinda surreal isn't it? I think we should worry...oh no, we shouldn't worry. It's life as per normal...oh no, it cannot be normal, we must be careful. Is it a pandemic? Not a pandemic? Or a qualified pandemic? Is the sky falling? Who knows anymore?
I think the regulatory authorities, and health ministries, including the WHO and our own MOH have kinda painted themselves into a corner, don't you think? Is it ever going to get better? Obviously not, because the number of cases will just increase until the virus loses steam. Maybe then we can live outside our artificially constructed bubble. What if it doesn't? Well, I think we got to get used to living in our bubble, cos the WHO too 'paiseh' to admit they got it wrong.
I wonder if anyone is keeping track of the economic costs of maintaining this charade?
But this Saturday under the Daedalus column, he touched on a topic that has been somewhat troubling to me, that of the conduct of clinical trials by mega pharma companies.
Drug companies claim that the cost of developing a new drug ranges anywhere between US$0.5 -2 billion. (Other people have suggested that this is grossly inflated and that perhaps only about a fraction of 10% of this is actually spent on FDA required activities.) Although the patent life of a drug is 20 years, about half of this is taken up by research activities before licensing of the drug, hence most new drugs entering the market have only about 7-12 years of effective patent life during which to recover the cost of drug development.
There is therefore a mad rush by mega pharma companies to get their products to the FDA finish line. Not many make it. Last year (2008) only 24 made it through. To regulate this R&D process and to make sure that there is global acceptance of the data generated by these rushing mega pharma companies, the clinical trials are 'regulated' by a series of harmonized dos and don'ts called the Good Clinical Practice (GCP) guidelines. There is a global set that has been harmonized by the International Conference on Harmonization (ICH). Singapore has a set that had is based heavily on the ICH-GCP document.
These guideline do give some comfort that the human experimentation that occurs as a result of the need to do clinical trials is to a large extent highly regulated. Even in Singapore. In Singapore, the Health Product's Act covers all such activities and the Health Science Authorities is the delegated authoritiy that approves the conduct of all clincal drug trials. Every investigator that is involved in clinical trials need to be trained in GCP. Every institution/hospital involved in clinical trials needs to have an instituional review board (IRB) which will provide the ethical review for all protocols.
All this looks very nice and comforting. As usual in Singapore, when we want to tell the world we are 'world class' we make sure that we have all the bases covered. At least on paper, lah....
Let me tell you what I have been concerned about... (and I hope the Ministry of Health are listening here)
a] Despite the existence of IRBs in all the restructured hospitals, not all the IRBs function at the same level of professionalism and competence. This gets worse outside of the restructured hospitals. There is no mandated 'training' or certification of IRB members so we do not know how competent or committed IRB members are in reviewing the clinical trial protocols. Most are just 'arrowed' to do the work, without any proper recognition of work done. To make matters worse, none of the IRBs are ever audited to make sure the processes are as intact as people assume they are.
b] Investigators(consultants,professors etc) are supposed to undergo training and be competent in GCP. But the only institutional expectation at both SingHealth and NHG clusters are only for them to be certified through a nominal online certification programme run by the Collaborative Institutional Training Initiative (CITI) (this one, anybody can pass...!!).
c] The IRBs never ever audit the clinical trials done in the hospital unless some shit hits the fan.
d] The HSA never ever audits any institution to see if they have the processes in place, and if they are actually compliant with whatever they say they are doing. I think basically HSA would rather not know.
e] The clinical trial units that do human experimentation are never audited, and there is no mandated certification of the facilities, so we can only assume that these units can handle emergencies and and manage the subjects if anything goes awry.
So do I have much faith in the environment that has been set up in Singapore so that we can play in the big league? Sadly, no. That we have not had a major incident here is probably more due to good fortune, than any good organization.
So do the investigators do what they say they are doing? Who knows? Does anyone really know what is happening? I have my doubts.
Tuesday, May 26, 2009
Prof Thio's speech in parliament was report in today's TODAY:
Prof Thio argued: “Secular fundamentalists are oppressive where they seek to mute religiously-informed convictions in public debate.” They do so “by demonising a view as religious in attempting to make religious faith a cause for embarrassment, or to distract citizens from the merits of an argument by discounting a speaker whose values are shaped by a religious” faith. Such militant secularism is “a recipe for social disharmony”, she added.
Actually, she's right. The environment for public discourse at the moment seems to me, a little lop-sided. One one hand, views based on religious convictions are easily demonized and discounted because of the religious affiliations of the proponent, while the opponent camp is relatively free to scream foul at every turn of the debate. I can understand and accept this if the secular voices are un-organized and free roaming, but if the secular views are part of an orchestrated chorus, shouldn't they be subject to the same criticisms and scrutinies levied against religious groups? I mean, isn't organized secularism just another religion?
