The Gigamole Diaries

The SCDF and CNB done in by a local Matahari?

2012-01-26T01:26:00.000-08:00

Slowly the story begins to unfold, and the public awaits the sordid details about the dramatic falls from grace of the SCDF and CNB Chiefs. Much has been made of the fact that no money may have changed hands and that they had been done in by booze, makan and a local Matahari.

But I think we might be missing the point here.

Fact is two very big guns from the Ministry of Home Affairs had been so easily snared by the wiles of one woman. A pretty mysterious one at that. So much for our national security. I mean, these were no less than two major units with the Home Ministry! The Mas Selamat debacle pales by comparison.

Methinks our Minister of Home Affairs need to give us a bit more reassurance than to tell us the guilty will be punished.

High salaries discourages corruption? A reality check.

2012-01-24T23:55:00.000-08:00

Singaporeans woke up this morning to the alarming news that the Chiefs of both the Singapore Civil Defence Force (SCDF) and the Central Narcotics Bureau (CNB) have been relieved of their position pending investigations by the Corrupt Practices Investigation Bureau (CPIB).

This must have shaken the civil services to the core.

Without presuming guilt of these two guys, but if the suspicions are true that they have engaged in corrupt practices, it must surely raise serious concerns about the validity of the logic that corruption is prevented by paying high salaries. These guys have certainly not been paid peanuts.

To my reckoning, if we use money as the main lure into public service, surely that must attract only those for whom money and more money becomes the driving force for their ambitions. Corruption is fueled by greed, and there is never enough to assuage that thirst.

The most effective way to stem corruption is to have an independent, transparent and effective CPIB, and a vigilant public who is prepared to whistleblow. Our CPIB has done an excellent job so far, thankfully. But if we want our politicians to be free from corruption, then the CPIB must have the freedom to investigate all officials including the cabinet and even the Prime Minister. That the CPIB reports to the Prime Minister's Office does not give it a freehand in performing this critical function. Perhaps this line of reporting should be reviewed? Since we have an elected Presidency, should not the CPIB report to the President, rather than to the Prime Minister?

LTA and regulatory capture? HSA are you listening?

2012-01-21T17:30:00.000-08:00

A week ago in the Sunday Times Senior Correspondent Christopher Tan write a nice article about the recent SMRT wayang and the LTA, raising the issue of a regulatory capture occurring between the transport regulator LTA and the transport industry.

The concept of regulatory capture is very much assocated with Economics Nobel Laureate George Stigler. It refers to the type of government failure when a public sector regulator has a cosy cosy relationship with the regulated service provider, to the extent that the regulator becomes a promoter of the regulated rather than a protector of the public needs.

Is the LTA a victim.... or are we, the public, victims of the regulatory capture between LTA and the transport industry.

This is actually not an isolated problem affecting the LTA, but can be seen to exist in many of Singapore's regulators.

The HSA (Health Sciences Authority) for example may be in such a predicament. Formed in the past from all the disparate MOH subunits in the Ministry of Health that the MOH wanted to decant from the Ministry, the functions of the various parts of the HSA range all the way from service provision, regulatory and promotional. Regulatory capture?...certainly many opportunities for this to develop in the HSA. Successive Board Chairmen and CEs have not made any attempt to deconflict all these functions, choosing instead to keep the easy and cosy relationships which made their work easier. However, unless this regulatory captures are dismantled, one has to question to what extent public needs are sacrificed to meed the needs of the industry.

By the way, George Stigler was also well known in medical circles for his attempt to optimize the daily recommended diet. Like all economic solutions, the result was totally unpalatable.

Experts disagree with NEA

2012-01-12T16:46:00.000-08:00

I read with interest the recent disagreement between an expert panel of drainage experts and the National Environment Agency (NEA) with respect to the annual rainfall trends. No discernable trend, sez the NEA. But the expert panel disagreed. You can almost see Prof Lui Pao Chuen shaking his head in disbelief. According to the panel, the annual rainfall has actually been increasing at about 15mm per year between 1968 and 2008.

And it's my turn to shake my head in disbelief. How can something so fundamental be in dispute? I mean, I can understand differences in scientific perspectives and theories, but the interpretation of hard numbers?? There is either a trend or not. How can there be such a fundamental disagreement about whether the rainfall is going up or not?

Intuitively, and not having access to the detailed data, I am more inclined to believe the expert panel. Global warming has been melting the ice caps. There is just so much more water circulating in the environment. Sea levels are rising and projected to rise even more. Surely more rain is cycling through the atmosphere. The increasing spate of ponding, oops, sorry, flooding says a lot about how much more rain has been falling.

It kinda makes me question what's happening at the NEA. How are they, and have they been examining the data they have been collecting? Can we trust their projections for the future? And can we trust any assurances that they are adequately preparing for the future?

This is just one of the indications that we really need our agencies to provide more publicly available information. Hitherto, the public has been trained to accept sanitized proclamations from our public agencies that all is well with the world, and Singapore, and that we should trust only their interpretation of fragmented and cryptic data shown to the public.

This is not acceptable any more.

This episode speaks volumes about why we need data to be made available to the public so that they can be scrutinized independently. More eyes are always better. French philosopher Henri Bergson said, “The eye sees only what the mind is prepared to comprehend.” How true.

In this case, the NEA mind appears to have been conditioned to comprehend a rather fixed set of reality based on historical weather models; models which are not applicable in today's world anymore.

