Miracle of birth

As we approach the date when all Christians spuriously celebrate Jesus' birthday (since no-one really know when that really was), here is an amazing MRI recently taken of a baby at the moment of birth!

Using a Phillips open high-field MRI scanner, the doctors at Berlin's Charité University Hospital, captured this amazing image.

Have a blessed Christmas, one and all!

Struggling with mid life disillusionment...

As fellow blogger Singapore MD struggles with disillusionment, I came across this interesting article in The Economist entitled "The U-bend of life". The article is well worth a read.

Apparently, contrary to general perceptions, old people are happier, and get happier as they age.

"When people start out on adult life, they are, on average, pretty cheerful. Things go downhill from youth to middle age until they reach a nadir commonly known as the mid-life crisis. So far, so familiar. The surprising part happens after that. Although as people move towards old age they lose things they treasure—vitality, mental sharpness and looks—they also gain what people spend their lives pursuing: happiness."

So the bad news is if you are heading towards middle-age, things may get a whole lot worse before looking up again. The good news however, is that it will get better!

Nigerian frauds and big pharma.....

One normally associates Nigerian frauds with those sob story emails that you get from time to time, but the recent Wikileaks exposés showed up another kind of fraud that happened some time ago in Nigeria.

Back in 1996, there was an epidemic of meningitis in Nigeria, and big pharma Pfizer, with a new antibiotic trovafloxacin (Trovan) in hand, seized the opportunity to conduct a clinical trial on Nigerian children who came down with symptoms of the disease. All well and good except that the study did not receive ethics approval as was legally required under Good Clinical Practice. Pfizer claimed the study received approval to proceed, and an approval letter was produced supposedly from the ethics committee. The trouble was that there was no such ethics committee at that time. The lead investigator of the trial, Dr. Abdulhamid Isa Dutse, subsequently admitted that the letter could have been drafted 1 year after the study started and then backdated.

If this is true, this is fraud, plain and simple. Clinical trials fraud. Pfizer has however denied culpability and Dr. Abdulhamid Isa Dutse apparently is now the Chief Medical Officer of the Aminu Kano Teaching Hospital.

Strange.

The incident would have been consigned to the history books if not for the recent Wikileaks revelations, which pointed a finger at Pfizer trying to manipulate legal proceedings by uncovering unsavoury details about corrupted practices by Nigerian Federal Attorney General Michael Aondoakaa, so as to pressure him to drop the legal suits against the company.

If these revelations are true, they do show that even big companies who are supposed to be ethical are not above playing dirty. More recently, some more Wikileaks exposés, this time about New Zealand, show the shadowy hand of big pharma in trying to unseat Helen Clark who was Health Minister at that time.

I hope our Singapore government can keep big pharma at arms length. Sometimes I feel they have become to close to big pharma because of the need to cultivate their engagement in our attempts to grow the life sciences and biomedical industry. They have to be careful not to let big pharma have too big a voice in shaping our national strategies.

Quote of the year

This is the first time I am posting a "quote of the year", but the opportunity is too good to pass.

"...as they say in the countryside, some people's cows can moo, but yours should keep quiet." Attributed to Russian Prime Minister Vladimir Putin.

Why is suicide a crime?

Which leads us to the question of why suicide is a crime. Not being anywhere close to being the smartest person in the world, I can only reproduce an excerpt from Cecil Adam's "The Straight Dope".

"Views on suicide have varied widely, both historically and culturally. Certain Asian societies not only haven't condemned suicide but have sometimes expected or even rewarded it--Japan is the obvious example, with its tradition of hara-kiri, but by no means the only one. Consider the Indian practice of suttee--before the British outlawed it in 1829, an average of 500 widows immolated themselves in their husbands' funeral pyres each year, and were often regarded as nearly divine for doing so.

The ancient Greeks and Romans tended to take a practical view of suicide. Most philosophers accepted that there were circumstances in which it was honorable--for example, to save the lives of others, or as a protest against tyranny. Judaism traditionally forbids self-destruction, but nonetheless many Jews continue to mythologize the mass suicide at Masada, where 960 are believed to have killed themselves rather than surrender to the Romans. Early Christians were even more ambivalent about suicide, as you might expect from followers of a religion founded on martyrdom. Virgins who preferred suicide to dishonor were also celebrated, and at least one, Saint Pelagia, was canonized. Islam alone among these three faiths has a clear scriptural ban on suicide, but as recent events have made plain, that hasn't prevented certain zealots from arriving at permissive interpretations thereof.

The Christian opposition to suicide hardened starting with fifth-century theologian Augustine of Hippo, who argued that offing yourself is never justifiable because it violates God's injunction "thou shalt not kill." Suicides were deemed to have committed a mortal sin and denied Christian burial. Church law influenced civil law, and by the tenth century suicide in England was considered not just a crime but a felony. English common law distinguished a suicide, who was by definition of unsound mind, from a felo-de-se or "evildoer against himself," who had coolly decided to end it all and thereby perpetrated an infamous crime. Such a person forfeited his entire estate to the crown. Furthermore his corpse was subjected to public indignities, such as being dragged through the streets and hung from the gallows, and was finally consigned to "ignominious burial," as the legal scholars put it--the favored method was beneath a crossroads with a stake driven through the body. Other European states established similar laws, apparently hoping they would serve as deterrents. As time went on the punishments lessened. By the 17th century an English suicide forfeited only personal property; his heirs could still get his real estate. But the basic notion of suicide as a crime wasn't swept away in France till the revolution, and in England it took even longer: ignominious burial wasn't abolished until 1823 nor property forfeiture till 1870, and the deed itself remained a crime (albeit only a misdemeanor, and a rarely prosecuted one at that) until 1961. In many jurisdictions you can still be prosecuted for helping someone kill himself, and assisted suicide remains a hotly debated topic not just in the UK but in much of the world.

In the U.S. suicide has never been treated as a crime nor punished by property forfeiture or ignominious burial. (Some states listed it on the books as a felony but imposed no penalty.) Curiously, as of 1963, six states still considered attempted suicide a crime--North and South Dakota, Washington, New Jersey, Nevada, and Oklahoma. Of course they didn't take matters as seriously as the Roman emperor Hadrian, who in 117 AD declared attempted suicide by soldiers a form of desertion and made it--no joke this time--a capital offense.