I have raised this issue previously, independently of Prof Thio (whom I am not acquainted with at all), but it appears that she is voicing similar reservations that I had.
Sunday, May 24, 2009
Prof Kong's response says a lot but actually says nothing much that we don't already know. ..that NUS looks very good on paper, when the right parameters are used. This is because NUS has a strategic approach based on certain metrics that will do well in ranking exercises. The fact that when the ranking metrics are altered, ranking falls so precipitously suggests a lack real 'health' in the system. I have posted recently on the management by metrics approach that many organizations take nowadays, and this is really what is happening here. So little of what Prof Kong says reflects on the NUS real commitment to teaching and training. Recruitment of new staff is fundamentally based on the research accomplishments rather than on a passion for students and teaching.
For professional schools such as engineering and medicine, this will result in sub-quality practitioners and professionals produced by the schools.
My suggestion to NUS....and NTU as well....get away from these artificial metrics and go back to basics about your strategic directions as a university. By all means recruit people who are good academics but please make sure they are also good teachers, and are people who have a heart for students.
So why this continuing alert that refuses to go away?
I suspect it is largely due to our being locked into the SARS frame of mind. Dr Margaret Chan's perception of the 'pandemic' has been framed largely by her extensive involvement with the SARS situation. Likewise, following upon SARS the global pandemic management processes are largely geared towards preventing a pandemic worse than SARS.
So now the world (responsible countries of the world) are locked in step with the WHO, who has been super 'kiasu' about a SARS type situation, and now too 'paiseh' to step down too quickly because that would be an admission that it had overreacted. Now everyone is in a pseudo state of alertness, in the midst of a toothless pandemic, pretending to be frightened and fanning a panic that no one believes in.
It's not a very healthy situation. Day by day, I see staff at hospitals and various organizations going through the motions of being concerned, but breaking rules and bypassing procedures. Persisting with this false alarm just breeds complacency and sloppy attitudes towards infection control procedures.
It's really about time people just come out and say, quite honestly, that the sky isn't falling.
Friday, May 22, 2009
The report prompted me the consider if MOE did make a mistake in managing this...and if it did, why? I have no insider insight into the workings of MOE, but certain patterns of events (some would say lapses) that have occured in civil service suggests perhaps that some systemic problem might underpin these apparently unconnected dots.
I am probably overstepping the boundaries of my expertise, but it seems to me as an observer that management in the civil service and many of the quasi-government organizations (including hospitals or course, and the universities) now heavily adopt the management style that is based on meeting various metrics. This is what management circles sometimes refer to as 'management by metrics' . The advantage of this kind of approach is that certain goals are set, and the management performance can then be assessed through their ability in meeting these emprically set goals. The disadvantage is that many important strategic goals may not be easily codified, and therefore can only be indirectly identified as a performance goal. Management then becomes artificially and wrongly fixated on delivering with respect to these proxy goals rather than the true goal (uncodified). (Read related posts on the Giraffe's neck.)
Take this sexuality education thing.
We all agree that sexuality education is important and long overdue. MOE sets goals to implement sexuality education. Timelines are set (checked). Get the vendors (checked). How many teachers do we need? (checked). Is there a curriculum? (checked). Anyone vetted? (checked). Which schools? (checked).
Yay!! Great work guys! Right on schedule! Somebody give the man a Tiger!
What could not be codifed were the softer issues like, content, appropriateness, acceptability, parent's buy in... So these don't appear on the radar screen.
So did MOE cock-up? I leave it to you to figure out.
Suffice to say we need to be careful about managing by metrics. Because efficiency isn't all there is about management. It's often really not just about how fast and expedient we are in getting to our goals.
Thursday, May 14, 2009
Really, Dr Satku?
I think the good doctor meant well in defending his Ministry, but I think he is way off wrong.
Infections occur all the time, and being contagious have always spread through the community in some way or other. This is the way the community builds up 'herd immunity' to bugs. We are not talking about some serious illness, or devastating infection, rather in this case, a viral infection that has way less bite than the seasonal flu.
Dr Satku, in case you haven't noticed, we don't live in a sterile bubble.
Whatever we may often criticise the gahment for, I must admit that at the crucial moments, they have been able to step in and provide the calming leadership that is required. This has been one such occasion. So I applaud the government for the very even handed way that they have now dealt with this issue. There have been a couple of slaps on the wrists where they have been needed, but I don't think anyone would dispute that they were justified. I don't think anyone would be shouting 'referee kelong'.