If it appears I am picking on the NEA, I am not. This problem exists in all our government agencies. They need to break free from historical models, and look at their data/stats with fresh sets of eyes. Today is a very different world. Importantly, my plea to all the public agencies is that Singapore's interest is best served by placing much more institutional and government data in the public domain so that independent conclusions can be drawn about what is happening, so that more independent options for the future can be contemplated.

Happy New Year!

2011-12-31T19:03:00.000-08:00

Happy New Year all!

Have a blessed Christmas all :The doctor never reported that the angels sang....!

2011-12-25T05:04:00.000-08:00

One of my favourite books in the Bible is Gospel of Luke. Luke, as well as the Acts of the Apostles are supposed to have been written by the Greco-Syrian physician, Luke. Although not an eyewitness to the many of the events he reported on, he drew heavily on eye witness accounts about the life on Jesus as well as the events which took place around the early church. His accounts all carry the trademark attention to personal details and emotions.

His account of the night of Jesus birth has provided many of the inspirations for the celebration of Christmas. Unfortunately they have been pretty much distorted by romantic notions and more recent commercial interests.

"Hark!" The herald angels sang. Or did they? The romanticized accounts all have mass choir of angels celebrating proclaiming "Peace on earth, goodwill to men!". Fireworks in the sky even!

But careful reading of Luke's account actually shows us a very different reality. The angels appeared to shepherds in the darkness of the fields. Their appearance was not at all comforting. In fact they were a terrifying spectacle.The angels had to reassure the shepherds. They had a simple message. Luke documented that the angels spoke the message rather than sang. There was no musical performance in the sky. Yes, the angels were praising God, but praises can be uttered and not sang.

It was a terrifying spectacle. And an earthshaking message. There was to be a major paradigm shift in the affairs of men. Their Messiah had been born.

It is like that for other aspects of life, isn't it? Major paradigm shifts are often terrifying events. The mistake Management often makes is to ignore how unsettling and terrifying paradigm changes are to the workforce. There is often no peace on earth and goodwill to men, other than to those in political alignment. The angels did make it clear, "...and on earth, Peace to those on whom His favour rests."

Nonetheless, Gigamole would like to wish that you all have a very blessed Christmas.

We need a major rethink of our educational system.... and please do so outside of the box.

2011-12-22T06:02:00.000-08:00

One of the areas that Singapore can be very proud of is how we have been able to make education so available to our kids, to the extent that we can say that no child will be denied a chance to go to school. In the previous generation there many capable people who had limited opportunities simply because they did not have access to education. But not anymore. Education has indeed been the great leveler for this generation. Because schooling is now accessible to every child regardless of his/her socioeconomic background, career opportunities are limited more by abilities and skills rather than the individual's socioeconomic stratum. Likewise for gender and ethnicity.

But sadly this appears true only to a certain degree.

The Ministry of Education (MOE) should be congratulated for making examination data available to the public. One wishes though that they would put up more detailed data, and not only cherry picked information for public consumption.

The recent data is quite instructive. They are really quite similar to previous years' data and therefore really doesn't say anything new. True, there are some wiggly movements in percentages, but they are relatively small changes. Over a long period one can see that the performance data is relatively stable. Boringly stable. This stability is actually both comforting and alarming. Comforting because it means the MOE has done an excellent job in providing education. Not much more to do. Alarming because despite all this effort, fixed disparities in educational performances between ethnic groups are apparent.

If we look at the performance at the Primary School Leaving Examinations,we see more than 90% of students pass the exams. But only the Chinese outperform the national average. The Malay students, as a group, under-perform everyone else.

This ethnic ranking not only persist at the O-levels, but the differences are markedly accentuated. And this is for 5 O-level passes. I am quite sure if we set more stringent criteria, even greater differences can be demonstrated.

This is alarming because the data is not improving despite what the amount of resources the MOE has put into the school system. I am sure the MOE is aware of this problem. But I hope they are not ignoring it. Something drastic needs to be done because the current models are not working.

To an outsider, looking at the data, such 'fixed' differences suggest a number of possibilities:
a] Our delivery of education has ethnic biases;
b] Our way of assessing has ethnic biases;
c] Ethnic biases exist in both instruction and assessment; or
d] There are real ethnic related limitations in abilities.

Since I do not subscribe to there being biologically and ethnically related limitations in ability, it must be that the first three are valid.

The MOE must spare no effort to get to the bottom of this problem. It must not rest on the laurels of its past accomplishments. There are unintended ethnic biases in how education is delivered to the public as well as ethnic biases in how the examinations are set. It is not adequate to congratulate ourselves on the performance at a national level, because this is invariably defined by the performance of the largest and most successful ethnic group. This is unfair to the minority groups who may have unaddressed special needs and considerations.

We need to remodel our educational paradigm to level the playing field for all ethnic groups.

Should the finger be pointing at the CEO? A moleview of the SMRT saga....

2011-12-19T07:45:00.000-08:00

image from here

All of sudden there seems to be deluge of bad news for SMRT. The latest involves a woman who fell and and sustained a head injury. Apparently she remains in coma. Gigamole wishes her well.

The public outcry against the SMRT is both understandable and justified. The hounds are now baying for the head of the CEO, Saw Phaik Hwa. The mass media has been particularly unkind, I think, and has dug up as many photos as they have on file that portray her in the most unflattering light.