— Cecil Adams"

Singapore obesity and the BMI

The recently completed National Health Survey showed a jump in the prevalence of obesity from 6.9% in 2004, to 10.8% in 2010. Strangely I can't find the report of the important survey online. Since it is unclear what the definitions of obesity here are, I must assume the survey used the WHO internationally accepted definitions of a BMI cut-off of 30 kg/m2. Between 25-30 kg/m2, you would just be overweight.

(You can check your BMI here.)

The problem with this definition is that Asians and women have greater percentage of body fat for any given BMI. What this means is that we are more 'obese' than we think by applying international (mostly Caucasian) definitions.

Regular exercises reduces primarily body fat and reduces( improves) the BMI. However, weight exercises which bulk up muscle tissue may artifactually increase the BMI.

Bisphenol-A - time for AVA to review?

Bisphenol-A has now been banned from all baby bottles in Europe. This stems from the increasing concern about the safety of the chemical that is found in hard plastic bottles.

There have been bans in Canada and Australia, and a few US states. The US National Toxicology Program (NTP) had issued a report in 2008 expressing 'some concern' about "effects on development of the prostate gland and brain and for behavioral effects in fetuses, infants and children". earlier this year, the FDA came round to the position that there was also "some concern" on their part.

Meanwhile our AVA has been silent about this problem.

IVF errors, or negligence?

So it has now been revealed that not only the Thomson Medical Centre was sloppy, but the Gleneagles IVF and the O&G Partners Fertility also did not follow procedures. They did not comply with procedures, and did not provide for a second operator to counter-check.

I don't know..... to my simple mole-mind, this doesn't really qualify for a procedural lapse, or human error. Smacks of negligence to me.

Seems to me that we haven't taken such clinic audits and licensing seriously enough.

IVF "lapses"

I must say I was disappointed that the MOH could not bring itself to go beyond just identifying "lapses" as being the causes of the error. Though it's kinda expected. It doesn;t say very much. We all know that accidents are due to lapses.

What we want really to find out is why those lapses occured. Was there a systemic problem that increased likelihood of lapses. Were the quality assurance procedures adequate? Were there previous audit findings that were not remedied? Were weaknesses in the system identified before but left unattended to for too long?

Human error can often be the consequence of systemic failures.

Patient Assisted Suicide

Last month, the SMA News carried an article by Drs Jacqueline Chin and Jacinta Tan about an ongoing research project in the NUS Centre for Biomedical Ethics to study attitudes on "end of life decisions". Such research is critical, as are healthy open debates on these issues. Hopefully, these will pave the way to sound decision making about euthanasia and the related practice of patient assisted suicide.

Personally though I am not hopeful. Attitudes here are relatively conservative and too 'kiasu' about the sliding down the slippery slope. Public opinions are constrained too much by sensitiveness towards perceived religious values. This is not wrong. But it does limit our options to be "progressive".

Let's see what happens.

For those who are interested, you can contact Drs Chin and Tan at: Dr Jacqueline Chin or Dr Jacinta Tan at EOL.Decisions2010@gmail.com.

I was horrified this morning to pick up the Straits Times and read those incredibly racist remarks about racial profiling by Dr Lee Wei Ling.

Really unexpected. And surprised that the newspaper allowed that through.

I wonder how she would feel to be on the receiving end of some really negative "racial profiling". And how she would go about "racial profiling" our ethnic groups here in Singapore.

C'mon Wei Ling, you're way wrong about this.

'Nuff said.

Euthanasia #9 - quo vadis?

Watching a loved one die an agonizingly slow death from terminal ovarian cancer is not the best way to pass a Sunday afternoon. She has said her goodbyes and now waits patiently for the end. Everyday her body wastes away.... literally rotting away before our eyes. Her body autocannibalizes itself...and the bugs begin to have a go at the rest. Yet she still breathes, blinks....and gasps meaninglessly.

We had some debates about euthanasia 2 years ago after Minister of Health floated one of his balloons on the subject. Since then there has been no progress on the idea. The idea seems to have died a natural death. Almost as soon as the idea was floated, it seems.

What gives.

Investigating aviation errors and IVF mistakes - a fair comparison?

Minister of Health Khaw Boon Wan made an interesting reference to the investigation of aviation errors while commenting or the recent IVF mistake which occurred at the Thomson Medical Centre.

He said: "Like the health sector, the aviation sector used to approach safety and errors through a largely fault-finding approach. When a plane crashed or hit a problem, the first question was to nail down the culprit: who was responsible, was the pilot at fault, was the engineer negligent etc? This used to be their approach a decade or two ago.

But they have since moved away from that approach. Instead, they took a system approach. Each time an adverse event occurs, they will conduct an objective and thorough investigation, not to witch hunt, but to identify the causes, especially if there are systemic flaws. Because they moved away from fault-finding, everyone was open in their comments, resulting in a speedy and accurate assessment of the true situation. Under the previous approach, the tendency was to protect one’s interest, resulting sometimes in cover-ups and the truth became elusive."

It's a very enlightened approach, and one to be applauded, although at some point in time there needs to be some accountability and someone has to take responsibility for not putting in place adequate measures to prevent errors. The MOM comes in hard for employers who put their workers in jeopardy by being negligent in not ensuring adequate workplace safety. In our research laboratories, the principle investigator faces a possible jailable outcome should lab safety measures be violated, or he has been negligent. Should not we expect the same rigour when medical professionals are negligent in situations such as this?

But I digress. The real purpose of this post is to explore the appropriateness or lack of, in the comparison with the investigation of aviation errors.

Avoidance of fault finding and cover-ups are two faces of the same coin. Often breakdowns in the integrity of a system/process extends beyond the party holding the smoking gun. If an error occurs in the regulatory functions, this would be less likely to be flagged out if the investigating team comes from the regulators themselves. In the investigation of aviation errors, to avoid this conflict of interests, an independent body forms the investigating team. Only thus, can the true extent of errors be discovered. If the investigating team is formed by the regulator, it is more than likely that a "fault" will be found only in the party in possession of the smoking gun.

In this instance of the IVF error, the investigating team is the Ministry of Health team. Yet it is the Ministry of Health which audits and regulates this industry. How can the Ministry then identify weaknesses in its own audit/regulatory systems covering the IVF facilities which allowed high likelihood of errors such as this to be committed? This is uncertain.

Should we not require some sort of pre-implantation diagnosis of paternity to be documented as validation of the integrity of the process before the embryo is implanted? Doing so will at least ensure that at the very least, there are no costly mistakes beyond the irreversible step of implantation.