But here's a thought worth pondering....I think.
We don't really want religious groups muscling into what we perceive as public space, and imposing their views on a secular activity (really? how about schools and hospitals? But I digress....). The public reaction against the perceived Christian takeover of AWARE was very clear even though it was really not a church-backed 'takeover', rather one that was coordinated by a group of like-minded people from the same church. But the message was unmistakable. But how about if so-called secular groups like AWARE were taken over by a group of like-minded activists of LBGT leanings? Shouldn't we be equally concerned?
Wednesday, May 13, 2009
They make good points. Essentially we need to rethink how health care needs to be provided. They are right in that most health care is provided at the primary level, which do not really require doctors (why else is the chinese sinseh market florishing? :) ).
They sa, "There IS a shortage of health care services being provided, but many of them are not best offered by a doctor. "
In Singapore, the problem is compounded by the way we train our doctors. Correctly we should be training our doctors to meet the needs of the public most of whose problems are best solved at the primary level. In the present rush towards academic excellence, the medical schools position themselves more as a research insititutes than practitioner schools. Medical students' expectations are inflated to think of themselves as cutting edge clinical researchers etc. Most are pushed into expecting lucrative careers as medical specialists. Is there any wonder that there is a 'shortage of doctors'?
In fact this 'shortage' is only relative. There is a surfeit of specialists in Singapore, whose eyes are focused on the revenue that foreign patients bring. Consequently few want to do the kind of job that they have taught to look down upon. Sad isn't it? No one wants to be the humble GP anymore.
I have posted on the need for another medical school before. Do we need one more? Yeah. No doubt about it. But we need one that can be clear about its mission to train doctors to be good compassionate practitioners of their craft. Physicians who do not think that providing basic care is beneath them.
Firstly, there was the opinion piece by US Bureau Chief Chua Chin Hon about "Rethinking MNC Strategy". (You can't find it on Asia1 without subscribing, but can find in The Malaysian InsiderOne frequent point of contention among analysts is whether Singapore was right in aggressively courting foreign multinationals instead of nurturing home-grown industrial giants as South Korea and Taiwan did. Over-reliance on foreign companies, critics argue, leaves Singapore vulnerable to economic downturns and political changes elsewhere — two factors that now loom large." :))The essential thrust of his insightful commentary was whether Singapore needed to rethink the national strategy of attracting MNCs, a strategy that has succeeded since the 1960's. In the article, he says, "
Secondly, Professor Jackie Ying, one of the big whales caught by ASTAR, was interviewed as saying Singapore should be focusing on developing dolphins rather than just drawing in the whales. Hor him, whales tend to be migratory and do not stay. Dolphins are helpful, seldom migrate and tend to stay. He was of course refering to world class researchers and academics. Many of the big whales caught by A*Star tended to make a big splash, contributed little locally and quickly made an exit, especially when times grew difficult.
Thirdly, there was that facile ranking of universities done by Quacquarelli. In the ranking of Asian univeristies, the National University of Singapore, floundered miserably at a pathetic position of 10. Let me say I am not one to take these rankings seriously, but the ranking fluttered more than a few eyebrows, and I am sure some senior people at the NUS must have convulsed frothing at the mouth. Managing Director Nunzio Quacquarelli said the results of the Asian University Rankings focus on regionally relevant measures of excellence, with the top performing universities distinguished not only by quality, but also by high productivity of research, compared to their regional peers.
What the three threads said to me was really that there is a clear recalibration in our thinking about our Asian position vis a vis the traditional ideas of Western leadership, whether this be about economics, academia or education. It has always struck me as strange that while Singapore's success was really a product of Singapore's unique leadership style and ideas, when it came to academia, we submissively sacrifice local efforts to the perceived dominance of Western academics. This is a mindset that seems to be uniquely Singaporean, because other Asian countries tend to have a bit more faith in their own home grown abilities. The Quacquarelli ranking may be disputed for years to come, but I think it has pointed out one very important thing to us, and that is, we are in Asia, and if we look at ourselves with Asian eyes, we are not as great as we pretend to be on the world stage. One could of course argue that we play on the world stage and not just Asia, and that would be true. But as the centre of gravity shifts towards Asia, we need to be careful we don't get flatfooted though our over emphasis on following the West.
Sunday, May 10, 2009
In truth, even at 74% satisfaction (or poor bottom place CGH at 66%), it is actually not too bad. Not that I am advocating complacency and suggesting that no improvement is required, but simply that patients and relatives are by and large, quite difficult to satisfy.