However, Gigamole somehow feels this antipathy against the CEO has been somewhat misplaced. Yes, because she heads the SMRT, the responsibility for all the mishaps falls squarely on her lap. Bt we should not forget that as CEO she acts upon the guidance of the SMRT Board. It was also the SMRT Board who examined her credentials and appointed her to the post. It was the SMRT Board who crafted up the directions and strategies for the CEO. By appointing Ms Saw to the post, the Board obviously prioritized the retail agenda above operational and service needs. Whether they did this as a conscious strategic decision is unclear. It may well have been it seemed like an OK thing to do at that time, and only now shown to be inappropriate.

It seems clear at the moment that the SMRT CEO did all she could within her capabilities. Unfortunately though her experience was principally in retail and marketing. Was she someone who had a good insight into the technical/engineering and operation needs of the SMRT? Should we blame her for lapses in areas outside her expertise. Yes, as she is CEO; but not entirely, as the Board should account for why they did not think operational/service skills were critically important for a train and transport company. Transport Minister Lui was spot on when he picked up the phone to speak with Chairman SMRT. This is a problem squarely shared by the Board and Management.

So for those who are happily shooting off arrows at Ms Saw, hold your fire a bit, and see if perhaps some of the arrows need to be redirected towards the SMRT Board.

The Singapore Medical Council Physician's Pledge - What motivates doctors nowadays?

2011-12-17T13:43:00.000-08:00

Pointing the finger at the SMRT for their Freudian slip prodded me to think about what motivates our doctors nowadays. Or at least what should motivate our doctors nowadays.

It seems to me that many doctors nowadays are quite happy to regard their practice as a business. Quite understandably so since every other aspect of health care has become such a business. Ever since the mid 1980s in Singapore, when Medicine became defined as one of the pillars of our economic growth, the practice of medicine has become increasingly premised upon a business-like quid pro quo relationship between doctors and patients.

Yet the very ethos of Medicine is not built upon any kind of a business model. In fact the Hippocratic traditions de-emphasized the rights (pecuniary or otherwise) of the physician and instead focused on the duties of the physician. The Hippocratic Oath was really all about the duties of the physician. Likewise, our SMC Physician's Pledge is heavy on duties and does not even mention payments for services rendered.

In fact the very first line of the Pledge reads: "I solemnly pledge to dedicate my life to the service of humanity". Some will of course argue that this is wholly unrealistic, and that doctors do have to make a living, and perhaps even to live in the lap of luxury. But they forget that this was the pledge they took. Theirs was to dedicate their life to the service of humanity. If this was unrealistic, perhaps they should not have taken the pledge.

The great Canadian physician Sir William Osler, made it equally clear - “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.”

In today's world, this calling is so easily brushed aside in favour of the allure of "Income Opportunities". I do not mean to belittle the sacrifices of many doctors who do have their hearts in the right place. Indeed there are many of them. Many I have had the privilege of knowing as teachers, friends and colleagues. But I think even they would not disagree that the practice of medicine in Singapore has to a large part, degenerated to a mere trade or business.

What is the purpose of the Physician's Pledge if we are not to take it seriously?

On another note, I wonder why hospital CEOs are not expected to take a similar pledge of service and duty to patients. After all, it is their management performance indicators that compel doctors to behave after a certain fashion. Can we expect a doctor bound in service to a hospital to put the patient's interest first, and disregard the clarion call to seize the hospital's "Income Opportunities"?

Can an organization such as the SMRT commit a Freudian slip? Of course...!

2011-12-16T12:49:00.000-08:00

In psychology there is a term, parapraxis, that refers to the situation when you do something that was really not what was intended. In layman terms, this is often referred to as a 'slip of the tongue' when you say something unintended. We excuse ourselves through the maxim, 'a slip of the tongue is no fault of the mind'. This is of course quite untrue. Slips of the tongue often reflect a primary fault with the mind, and often betrays what the the speaker is covertly thinking, albeit subconsciously. At cocktail parties, we laugh at such Freudian slips when people chatter about meaningfully under the influence of alcohol. At other times, such Freudian slips occur when a persons guard is let down, or he/she is operating under duress.

So I was quite amused by the recent gaffe by SMRT when it sent out the message to taxi drivers during the breakdown of train services. "Income Opportunities" headed the message that the SMRT had trumpeted to taxi drivers. Quite insensitive and inappropriate. Of course the SMRT quickly came out and apologized for the message. It was a template message which had been wrongly used. Of course. In normal conversation, this is exactly what happens when someone says something unintended. He/she had used the wrong template message in his mind. It is nothing more than parapraxis. A slip of the tongue. A Freudian slip that revealed what the speaker had been thinking about.

So the SMRT really did have a Freudian slip. One could of course argue that an organization such as the SMRT, not being alive, does not really have a mind, and is incapable of committing a Freudian slip. But in reality it does have a corporate mind and a corporate consciousness. So the Freudian slip gave us a rare glimpse of the SMRT corporate mind. And the image is not at all attractive. "Income opportunities". Is that what it is all about? We know that SMRT has a duty to return shareholder value, but we should seriously question the SMRT about its raison d'etre.

At a broader level, we should be concerned that our society has become so preoccupied by "income opportunities". Sadly it seems like things are only worth doing if it has a clear potential for revenue generation. Tragically the practice of medicine seems to be rushing down that road too.

Congrats, Yasmin!

2011-11-24T20:12:00.000-08:00

Topped the PSLE. Loving mixed-ethnicity family. Muslim. Neighbourhood school. What else can I say?