Perhaps the Ministry of Health could consider releasing the last audit findings of Thomson Medical Centre so that the public can gauge if the audit was done with the stringency we expect, and/or the facility failed to act of recommendations.

As the Minister pointed out, this should not be to find fault but to enable everyone to correct all the deficiencies of the system. Following which, we can move on.

Happy Deepavalli!!!

Organ trade tenesmus in Malaysia

Malaysia is for living unrelated donors....., or not?

First it was reported that Minister of Health for Malaysia Datuk Seri Liow Tiong Lai said his Ministry was looking at improving the National Transplantation Act which was being drafted to serve as a guideline on unrelated live organ donations.

He said the new law would enable the authorities to monitor live organ donors which at present were encouraged for only family members and relatives of patients.

"We have to be careful because commercialisation of organs is a big problem. The selling and buying of organs is against human principles and not ethical," he said, adding that if non-relatives want to make live organ donations, it should be out of sincerity and not for monetary gains.

Sure sounded very much like Singapore's position a year or two ago.

Then almost in response, the Health Director General Tan Sri Dr Ismail Merican in the 4th November New Straits Times, was reported as saying, "Malaysia is against living unrelated donors donating organs because of the risk of organ trading and trafficking...... If living donation is to be carried out, it should come from genetically, legally or emotionally related donors."

Hmmmm..... a bit of tenesmus there.

Singapore, by the way passed a law allowing compensation of organ donors, effectively allowing living unrelated donors to receive compensation for donating their organs. Not sure if it is just engaging in semantics to suggest that this is essentially organ trading.

What is needed now after more than 18 months of this law, is for MOH to update us with respect to how many such unrelated living donations have been effected, and the details of such donations. One of the major concerns had been the exploitation of poor donors from neighbouring countries, and servicing of wealthy recipients who are no citizens. It would be really nice and reassuring if the MOH to tell us what the numbers are, and how we are actually monitoring/regulating the situation.

Thomson Medical Centre - suspension of assisted reproduction activities

Well done, MOH!! The Thomson Medical Centre has been whacked with a suspension following the IVF mix-up. Iwould have prefered that the suspension had been immediate upon news of the mistake, but better late than never.

What is further required is a full and proper audit of all IVF facilities to ensure that procedures are not only in place, but that centres are in full compliance of procedures. In addition, regular annual audits should be implemented, perhaps with a way to monitor outcomes... for example routine genetic screening of babies to ensure babies are who the centres say they are.

Singapore's "first" IVF mix-up?

In the process of being taken over by billionaire Peter Lim, the Thomson Medical Centre gets this unexpected bombshell - a dreaded mix-up in the IVF procesure where the mother's egg had been apparently fertilized by the wrong sperms!

Previous posts had highlighted this error and asked for clarity on this issue with respect to the local situation. Now this dreaded error has been reported in Singapore. It is no comfort to say that the risk is very low. A single accident is one too many already. Patients deserve better.

There needs to be more public assurances about the practices procedures and processes in place that will prevent accidents of this sort.

I think a public 'fessing up of what actually went wrong is needed. Dr Cheng LC of Thomson Medical Centre was quoted to have said: ... the centre's operating procedures "meet all regulatory requirements, and are of the highest international standards".

All very vague. Just what are these regulatory requirements? And are they adequate?

The Ministry of Health should tell us how the various IVF units fare in terms of the procedures and procedural compliance. Or are they never ever audited?

The NTU-Imperial College Medical School

So it's out in the open now, as NTU and Imperial College London signed an agreement to form Singapore's 3rd Medical School. Target is 150 students, which is quite substantial compared to the current 250-300 at the NUS Medical School.

Prof Stephen Smith is the Founding Dean designate for the new school. A gynaecologist, Prof Smith was the Principal of the ICL in 2004, and subsequently also became the Chief Executive of the Imperial College Healthcare NHS Trust.

The formation of the 3rd Medical School is being watched with considerable interests from those who have been involved with medical education in Singapore. How will it differ from the approach NUS had taken? So far the leadership have been saying all the right things. Exploiting existing strengths in engineering and business, the new Imperial College London-Nanyang Technological University Medical School (ICNMS), will focus on training good doctors "equipped for tomorrow's challenges".

All nice words.

Many are hoping it will not fall into the same trap that the other medical school did by over-investing in the clinician-scientist mission. No doubt we need clinician-scientists to fuel the biomedical industry, but this should not be the main mission of a medical school. Singapore needs good caring doctors who can look after patients - not doctors whose primary mission is to serve the biomedical industry. Many have felt that the NUS Medical School had so over-reached itself to pursue the research agenda that the medical mission had been severely compromised.

If the new ICNMS remain true to the educational mission, the worrying outcome may be that many committed medical educators may decide to jump ship for a school environment that is much more aligned to medical education and the training of good doctors.

Death blow to the idea of gene patents

Finally!

In a landmark ruling, the US government has finally come out to declare that patent genes are not legal. This is the tail-end of a struggle which began earlier this year with Myriad Genetics claims to the breast cancer genes BRCA1 and BRCA2. No doubt Myriad will appeal the ruling. And they have a lot of muscle on their side, given that another 2000 or so genes are also under patent cover elsewhere, with an industry worth billions of dollars at stake. Also covered under the ruling are diagnostic tests based on gene sequences.

This blogger cannot be more pleased with the ruling.

Hopefully it may also recalibrate the research funding towards more understanding rather than just chasing after patents and the fast buck.

Lilly Singapore Center for Drug Discovery gets the chop

In 2001 the EDB inked a deal with Eli Lilly to set up a research facility for systems biology in Singapore. Along the way the systems biology bit was morphed into a Center for Drug Discovery. Now after 8 years, Eli Lilly has given the Center for Drug Discovery the chop. About 130 jobs will be on the line, although it is not clear how many of these jobs are local jobs, and how many are 'foreign' talents.

The EDB has a mission to bring in big names to 'buzz up' the local R&D environment. For this it has been given a fairly massive war chest. The strategy appears to be to throw money at big named companies to entice them to set up research facilities in Singapore. Create a buzz, has been the buzzword. Eli Lilly was not the only company to have tasted of these low lying fruits. Now after sampling these fruits for 8 years Lilly has decided that it is better off elsewhere, especially after the EDB grants wear off.