What is interesting, and also important to note, is that patient satisfaction does not seem to parallel the amount of investment the hospital put into developing technology, or providing services. I had a recent experience of relative who had been diagnosed with cancer, and I must say I was pretty peeved at the service she received. Yes, there was electronic medical records and transmissibility of information across hospitals, and all kinds of technology access etc, but the common touch that showed the doctor(s) actually cared for the patient was glaringly missing.
This I believe is something the hospitals need to pay special attention to. Increased technology, impressive glass and steel only increase health care costs. Overall patient satisfaction probably can only improved through proper staff training and change in mindsets of our healthcare givers. Let me say that by and large many of our healthcare givers are committed caring individuals.....otherwise the patient satisfaction cannot be 'so high'. But there is a distinct population of relatively inexperienced and poorly trained/motivated staff which drag everybody down. This is where the hospitals need to place their emphases on.
Thursday, May 7, 2009
It's a very good question. Scientists everywhere are working round the clock to develop a vaccine against the virus, but here is the virus, relatively mild, going round the block, and we try so hard to prevent it from infecting people when that innocuous infection will clearly build up an immunity against that very virus.
So did all our overzealous health authorities overdo their pandemic hysteria and miss an opportunity to innoculate the community and produce immunity against the virus?
Methinks ....yes. Even though the US CDC says it's a bad idea. Maybe because the pharma industry won't make any money from a naturally occurring vaccination programme.
Wednesday, May 6, 2009
Well...finally we are starting to stand down. Kudos to the MOH for taking this brave decision. It was an over-reaction, but perhaps a necessary one. Being able to recognize it as such is critically important to avoid as Minister Khaw pointed out, 'flu fatigue', or being seen as 'crying wolf''.
In TODAY today, there is a reprint of an article from The Guardian entitled 'There is No Known Antidote for Panic' by Simon Jenkins, which raises some interesting issues. Suggest you go read it.
In a free market world there are all kinds of lobbies out there which have less than noble missions. People want to sell newspaper, medicine, medical equipment, thermal scanners....I think you have gotten my point. People actually have vested interests in fanning a panic, in this case a pandemic panic. Think of the masks seller, thermometer sellers, thermal scanner sellers....and the Tamiflu sellers? Not to mention the research labs trying to get research grants to make vaccines against the flu virus that keeps changing its disguise?
It's hard to separate truth from chaff nowadays.
Breaking news from Asia1
(snipped and pasted from Asia1)
MOE has examined AWARE's "Comprehensive Sexuality Education: Basic Instructor Guide". The Guide contains some positive aspects, like the accurate information provided on STIs/HIV and role-play practice for students to say no to sex.
However, MOE's assessment is that in some other aspects, the Guide does not conform to MOE's guidelines. In particular, some suggested responses in the instructor guide are explicit and inappropriate, and convey messages which could promote homosexuality or suggest approval of pre-marital sex.
In view of this, AWARE's programmes in schools will be suspended and subjected to the new vetting processes.
Monday, May 4, 2009
There has been only one death outside of Mexico, and it looks like the infection is not even as deadly as the seasonal flu. People are starting to react very negatively to what they perceive as unnecessary restrictions, which seem more and more like symptoms of a severe infection of the 'kiasu'-bug.
Was the global reaction justified? Yes, I think so ..... initially. But as data accumulates, the reaction looks less and less appropriate. People are beginning to complain, and are becoming less and less convinced about the necessity of all the quarantine, screening and travel restrictions. The various governments, including Singapore, should be very careful not to let this public cynicism get out of hand. They should be brave and decisive enough to say 'enough is enough'. Cukup, lah.
This so called pandemic was a false alarm. Let's pack up and go home. Sure, the virus may surface in a more virulent form. But the H1N1 was always threatening to do that anyway. Nothing new about this virus. Various strains of H1N1 are already among us. This recent strain is not any different. Heroic attempts in keeping out this very mild virus isn't going to reduce our chances of having a serious (real) pandemic in the future. In fact letting this virus circulate may in fact create a stronger herd immunity against a future more virulent reassembled strain of H1N1.
There are dangers in crying wolf.
Saturday, May 2, 2009
Was it ever an pandemic? Yeah, I think so. It quietly became a pandemic when human to human spread was demonstrated outside of Mexico. But I think everyone is fast recognizing that virus isn't as problematic than what had been anticipated. Not that it would not later mutate into a greater evil, but for the moment it seems as tame as a pussy cat.
Over reaction? Most definitely, but with the wisdom of hindsight. Better safe than sorry? Possibly. But the problem is that with each false alarm, people begin to take it less and less seriously.