We are all superly happy and proud of you, Yasmin! And if this represents what Singapore is about, I can say I am damn proud to be a Singaporean!

But there is a flip side to this story.... we should ask ourselves (and the MoE), why it should be this way? Why should a Primary 6 examination, which is supposed to be nothing more than a competency exam to enter Secondary school, be an exam where we identify top students? It is about time we put a stop to this madness.

Curiouser and curiouser..... sharing the skeletons

2011-11-07T22:48:00.000-08:00

Image from here

An independent investigation is not always the most intuitive thing to do when a problem arises. The management of an organization will always seek to retain control of the proceedings so that the damage can be contained should any wrong doing be uncovered. Yet we all know that a less than independent investigation will in the end prove to be the least beneficial for the organization in the long run.

A number of recent incidents locally highlight the need for external and independent invistigations or audits.

Late last year, an IVF mistake occured in Thomson Medical Centre. In response, the Ministry of Health held its own investigation rather than to leave it to the TMC to uncover and report its own lapses.

More recently, an accident occured in the Singapore Air Force. Apparent a technician ruptured his liver during an induction exercise. The internal Board of Inquiry, disclaimed any association with the activities during the induction. It was only after the coroner made its findings that the BOI backtracked and agreed to consider that the ruptured liver could have been related to the tunnel crawl during the induction activities.

Now there are allegations of publication fraud and self-plagiarisms at the NUS. One wonders if the NUS sees it as in their interest to keep the investigation 'in house' and secret. Should it not be in everybody's (including NUS's interest), to have an external party audit whatever happened? This is especially as senior members of the faculty are associated with the allegations. Even if the senior members are innocent of any wrongdoing, the perception that the investigations are less than independent is damaging to the credibility of the NUS.

Instead, there is this very bizarre situation where the lead investigator is a Director of Research Admin, in the Office of the Deputy President (Research&Technology) while his boss himself is the subject of certain allegations of self-plagiarism and is associated with two of the Melendez list of publications.

Curiouser and curiouser.

The graduate student squeeze

2011-11-02T16:51:00.000-07:00

I am told the recent research fraud allegations flying around the Singapore biomedical research environment have produced some rather grim ashened faces. I don't blame them. The uncertainty about how the die will fall can be somewhat unsettling even if you are innocent.

It is likely however that the investigations will point to the guy (or gal) who occupies the lowest position of the food chain (usually the graduate student). This does not necessarily indicate some high level conspiracy, and merely point to the reality that he/she is the one who is in the position to generate the raw data and to output the findings. Often the supervisor is really unable to verify every bit of data generated as gospel truth.

In such situations people often overlook the weaknesses in the environment leading to the wrong doing. I am not trying to justify any wrong doing here.... but merely pointing out that a dysfunctional environment can predispose and even encourage such malpractices.

The graduate student does not have an easy lot in Singapore. Cost of living is high. And even though scholarships are quite generous, the tenure of of the scholarship is strictly limited to 3 .5 years with almost zero chance of extension. Students are well aware that at the end of this time, they are pretty much out on their own. And if they cannot get a job and convert perhaps to a part-time studentship, they are out of the programme. Which means really research and development for graduate students in Singapore is really about the predictable production of data for publication in high impact journals. It is really all about D rather than R&D. The problem is compounded by the reality that the support for graduate student research is funded through research grants, whose granting agencies also impose a very high expection on the promise of a translated product, as well as very tight constraints of the tenure of the grant. The flow of money is switched off as soon as the clock strikes twelve.

Under such conditions the students know that if they do not produce results before midnight, the golden carriage they ride in will be turned into a pumpkin and they will revert to being field mice.

Contrary to expectations, graduate students generally do not have any say in the shaping of their projects. How can they when the project is regulated so tightly by the terms of the research proposal designed by their supervisor even before they have been accepted as students. And since their supervisors had to inflate expectations in order to win grants, they are left in the unenviable position of having to meet unrealistic expectations in generating publishable results in high impact journals in the shortest possible time, even though the hypothesis may be flawed.

Under such conditions, one can understand if the student is tempted to 'generate' the results that their supervisors expect to see.

Plagiarism? It is easy to see how this often happens. The graduate students from other Asian countries do not often have the language skills to write their reports/theses. This is especially so for the introduction and discussion sections. It is very tempting to snip and paste from a source that has explained so well the concept you want to present. I am not refering to the student misrepresenting that new knowledge or ideas originate from him/her, but just that he/she repeats chunks that are already in the public domain, unfortunately without citation.

I don't think that the situation here in Singapore is very different from many other high performance univeristies. But I do think that it is quite a bit more exaggerated because of the impatience in the system to compete and achieve blobal recognition almost at all costs.

Early history of hospitals ... Happy Deepavilli!

2011-10-23T17:10:00.000-07:00

Historically the care for the sick tended to occur within temples and other religious establishments. This I believe was largely related to the tendency to associate illness and healing with spiritual events. Thus the early concept of hospitals in Europe was nothing like what we encounter nowadays.

The earliest evidence of a specially constructed facility for the care of sick was apparently in Sri Lanka. This was early as the 3rd to 4th Century BC. According Wikipedia, the Carakasamhita (Compendium of Caraka) and descriptions by the travelling monk Fa Xian, India probably had the first "organized cosmopolitan system of institutionally-based medical provision" in the world. This was approximately at the turn of the first millenium. Europe continued to develop their hospital concept largely as part of the religious establishment, the modern hospital concept seen in Asia and Persia never really took root until the social and civic reforms following the French Revolution.