I am personally not so convinced of the EDB's strategy to just throw money at these companies for dramatic short term buzzes. I am unsure how much real benefit follow from such extravagance. A high end research facility employing how many locals? Did the research facility really benefit the local research environment; really result in long term enhancement of the local research infrastructure? I am more than skeptical. The money could have been better spent developing real quality in home grown efforts. Methinks this would have had more enduring effects than the printing of glossy annual reports.

Who audits the EDB, I wonder?

Prof Su Guaning steps down as President of NTU

So after 8 rather tumultous years, Prof Su Guaning steps down as President of NTU.

It seems not to have been an easy time for him managing the transition between the past and the future. I guess it never is. But NTU has always seemed like it lacked the ability to learn from the 'mistakes' NUS made during her transition. It had clearly been a painful process for the NUS, and NTU proceeding half a step behind could have avoided some of the pitfalls that NUS appeared to have made, but somehow it did not, and in the process, generated a lot of unnecessary heat and heartaches.

Not a good thing when you want to cultivate supportive alumni.

So I wish the new President, Prof Bertil Andersson all the best, though I am not too hopeful as he seems to have developed a reputation for being far more brutal and cold in his approach towards academic excellence; perhaps good for university rankings, but not necessarily best for students and staff.

Do we need to be concerned that 3 out the 4 local universities have foreign Prezzies? Nahhh....It's not a big deal. Locals are not necessarily more considerate of local cultures and needs, since they can be just as cold and heartless in their pursuit of institutional KPIs.

I am actually far more concerned that all 4 of our varsities have missions to be at the top of their league. This is not necessarily a bad thing, but it means we will have no universities that cater to the average students who do not necessarily want to be Nobel Prize winners. Take for example, the medical schools we have. If all of our 2 + 1 medical schools strive to train clinical researchers par excellence, then who will train good doctors; doctors who care, but do not necessarily win academic awards, and chase fame and fortune?

Road hogs and tailgaters

Intrigued by a report in today's Straits Times, I googled "road hog"to find out what it actually referred to. Three possible meanings popped up:

"A motorist whose vehicle overlaps the traffic lane used by another motorist."

"a selfish or aggressive driver"

"a driver who obstructs others"

Clearly there isn't much of a consensus here, and the derogatory term could just as well refer to the tailgating speedster on the fast lane or to the guy who refuses to speed while on the fast lane of the expressway. Both have a right to be there, but the tailgating speedster is more likely to be breaking the law. The guy who is keeping to the speed limit is really not breaking the law; after all, where can he drive if he keeps at the speed limit? The middle lane is really going too slow. It seems unreasonable to expect that he should be the one who bears the burden and risk of continually changing in and out of the fast lane so that Bob (see above) can have his religious experience.

Mdm Kwa Geok Choo, requiscat in pace

No doubt she was the pillar of strength behind MM Lee, but I think Mdm Kwa truly distinguished herself in not doing the one thing that many women in her position are most prone to do, id est, self-aggrandizement.

My heart goes out to the family.

Mdm Kwa, requiscat in pace.

Mammograms? Much ado about not much, apparently...

A new study published in the New England Journal of Medicine once again has debunked the exaggerated benefits that mammograms produce. Not much, apparently. Have to screen 2500 women over 10 years just to avoid one death. This is not even considering the numbers of unnecessary screening, false positives and needless surgeries.

But I am not surprised.

When mammograms were first introduced, it was really difficult for anyone to refute the arguments that more screenings mean more lives saved. Of course in the process, more sales of mammography machines, more money to screening clinics and more money to breast surgeons. All happy, of course.... except the women who had to undergo needless breast surgeries. They were a small price to pay for the peace of minds of everyone else, apparently.

So now we know.

NTU down 101 places in latest best university rankings..... kept the eye on the wrong ball??

Changi Airport has apparently waltzed home with a whole barrage of best airport awards. This is kinda something Singaporeans have come to accept and to take for granted.

Singapore plays this game extremely well. I think it's something taught in the civil service school.... Best Awards 101 - "How to game the system". Almost every gahment and quasi-gahment organization picks up best awards galore, often by just astutely gaming the system. Doesn't matter what falls in the cracks, as long as the main checklist boxes score max points. Such training actually begins in school at a very young age, and schools, parents and students conspire ad work furiously through the year to pick up max points for all spheres of educational "excellence".

The universities play this game as well.

Once a while though, this gamesmanship backfires.

The Times Higher Education (THE) World University Rankings recently revised her ranking criteria to apparently deliver the "most rigorous, transparent and reliable rankings tables ever".

With a single stroke, our Nanyang Technological University fell 101 places to a pathetic 174th in the world. Our National University of Singapore maintained her position, just dropping 4 spots to 34th.

So someone in NTU now has a bit of egg on the face.... spending $$$ to restructure and game the system, only for the rules to change.

Is this a problem of not keeping your eye on the real ball...... going for the cosmetic rather than the substance.

Living to work.....or working to live?

I was one of those cheering MM Lee's comments about working,....and working on old age. Yay..! I don't want to retire....I love my work too much. I don't mind winding down as my brain neurones apoptose as I get older, but I do not really want to stop work altogether.

But I realize not everyone is as blessed as I am to be in a professional role that I enjoy.

You see, I live to work. As I am sure MM Lee does. If you live to work, it is not really work. You don't really want to stop working because only death will do that.

But many others (and I am sure they out-number people like me) who are not as blessed. These actually have to work in order to live. They do not have much of a choice. If they do not work, they potentially cease to live... Everyday I walk past the cleaners and menial workers who populate the corridors of the hospital, and I wonder if they share the same enthusiasm to not retire. To reach 55, or 60, or 65.... and to not see an end to this life of labour. A blessed existence? Hardly.

Surely we can have a society where we can be a bit kinder, and more gracious to those who have spent their lives struggling against a world that seems overwhelmingly stacked against them. Surely we should be able to say " Enough, uncle (or auntie),...enough, it's time for you to take a rest.".

But sadly, I don't think we have it in us.

Forgiveness and charity

Like all religious festivals, I am sure Muslims can also easily get distracted by the festival, and forget the religion. But I really hope not, because though not a muslim, I must confess to actually having a very high regard and yes, even love, for the Hari Raya spirit.

I love that the focus is on contriteness and forgiveness. Mohon maaf zahir dan batin. That gets to the core of all human relationships, doesn't it? None of the self absorbed wishes for wealth and prosperity. In fact muslims are required to perform the zakat (giving of alms) as part of their worship during this time.