This perspective is important to have as we look at the continued evolution of health care provision. The usually eurocentric portrayal of medical history tends to convey the fallacious idea that all things good flowed out of Europe. This is only true to a certain extent because of the renaissance and the industrial revolution. But it is important to recognize that that renaissance was deeply rooted in wisdom that had originally flowed westwards from Asia.

This is a good account to read:
Medicine and Society in the Medieval Hospital by Tatjana Buklijaš (2008)

India was very much where the action was in the development of the modern hospital concept. And they were more than half a millenium ahead of Europe.

Nice to know that....especially as we head towards the Deepavalli celebrations.

Happy Deepavalli all!

The culture of bandwagons, whale-ariums and the authorship mass-graves

2011-10-22T16:42:00.000-07:00

Bandwagons are great things to have in the neighbourhood, but they are not something that Singaporeans are very familiar with. The closest we have to bandwagons would be the floats that used to be paraded across the grandstand during National Day parades. These floats would generally profile the organization and trumpet its most recent achievements. But few personalities ever get to reap any reflected fame by jumping on these bandwagons. Another version of the bandwagon is the local 歌台 ge tai's. Here's where aspiring politicians sometimes flaunt themselves during 'hungry ghosts' season hoping for some public attention.

The version of the bandwagon seen in academic circles is that associated with 'successful' and high profile researchers (or research). If you have one in the neghbourhood, you'd be very blessed indeed. By jumping on such a bandwagon, aspiring wannabe researchers collect instant fame and fortune. In the past, when few bandwagons were apparent in the local scene, we used to have to send aspiring researchers to high profile universities or research insitutes where they get access to high profile bandwagons. These researchers then return covered with reflected glory and certainty of an equivalently high profile career.

Nowadays of course, there's is a lot more money floating around and we can afford to bring in some of the bandwagons instead of sending our novice researchers out to them. Net benefit to us, as not only our young researchers but Singapore gets to bask in the limelight of these bandwagons. In order to not look so crass and obvious, the bandwagons have been camoflaged as travelling whales, as if we were recruiting for an oceanarium in Resorts World Sentosa.

It is of course, nice to have whales in the neighbourhood. Up to a certain point.

It's unfortunately been somewhat overdone. Nevermind that the rest of world also play this game. But the game of cultivating whale-ariums has taken on a life of its own, complete with its own set of KPIs. Senior management of universities, research institutes and other high profile research establishments spend enormous sums of money bidding for top performers for their whale-ariums. These senior management KPIs are based on how many whale Michael Jacksons (or Lady Gaga) they can attract. Don't worry about whether there is real transfer of technology or not, just make sure the whales perform, and as many as possible get to ride the whale.

Too cynical Gigamole is being?

Well, look at our grant agencies, and see how they look disdainfully down on local content. Woe betide your chances should you not have a significant performing whale leashed to your proposal, and are not part of one of these existing whale-ariums. Your career on the other hand, is pretty much secured for life if you can convince the grant agencies to advance you enough credit for you to lease your own whale-arium (otherwise called a programmatic grant) with at least one performing whale on board. All you need to is to sit back and collect the gate fees (otherwise known as research credits).

Correspondingly an entire culture has grown around the bandwagon/whale-arium 'ge tai'. The output of such whale-ariums has become a major KPI. Hence chalking up such research credits through being involved in publications can make or break a young scientist's career. Publication authorship lists have grown exponentially over the years. Endorsements of major performing whales become essential in providing gravitas to these publications. This gravitas is important because it provides better odds in getting your publication into major journals. Such heavy publications are referred to as having 'high impact' and secure much credit for the authors on these publications.

The university actually encourages the formation and farming of these whale-ariums.

Academic staff performances are graded according to their abilities in securing funding to lease a whale-arium or a significant bandwagon. Individual local efforts are frowned upon, regardless on whether they are meritorius (in fact a medical school Dean has been famously quoted as having disparaged his staff "How good can you be?"), or not. Involvement in journal publications are extremely important in the KPIs of academic staff. Here again the university/medical school also encourages long authorship lists to develop. It's a no brainer. Everybody stands to gain from long authorship lists. It's just a mathematical reality. More people benefit from a single publication. Young staff without an established reputation gets ahead on the (coat) tails of senior and more prominent whales. Senior academics without much research output get free rides on the backs of their more energetic and younger colleagues. The university glows with pride as all this light gets reflected back and forth. Of course the university ranking gets to climb a few notches.

Too cynical Gigamole is being?

Well, look at how the medical school computes research performance credits of it staff. Performance credits get elevated disportionately of the actual impact factors of the journals. These credits are freely awarded to co-authors without the main authors losing out on their own personal credits, resulting in total credit inflation. Hence total credits often exceed 100% of the expected credit score of any publication. Co-authorships are tacitly encouraged even if real participation is minimal. In fact, mathematically, it makes more sense to be a nominal participant on these bandwagons than trying to develop your own ideas and independant research.

Journals are supposed to require authors to decalre their actual involvement in any publication. But they seldom do. According to Wikipedia:
"In the medical field, authorship is defined very narrowly. According to the Uniform Requirements for Manuscripts Submitted to Biomedical Journals, in order to be considered an author, one must have satisfied all three conditions:
Contributed substantially to the conception and design of the study, the acquisition of data, or the analysis and interpretation
Drafting or providing critical revision of the article,and
Provided final approval of the version to be published
The acquisition of funding, or general supervision of the research group alone does not constitute authorship. Many medical journals have abandoned the strict notion of author, with the flexible notion of contributor."

I have never seen these criteria being applied.

Wikipedia further elaborates:
"the U.S. National Academies specify 'an author who is willing to take credit for a paper must also bear responsibility for its contents. Thus, unless a footnote or the text of the paper explicitly assigns responsibility for different parts of the paper to different authors, the authors whose names appear on a paper must share responsibility for all of it.' "

Really?

Let's watch the Alirio Melendez story unfold as the investigations continue. The Straits Times recently reported on another investigation of a prominent whale-arium.

These whale-ariums have lives of their own. Time to re-boot the system?

Bandwagons, clowns, whales and massgraves - perspecting the Alirio Melendez story

2011-10-20T17:15:00.000-07:00

The Alirio Melendez story broke sometime last week. In fact the story had for some time, apparently already been quietly whispered about along selected corridors of the YLL Medical School campus. There have been accusations about fabrication of data, and major scientific papers have been withdrawn and investigated. I really don't want to presume I know too much about the case, nor about Professor Melendez's guilt or innocance. But certain things are interesting to reflect upon.

The phrase 'jumping onto the bandwagon', comes readily to mind. The phrase, according to my fav source for info, Wikipedia, apparently came about because of activities related to a less than famous clown-politician in early American history. Apparently he had been extremely successful in exploiting the mass media technology platform of his time, the bandwagon, to exhibit his political ambitions. Soon every other politician wanted to jump onto his bandwagon to share his spotlight. Thus arose the disparaging phrase 'jumping onto the bandwagon'.

What's all that got to do with us?

Well, observers of the Singapore approach towards biomedical research excellence cannot fail to notice that we spend a lot (in fact massive) amounts of money on bandwagons. Some have disguised these bandwagons as whales so as not to be too obvious. Bandwagons are obviously quite useful when you want instant fame and recognition, but it is not based on reality or substance. Coming from our Singaporean success on planting instant trees there is a fallacious thinking among some that there is an 'instant success' equivalent for biomedical research. So we rush about frantically planting those instant whales.... sorry, I meant trees.

Research bandwagons have however been extremely successful in transforming the Singapore research reputation. Suddenly we have a Nobel Prize laureate among us (transplanted, of course). Lots of whales (recently some apparently in migratory mode). And suddenly our local researchers look good, and get to cavort on the world stage. Can't complain too much....since as local guppies we've had many covert opportunities to grow fat off some of the crumbs falling from the mouths of whales.

But the problem is fame gotten from being on bandwagons is not necessarily real, and can be fleeting. And when the bandwagon topples - voila, you have an instant mass grave.

It was an interesting exercising looking up the Melendez publications generated in Sinapore. Anyone can do it. Just go to Pubmed and search for 'Alirio' 'Melendez' 'Singapore'. Or if you are lazy, just click here. You will find a listing of 50 publications generated during his time in Singapore. These publication date between 2002 and 2010.

It was very interesting going through this publication list because you find a lot of research associations in the authorship lists. Apparently all these papers are now under investigation. And all these authors now become somewhat tarnished by their association with Melendez because of these accusations of academic dishonesty. Again, I don't want to presume the outcome of the investigations, and I do hope that it will not uncover any widely endemic dishonesty within the scientific community. But the authorship list for Melendez papers reads almost like a Who's Who in the medical school, and includes heads of departments, Vice Deans and prominent individuals in the office of the NUS Vice President. Interestingly Prof Barry Halliwell, who is NUS Deputy President (Research and Technology), and who has been cited as fronting the investigation into the Melendez publications is himself associated with at least 2 Melendez publications.

Mass graves? These tend to develop when over-populated bandwagons fall over. But more about this in another post.

The Singapore Medical Council Physician's Pledge - respect for teachers

2011-09-23T17:44:00.000-07:00

Upon graduation, all newly minted doctors in Singapore have to take the SMC Physician's Pledge. The pledge is our local adaptation of the Hippocratic Oath and the similarities are obvious if you lay them out side by side.

In the original Hippocratic Oath, the very first para addresses the issue of respecting your teachers. It reads :

"TO RECHON him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look up his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according the law of medicine, but to none others."

I guess it was something very important to Hippocrates, or at least to the Hippocratic School.

Our SMC Physician's Pledge more succinctly states "give due respect and gratitude to my teachers". That it is placed second only to "dedicate my life to service of humanity" but before all the other practice related oaths also indicates the relative importance of such a value.

Unfortunately though, as undergraduate medical teachers, few of us observe the expression of this in the hallowed halls of learning. In fact a common refrain among medical teachers is that medical student behaviour is arguably the worst among the undergraduate population. They come late for class, talk, send text messages, surf the net, and play with their smart phones during lectures. And generally are somewhat lacking with respect to respecting their teachers. I do have to qualify that the above probably applies to only a section, and perhaps only a very visible minority of the medical student population. Yet it is a significant enough segment to create the impression that there is very little respect in the class for the teacher who is in front of them trying to start a lecture.

I have always wondered why this is so. Perhaps it is because the students have not yet been exposed to these noble values as articulated in the Physician's Pledge. It does seem a bit late to take an oath to respect your teachers only after you have graduated, and after having spent 5 years abusing your teachers. Perhaps the medical students ought to take a earlier version of the Physician's Pledge, a Physician's Pledge Lite, for example, that might encourage them to consider value systems they need to cultivate and express during their undergraduate years.