It's a lovely time of year to cherish, even as our society moves along in her mad rush towards calculativeness, self-centredness and gracelessness.

Islamic contributions to medicine

It is easy in today's world, especially when anything Islamic is receiving such bad press, to forget how important the Islamic civilization was in the development of modern medicine. While medieval Europe languished in darkness, it was the Islamic civilization that carried the torch for medical education, research and practice.

While we look to Hippocrates as a 'father of medicine', it was probably ibn Sina (Avicenna) who should best be regarded as the 'father of modern medicine'. But sadly, we remember Hippocrates and too readily forget ibn Sina.

Few also realize that the idea of hospitals ( although the word derives from the hospices of medieval Europe), was most likely copied in idea and design from the Islamic centres of excellence. There was licensing of physicians and the hospitals were sophisticated, well organized institutions that were way in advance of what Europe had. It was probably the returning Crusaders who brought some of these ideas back to Europe.

The practice of medicine was held to a much higher standard of ethics than was in Europe. The treatise by Adab al-Tabib (Conduct of a Physician) is well known, though not by those of us with a narrow European perspective of medicine.

He writes:
'If the patient and the one who serves him understand, then the physician describes the remedies to them and allows them to go on with the therapy If it is not understood, then he must, with his own hands, undertake the treatment that is necessary; he (i.e. the physician) does not explain anything to (the patient). In maintaining silence as to the diagnosis for one who would not understand, in case of error, it is better for the patient and for the physician. After he has completed the visit to his patient he must return to the above mentioned office to treat any of the patients and to understand the problems.'

'The physician must better his relationship to and endure the distress of the patients. He must pay attention to any statement heard from them. No matter what the circumstances, he must acquire information from anywhere or anything which may prove beneficial to the recovery of the patient. The physician must not discourage any complaints of the patient or display of his distress since these symptoms which occur may be important in the diagnosis of the illness. The physician must show mercy; this is not possible except by the fear of God. If the physician has these traits, then he speaks only the truth and does good for all the people.'

We can definitely learn more than a thing or two from the Islamic civilization.

Selamat Hari Raya Aidilfitri

Hippocrates - relevant today? Or, perhaps not......

Hippocrates who lived almost 2500 years ago is pretty much accepted as being some sort of a 'father of modern medicine'. At least the Western model of modern medicine. After all our Physician's Pledge is heavily modelled after the Hippocratic Oath. Among other things, Hippocrates, or at least the Hippocratic school has been credited with moving the practice of medicine away from superstition/dogma towards one more based on careful observation, and the positioning of the patient in a holistic context where he has an integrated relationship with his environment and the physician who is managing his disease. This line of thinking actually grew out of a medical philosophy that prevailed in the island of Kos where Hippocrates lived, and is collectively called the Koan philosophy.

Few people are aware that there was also a alternate line of thinking at that time which was developing on the peninsula of Knidos, just opposite to Kos. The Knidean philosophy emphasized the disease, and took great pains to dissect out, and diagnose the disease. The Knidean approach therefore focused on the specifics of the disease and specialized therapies.

The irony is that today, while we imagine we draw our heritage from the Hippocratic (and Koan) philosophies, the reality is that our prevailing medical practices are far more aligned with the Knidean school of thought in that we are far more concerned about diagnoses, categorizing and sub-categorizing disease, and aggressive highly specialized therapies.

The idea that the patient is a person who lives in an environment with family and friends, is often forgotten. So is the idea that there exists a relationship between the patient and his physician.

We desperately need to return to our roots.

Does YLL SOM have anything to worry about?

$26 million loss at the casino - hard to feel sorry.

Try as I may, it is very hard to feel sorry for the businessman who reportedly lost $26 million at the RSW casino. There is no accounting for stupidity. Yet the report is indicative of the size of the social problem the casino foists upon us.

Is this the kind of society we want? The kind of money we want to make?

The cyclist vs motorist debate..... why is the LTA silent?

Yesterday's ST carried a surprising and gracious letter from a Mr Damian Evans....apologizing for some bad behaviour as a cyclist. Surprising because apologizing is not something we have come to expect in Singapore society.

Today's ST then followed with a letter from a motorist who was responsible for the incident.

It was an interesting exchange of views, which highlighted one thing for me. Neither was out to cause grief. Yet their encounter on the road resulted in a potential for conflict....or worse, for physical danger to one of them.

A major reason for this I belief is the lack of clarity of what is expected of cyclists' behaviour on the roads. Motorists are generally confused by signals being sent about how cyclists should cycle..... or not cycle. I know cyclist s who firmly believe that when they are on the roads they should cycle in the middle of the left most lane. They believe that this increases their profile and reduces their risk of being forced to the kerb or being hit by a car. To me this is foolhardiness, but this is what they believe. If cycling in a group, I have heard of cyclists being told by their group leaders that they should cycle abreast for the same reason.

Yet this is blatant violation of the law, which is explicit in forbidding cyclists from cycling abreast.

In all this time, the Traffic Police and LTA have been pitifully and disappointingly silent. Should they not come out and say clearly what is allowed and what is not? What is allowable and what not? Why are they so coy about this?

Clarity preempts conflict.... and hopefully will prevent unnecessary accidents.

When they do break their silence, they should also be explicit about what stretches of roads are out of bounds to cyclists....e.g. expressways, semi-expressways, overhead passes etc.

Did Corrinne May's "Song for Singapore" do it?

Not for me it didn't.

Lovely girl with great vocals. But it was too much lounge music to connect emotionally too. And it just lacked the confidence that it could actually be a true Singapore song. So it just too easily went for treacly nationalistic imagery.... Brothers and sisters flying flags together....? Give me a break.

Nope. It just didn't work.

The Kit Chan/Dick Lee song "Home" still worked. Though far from perfect, it had the common sense to stay away from imagery associated with "peace, and prosperity and progress for our nation" kinda stuff. Just simple things about home and family, and what Singapore really meant to all of us. Yeah, home is where the heart is. And of course the river, that unfortunately had stopped flowing since Marina Barrage. Thanks Kit and Dick for that song - one that will I am sure eventually become a classic Singapore song.

Oh, and by the way....someone should arrest the fella who designed Corrinne May's dress that evening.

HAPPY B'DAY SINGAPORE!!!