Some shrug their shoulders, capitulating to the idea that this bad behaviour is really just our local manifestion of the global modern 'Gen Z plus' university student phenotype. But I disagree. I have been to universities in Japan, Korea and even Taiwan where University and Medical School teachers are held in high respect and where students are appropriately deferential to their seniors and their professors. And it seems like the non-medical student classes in the NUS are somewhat better behaved.

Please do not get me wrong. I am not arguing here for blind submissiveness. I am all for a fiercely independantly thinking medical students. Students who can be clear minded and innovative enough to challenge traditional professional paradigms. But our students need to be taught that the development of independent and creative thinking does not mean a jettisoning of responsibility and respect for others.... especially their teachers.

So Minister Heng Swee Keat, please have a look at our universities and medical schools as well.

The new educational focus on values and character - a long overdue initiative

2011-09-23T16:53:00.000-07:00

It was certainly refreshing to read of the new Education Minister Heng Swee Keat's take on the future strategic educational mission. Apparently the new mission will focus on values and character.

Great stuff! I hope this is not one of those empty promises that serve no other purpose than to look good in annual reports and glossy brochures.

For too long our educational system had fostered this mindless ultracompetitiveness to excel academically. It seemed like all that mattered was getting those As and distinctions. Those that couldn't fell by the wayside, as did the noble values of respect, integrity, discipline and selflessness. We have seen this precipitous moral erosion among the undergraduate and medical student population. It seemed clear to many that this decline in values among the university student population was largely due values and behaviours inculcated during the preceding 12 years of schooling. Many have been dismayed by the apparent lack of concern shown by the school and ministry leaders,many of whom were clearly motivated by chasing after those elusive academic KPIs.

Fancy pedagological approaches such as 'student centred learning' and 'the student as the customer' became cliched excuses for spoiling students and fostering negative student attitudes and behaviour.

So Minister Heng's position is to be applauded. Not only is it timely, but in my opinion, long overdue. But it is a difficult task and there will be many who will resist him. I certainly wish him and his Ministry well, and will certainly go all out to support his initiatives. We have too much to lose if he does not succeed.

The great Islamic physician Muhammad ibn Zakariya al-Razi

2011-08-29T17:32:00.000-07:00

Modern medicine owes a great debt of gratitude to the great physicians who populated the medical world during the Islamic golden age. For while Europe languished in darkness, it was the Islamic physicians who systematically collected, archived, translated, studied and innovated upon the classical medical texts from the Greeks and Romans before them. It was this vast corpus of knowledge that eventually fueled the developments during the European renaissance.

One of the great physicians of this period was the Persian physician, Muhammad ibn Zakariya al-Razi, also known by the Latin form of his name Rhazes. Al-Razi was not just a physician, but also a great thinker, philosopher and rationalist. That he not only survived, but flourished during this period was a testament to how open minded and tolerant the Islamic society of those days were to non-conformist ideas.

He was known for a great many innovations and discoveries in medical practice. He identified for example, allergic asthma, and was the first to distinguish smallpox from measles (a great achievement considering the state of ignorance at that time of the microbial world). He was also the guy who pioneered the distillation of alcohol.

After his death, a compilation of his writings became a widely regarded classic of medical science and philosophy, The Virtuous Life (Kitab al-Hawi الحاوي).

Widely remembered as arguably one of the greatest physicians of that period, and possibly the Father of Paediatrics (having written the first ever treatise on Paediatrics,The Diseases of Children), he was not only a great mind, but also an ethical and compassionate physician.

"The doctor's aim is to do good, even to our enemies, so much more to our friends, and my profession forbids us to do harm to our kindred, as it is instituted for the benefit and welfare of the human race, and God imposed on physicians the oath not to compose mortiferous remedies."

Selamat Hari Raya Aidilfitri!

2011-08-29T05:37:00.000-07:00

To my Muslim friends everywhere, "Selamat Hari Raya Aidilfitri"! Please forgive me if I have wronged you in any way.

The elected President will have considerable moral authority but should not aspire to be our moral authority.

2011-08-26T16:19:00.001-07:00

So we will have our Presidential Elections today. Very exciting because it is a very significant milestone in our political development. I like the political awakening I see yet I remain somewhat concerned that this new political energy has been too enthusiastically injected into this presidential contest. Wasn't it supposed to have been a non-partisan affair? But then, I suppose, any kind of election will inevitably be 'political'. By this logic then, the very act of creating the elected presidency had already begun politicization the highest office in our country. Even though it was not intended to be, it has become the new reality.

Instead of being a purely ceremonial position, the Presidency has now become a lightning rod for all kinds of things. Because of the political energy that has been vested into electing the President, regardless of what the Constitution tries to curtail, the elected President will receive a considerable moral authority to do and say things. This authority must come with responsibility. The elected President must realize that notwithstanding the electioneering and promises made in the heat of the moment, the Presidency is a position that must chiefly unify and inspire. He must try and embody all the noble values that will bring us together as a united citizenry.

But should he speak up for all kinds of perceived wrongs and champion pet causes? Though we may wish it to be, I believe he should not. This is not to say he cannot support community based projects and causes. But that he should be careful not be a social activist for causes which may be controversial and divide the society. Can the President be the standard bearer for justice and morality in our society? To be the heart....or voice ....of the people? I don't think so. Because, how is he to decide what is just and unjust,what is moral and what not? The election does not confer upon him the supernatural ability to make those judgements for the rest of us. So inevitably, to place himself on a pedestal to champion a particular position in such causes will cause him to elevate some ... and in the process, decrease some. And make the position open to all kinds of political lobbying. He should therefore ask himself if such activities serve to unite or to divide.