Impreza ploughs into 18 cyclists - or, why should you stick a christmas tree in the middle of a highway?

Early this morning a Subaru Impreza ploughed into a swarm of cyclists on the West Coast Highway, injuring 5 of them, but thankfully no fatal injuries. Even without further investigations, I would be pretty confident to say the driver was at fault. There is really no reason for a car to tear into bunch of 18 cyclists. One of the cyclists pointed out that there was no way the driver couldn't have seen them as there so many of them and they would have been lit up like a 'Christmas tree'. Was the driver drunk? Don't know, but we'll find out soon enough.

Though my sympathies are with the cyclists, there are a number of things I am not comfortable with. Firstly, should this swarm of peloton cyclists be on the West Coast Highway in the first place? The law on this is somewhat grey. It is clear that the law forbids cycling on expressways, but it is a bit unclear if this applies to the WCH. Cycling fora argue that a highway is not an expressway, so cycling is not forbidden on the WCH. But on the other hand, the LTA lists the WCH as a semi-expressway, implying that the law would likely look at the WCH as an expressway, thus cycling on the WCH is not allowed...which makes sense because it is actually a very fast and busy highway.

Secondly, is a swarm of cyclists legal? We see this more and more often. Just this morning, after my mandatory pilgrimage to the fast disappearing wet-market, I encountered a similar swarm of Sunday cyclists riding 3 and 4 abreast.... I wasn't too pleased but because the road was quite empty at that time of day, I was quite content not to let them spoil my day. But the law actually is quite explicit about this issue. I quote from Chapter 276, Section 140 of the Road Traffic (Bicycles) Rules: (1)No bicycle shall be ridden on the right of another vehicle proceeding in the same direction except when overtaking such other vehicle. (2) No bicycle shall be ridden on the right of any two other bicycles proceeding abreast in the same direction except when overtaking such other bicycles or on parts of roads or paths set aside for the exclusive use of bicycles.

So the cyclists were actually breaking the law.

So yes, the driver was at fault for running into these cyclists, but the cyclists should 'fess up to being somewhat reckless, irresponsible, and somewhat lacking in common sense. The traffic police has I believe been a bit too soft on cyclists who are clearly breaking the law, especially with respect to the above two points.

And my appeal to cyclists is this....please show some common sense.... it is fine to claim you are as lit up as a Christmas tree, but really, does it make any sense to stick the Christmas tree in the middle of a highway?

An act of God?......sez who?

It is pretty much of in our human nature to claim credit for the good things that happen and blame God for all the bad stuff. Take the recent flood for example. The flood mitigation efforts are all credits and kudos to PUB, but when floods occur, it's an "act of God", no less.

It kinda made me wonder where this expression came from. Actus Dei. Not much help from my fav source of knowledge, Wikipedia. Phrase Finder tells us that it originated from religious texts dating back to the 13thC CE. Not a particularly enlightened period of european history. It apparently began to appear in legal documents in the 19thC.

I would actually prefer the other phase "vis majeur" refering to a "superior force of such a degree that no effective resistance can be made to it". No need to blame God. Our own stupidity, ignorance, incompetence or negligence can also be that superior force.

On another note, I was also wondering what that term meant to atheists, who clearly do not believe in God. Actus Dei? Or actus non-humanus....., or simply, 'whatever it is, don't blame me'.

Avandia bites the dust - oh, but not quite...

So the FDA advisory panel has finally come out to put a finger on the antidiabetic drug Avandia. Or has it?

The drug has been under scrutiny since about 2007, and it has been increasingly been associated with increasing risks of heart attacks. Now the FDA says yes the evidence is clear enough for an expanded warning to be included, but not clear enough for the drug to be yanked off the market. GSK, makers of the drug apparently didn't do a good job generating safety data. FDA expert, Dr David Graham was quoted as saying the GSK RECORD trial was "garbage". Furthermore, GSK apparently withheld information, and submitted poor data, including patient deaths, of patients on Avandia. GSK has already agreed to settle over US$400 million of lawsuits.

In the light of all this, the FDA appears to be waffling a whole lot in not wanting to withdraw the drug. Benefits outweigh the risk appears to be the mantra. Certainly the mantra being chanted by GSK sources.

But this is really not the point....

The critical issue should be whether the drug is as effective and as safe than alternative options. A Japanese (Takeda) alternative, Actos currently appears to do the same job but without associations of increased heart attack risks. So Anadia currently stands as a worse option. It is also not a case of patients currently on Avandia being forced out into a vacuum, should the drug be withdrawn. There are safer alternatives.

So FDA's pussyfooting round the issue is hard to comprehend. To what extent one wonders, is this wanting to allow GSK to recover as much of the drug development costs as possible. The bulk of pharma's drug development cost is recovered in the first few decade post registration. Despite falling sales, every year of delay in taking the drug off the market is a big pot on money for the company.

Let's hope other regulatory agencies, including our own HSA, will be a bit less muddleheaded.

Obesity - a KPI? How silly can you get?

Mr Liak Teng Lit, CEO of Alexandra Hospital and the coming Khoo Teck Puat Hospital was reported as saying "....All things being equal, if you are grossly obese, we won't promote you."

My goodness! Obesity as a work KPI (key performance indicator)!

Innovative? Definitely.

Attention grabbing? Most certainly.

But it is the height of arrogance, silliness and preposterousness to even consider such an option. Mr Liak should read the CDC feature, as well as the recent article in Newsweek Magazine, "The Real Cause of Obesity. It's not gluttony. It's genetics. Why our moralizing misses the point."

Perhaps Mr Liak should also penalize those who can't pass their IPPT (Individual Physical Proficiency Test). Not to mention the elderly, myopes, diabetics and hypertensives as well.

Prof R Kanagasuntheram - why we cannot recognize the inspirational amongst us.

Last Saturday, an ex-teacher of mine from medical school passed away. He was in many ways an inspirational teacher of Anatomy - knowledgeable, always caring about his science, and especially of his students. Although he had retired from academic life many years ago, many came forward toexpress their condolences.

But the University and Medical School have remained fairly silent. I am not surprised.

Our institutions here find it very difficult to recognize greatness in our midst. They prefer to laud the highly visible achievers from the West who never contributed anything significant to our development. Or big 'Johnny come lately' donors. So you will find not find any lecture theatres, or buildings called after local heros.

So sad.

Why are we so afraid to be gracious? So reluctant to recognize our own people?

Worker's safety - are we serious?

The Straits Times today also carried a report on the recent lorry accident where 3 workers riding in an open topped lorry died. The accompanying report by Ng & Chin, highlighted the inadequacy of safety measures in the transport of workers to and from their worksites.

I was horrified to find out that employers were given up to 2012 to comply with the improved safety measures. 2012? If measures are unsafe, they should be stopped dead in their tracks. Full stop. Is the MOM and the LTA really serious about workers health and safety?

These have obvious resonance with a previous posting on safety vests worn by workers. In case employers and the MOM don't know, the purpose of wearing the vests is to improve visibility. There really is no point in wearing those fluorescent green vests if they are muddy faded and no more fluorescent.

We had similar nonsense during the recent H1N1 shamdemic when we had rules galore, which no one seriously implemented. Just a show about being safe. Similarly, pages of lab safety guidelines that sounded fantastic, and which can be shown to accrediting agencies, when everybody knew that they could not be implemented.

I mean, are we really serious about worker's safety?

The missing genius? Indeed.

The Straits Times today ran a full page report of an interview with physicist and futurist Dr Michio Kaku. He fingered Singapore's lack of originality, and perhaps a chief limitation to Singapore's success. He said, 'If you want to be a leader, you can't just copy, you have to create'. How true.

So much of what has passed for leadership in Singapore unfortunately has been based on frenetic and often thoughtless copying, instead of true innovation. Leaders are rewarded for how rapidly they can introduce changes based on Western (often US) ideas and developments. To me this is not leadership. I have posted earlier on Dr Goh Keng Swee's exception leadership qualities, as well as the poor simulate of leadership we have currently in our medical environment where we just mindlessly ape US methods, as if those were going to automatically determine success. PAH!!

So often we have seen local ideas and innovations poo-pooed simply because they do not conform to US ideas of how things should be done. Original research ideas are artificially aligned with US ideas of how things should be done, and rejected if they do not match up. Sadly, often we see them resurrected years later only after some US guru suddenly proclaims them to be the latest research fad.

So where's the originality? Where's the creativity? Where's the true leadership?

Indeed, 'if you want to be a leader you can't just copy, you have to create'.

So here's a plea to our would be leaders, ....please lead...please help and facilitate our originality and creativity. Stop going for those low lying fruits. And playing those self gratifying numbers games.

Teaching a new ball old tricks...

I was reading this interesting account about the new Adidas ball they've been using for the 2010 World Cup. The Jabulani ball.

Not very well received so far. Many complaints. But for intents and purposes, a technologically superior ball compared to previous versions of the football.

I found it quite interesting.

So here's a question to ponder.... is everything better always...better?

I can think of the software upgrades we keep getting. Each versions gets better and more powerful ...but invariably bigger, messier and more difficult to use. In many ways they become less intuitive and we need more keystrokes to get to the same point. Is better, better?

Our work 'software' has the same problem. Office and management 'improvements' keep destabilizing the work process , and I often wonder if productivity is improved.... or actually degraded through these frequent changes.

Seems like there is a certain efficiency in familiarity, and a certain loss in efficiency when we operate on the learning curve. If changes occur frequently, even though they may ideologically be 'improvements', a certain inefficiency is introduced by moving workers from a position of familiarity (and its associated efficiency) to an unfamiliar uncomfortable position on the learning curve.

Not everything that is better, is actually better.

Closer to home....I think our health care system as well as medical education environment needs a period of stability so that we can all start mastering the processes rather than keep chasing endless series of changes.

NKF short of money?? You must be kidding....

The headlines in one of ST's reports screams "NKF short of money and nurses".

Really? I am not disputing the nursing shortage....this is probably something being experienced in every sector of health care. But short of money??

The report is very similar to the one floated in Nov 2009.

While I am not criticizing NKF for doing great work with kidney disease, I have 2 questions:

a] What is wrong in occasionally, or even habitually dipping into the reserves? Especially if the reserves are in access of S$250,000,000.00?

b] Why is it perceived that somehow renal patients are more deserving of charitable support than patients with other chronic or catastrophic diseases....? That NKF should sit on such great wealth while other charities are languishing?

Census definitions of race and ethnicity

Since we are discussing definitions, here is something interesting I stumbled across...

This year as most would know by now is our population census year. This is when the government goes out to find out as much as possible about all of us... One would expect they would have gotten all their definitions down pat by now. But there in the glossary, I found this section about how the census will define race and ethnicity.

Note that the title of this section reads "Ethnicity/Dialect Group". Really? Are they capturing ethnicity or dialect groups? Then it goes down further to tell you how dialect groups are defined within the ethnic groups..... and in the subsection are all kinds of terms, most of which wouldn't be considered dialect groups.

The first sentence of the section adds to the confusion...."Ethnic groups refer to a person's race". Hmmmmmm........ We have discussed this issue a bit before. While the two terms may often be used interchangeably, they really refer to separate entities. Race has biological connotations, and really shouldn't be used anymore to classify people (see UNESCO 1950). Ethnicity refers to identifiable common social-cultural characteristics of a group of people. Usually when the gahment comments on these issues, it is really talking about ethnicity rather than race.

But here, in this masterpiece of confusion, the census definitions essentially says Race = Ethnicity = Dialect Groups. So one wonders what data is actually being collected. It's time they tossed out their archaic world view.

MRSA infections in hospitals - who bears the responsibility?

Following from the previous post, I was wondering who actually bears the financial burden of an MRSA infection... or any other hospital acquired infection?

If we consider SGH (not picking on poor SGH, but simply 'cos there are stats available for me to play with), in 2008, the MRSA rate was 0.6/1000 patient days. Since SGH clocked about 440,000 patient days in 2008, there were 0.6x440 MRSA infections..... about 260 MRSA infections in that year alone. In absolute terms, that's quite a significant number. Now, for each of these 260 patients who picked up an MRSA infection while in hospital, there are increased bed stay charges, expensive antibiotics etc. Since the infection was caused by the hospital, shouldn't the cost of managing the MRSA be borne by the hospital and not the patient....?

MRSA infection rates in Singapore hospitals

TODAY newspaper published a nice article on the efforts made by hospitals to control MRSA infections. The overall infection rates (over 6 public hospitals) have fallen from from 0.4/1000 patient days in 2007 to 0.3/1000 in 2009. Whoohoo...!!

errrmmmm....

Need to look at this in a bit more detail....

Here are the figures across 6 hospitals (2007-2009):

Year 2007 2008 2009

Overall: 0.4 0.4 0.3

AH 0.2 0.3 0.2

NUH 0.4 0.3 0.1

TTSH 0.5 0.5 0.3

CGH 0.2 0.3 0.2

KKWCH 0.1 0.1 0.1

SGH 0.6 0.6 0.4

Seems like not a clear pattern here. Yes, 3 hospitals showed a drop especially between 2008 and 2009. But a couple of hospitals had numbers bouncing around. And it is unclear if the overall improvement was heavily biased by NUH's spectacular drop in 2009. (I am actually quite appalled that our SGH is the dirtiest....

Actually part of the problem looking at these numbers is the lack of clarity in the definitions used in the collection of data. An earlier report by Straits Times had pointed this out, i.e. if the bug is on the skin when patient is admitted, and an infection occurs, it is not counted as an infection....

I looked at a MOH report by Dr Helen Goh in 2007. She had then defined the rate as being based on the CDC-NNIS methodology:

"The National Nosocomial Infections Surveillance (NNIS) system defines a nosocomial infection as a localized or systemic condition that a) results from adverse reaction to the presence of an infectious agent(s) or its toxin(s) and b) was not present or incubating at the time of admission to the hospital. For most bacterial nosocomial infections, this means that the infection usually becomes evident 48 hours (i.e., the typical incubation period) or more after admission5. The diagnosis of nosocomial infection is thus a combination of clinical findings and results of laboratory and other tests."

Assuming the definitions haven't changed and are consistent across all hospitals (of which I am doubful) ....... we should be able to splice her data with TODAY's info:

Year 2002 2003 2004 2005 2006 2007 2008 2009

Overall: 0.6 0.5 0.5 0.5 0.5 0.4 0.4 0.3

AH 0.3 0.3 0.3 0.2 0.3 0.2 0.3 0.2

NUH 0.8 0.8 0.9 0.8 0.7 0.4 0.3 0.1

TTSH 0.6 0.6 0.6 0.6 0.5 0.5 0.5 0.3

CGH 0.1 0.1 0.1 0.1 0.1 0.2 0.3 0.2

KKWCH 0.1 0.03 0.1 0.1 0.1 0.1 0.1 0.1

SGH 1.0 0.9 0.7 0.8 0.7 0.6 0.6 0.4

Yes, overall the improvement is to be applauded. SGH still looks incredibly filthy. KKWCH looks too good to be true, and CGH actually getting worse.

Lapses in audit? Suggest they check if MOE's budget for medical education has been appropriately used.

The Public Accounts Committee released its report on the MDA, MTI, MOE and Mindef showings lapses in the audit books.

It's all very interesting, but seems like chicken feed to me.

From where I am sitting, it always seems to me that whatever has been budgeted for medical education always seems like not enough. I have always wondered if the MOE budget for training of medical undergraduates, which I understand is based on number of graduating doctors, has been appropriately spent by the medical school. The number of students per graduating class has increased, so the total budget (MOE budget and school fees) must have gone up. The number of students per lecture theatre has gone up so the classroom cost per student must have gone down. The number of labs have been slashed, so the costs of providing labs must have gone down. The problem based learning platform that they migrated to some years ago utilizes 'non-expert tutors (facilitators)'....so the cost of tutoring must have gone down.

So if the budget has gone up and teaching costs gone down....how come the shortfall appears going up?

To what extent is the increasing costs due to non-teaching expenditure, such as research related ventures. I wonder if the Public Accounts Committee had looked into this?

Watch out for the next round of student fee increase.

Worker's safety: Fluorescent safety vests - what's the point?

It is wonderful to see a greater number of workers routinely put on those high visibility vests in the work place. Now that there is so much construct around the Bukit Timah area, I see them all the time. I think it is mandated by the Worker's Health and Safety Act, but I can't seem to access the MOM website and download the Act.

But what seems obvious to me is that the construction sites, and their managers appear only to be concerned with the appearance of being 'safety conscious' without actually being 'safe'.

What's the point of making the workers dress up in all those fluorescent green high visibility vests, when most of them are so faded and dirty that they are no more visible than a dirty t-shirt.

General requirements for a high visibility safety best can be found at this eHow site. According to the site, "The American Traffic Safety Services Association estimates that safety vests worn on a daily basis have a service life expectancy of approximately 6 months. Apparel that isn't worn daily may last as long as 3 years. Vests worn for very dirty work, work in hot climates or work at high altitudes may be more subject to fading and soiling and may not last as long. Any garment that is not visible from at least 1,000 feet away, both day and night, should be replaced."

Somehow i don't think our construction sites care. Perhaps the MOM should look into this.

Singapore population growth

This year is census year, and we should soon have some exciting demographic info to think about....

Statistical information about Singapore is often patchy and incomplete, though not necessarily unavailable. We know for example how fast the population is growing, but to try and figure out how much of this growth is natural, i.e. born here, as compared to immigrants requires a bit of detective work.

Here are some interesting ideas. Bear in mind I am neither a statistician or demographer....rather a kaypoh as usual... :

in 2000, when the last census was done, we had a population of 3.210822 million, out of which, 2.647393 were born in Singapore. So that can serve as a convenient starting point for us. Since population growth every year is birth rate - death rate + immigration rate, we can calculate natural population growth by just using birth rate - death rates. These rates (annually since 2000) have been conveniently provided for us here (birth rate), and here (death rate).

Plugging these into my outdated Excel spreadsheet allows me to chart the natural growth of our population since 2000. (Probably only an approximation since the birth/death rates are for whole population rather than just for Singapore born folks. But it gives us an idea.)

Year 1000s

2000 2,647

2001 2,656

2002 2,665

2003 2,673

2004 2,681

2005 2,687

2006 2,692

2007 2,697

2008 2,702

2009 2,707

Accordingly, if we had gown naturally we should have had a population of 2.707 million in 2009.

By contrast, our 2009 population is 4.988 million, out of which 3.734 million are 'residents' (citizens and PRs), i.e. approximately 1 million residents in Singapore were not born locally. Interestingly, as our current citizens are 3.201 million, it implies that about 0.5 million citizens were not born in Singapore since 2000. Also our total population is almost twice as numerous (4.988/2.707) as those Singaporeans who were born locally.

Interesting. I can't wait for the 2010 census data.