When we elect the President, we willingly confer upon him the moral authority to assume the highest position in our land, but this does not make him eligible to be the authority for our morals.

Why I find it difficult to support Tan Jee Say for President

2011-08-24T00:03:00.000-07:00

He would seem to be the ideal candidate for President.... scholar, humble origins, family man, and very personable. Someone who can comfortably be at the wet market, engage academics in scholarly discussions and also hobnob with world leaders.

But I have reservations.

There is something in his past that I have not been able to understand. Here is a guy who worked his way up the admin service for 11 years and then served for 5 years as the PPS for the then DPM Goh Chok Tong. Now, I know some out there will deny this vehemently, but to my reckoning, nobody goes through this kind of career trajectory without first conforming and then succumbing to a certain degree of political and admin group think. But somewhere along this trajectory TJS appears to have experienced an epiphany of sorts to suddenly become a highly political animal of the opposition sort. But not only an opposition figure but a key figure of the most vehemently anti-PAP and anti-government opposition parties out there.

Now I may be way off course here, but common sense tells me that something happened in TJS's life. Something which we do not know about. He is not saying. And obviously neither is the government. This is important gap in our understanding of the man, because it will give us a better idea of his true drives in seeking out the presidency.

The other reservation is linked to the first. TJS has come across as a bit to combative, and rather too willing to confront the government on too many populist issues. I think this goes beyond just electioneering. I think these are pet opposition issues that an opposition party should confront the PAP government about. But these should not be issues taken up by the President. By all means debate these in Parliament but these should not form the contentious bickering backdrop for the relationship between the President and the government. I certainly do not want an opposition party to usurp the post of President. And although TJS has stepped down as a member of the SDP, it is clear from the rabid and almost exclusive support given him by Temasek Review Emeritus that he remains very much their man. To what extent he can maintain a position free of SDP influence if he does become President remains to be seen. But I am doubtful.

To this latter ends, I would like to suggest the the criteria for eligibility for President must be non-association with any political party for a period of at least 5 years. Otherwise the criteria of not belonging to a political party is meaningless.

So TJS, sorry, no support from me. I suppose this would only leave two options for me on Saturday.

Why I find it hard to support Tony Tan for President.

2011-08-18T16:30:00.000-07:00

Much has been made of his dead fish handshake. Sadly, I have been at the wrong end of that dreaded handshake with presidential hopeful Tony Tan, so I can vouch for the veracity of those allegations. For me it had been a significant turn-off.

But a limp and damp handshake is too frivolous a reason for rejecting a presidential candidate.

In 1991 when the elected presidency was introduced, its purpose was to act as a check against a profligate government. The custodial powers of the elected president would include powers to check governmental abuse of power as well as to have custodial powers against governmental raiding of our national reserves. It seems clear that the PAP introduced this scheme not to check itself but to protect against a freak election result which allowed an opposition group to take over government, and therefore be in a position to 'raid' the reserves.

Increasingly though, the people are now coming round to the idea that the national reserves as well as public service appointments are actually assets belonging to the nation and should be managed in a non-partisan way. The elected president should therefore have custodial powers over the reserves and public service appointments, regardless of which political party is in power. Previous President Ong Teng Cheong had tried unsuccessfully to exercise these powers. But the shabby way he was treated as the people's President because he had the audacity to do his job remains deeply etched many people's minds. I have to confess I still harbour deep resentment for his being denied a state funeral when he passed away.

So never again.

Logically therefore, the uber establishment Tony Tan should automatically be disqualified from the job as he is just too deeply enmeshed with the PAP leadership and the GIC management of our national reserves. How can he be the second key for the reserves when he has been such an integral part of the first key? The increasing litany of endorsements from leaders of unions and establishment groups just continue to flag him out as being so ultra-establishment and so pro-status quo that I find it harder and harder to consider his legitimacy for the elected presidency position. In fact I find it increasingly difficult not to see him as a desperate attempt by the government to stem the growing movement towards greater expectation of a higher level of transparency of government and of the management of our reserves.

It does not help also that he has not 'come clean' about the allegations of preferential NS deferment for his son Dr Patrick Tan. From what I have read of the incident and of his early rebuttals, the whole thing seemed somewhat irregular. And if he as a very senior political leader, cannot see that it was irregular and should not have happened, then I am more than concerned. So be it if it was a lapse in judgement. I can accept that. But if it remains unaddressed, it sets an awful precedence for all our subsequent generations of leaders that such 'white horse' decisions are acceptable and defensible. That's not the road I want our country to go down.

I have actually tried very hard to avoid commenting on the presidential election, but I find it very difficult because it continues to grate upon my conscience. I want my President to represent my country and to function correctly as the custodian of the reserves and a guard against a profligate government. And I am not sure Tony Tan is the man for the job. Sadly though, he may still end up getting the job because of the continued silliness of the other candiates in not wanting to coordinate their efforts for Singapore's sake.

Which of the other three candiates would I vote for? I am not telling you. But two of the three appear to be too driven by their egos for my liking.

Happy National Day !! Majulah Singapura!

2011-08-08T18:52:00.000-07:00

Assoc Professor Paul Ananth Tambyah's speech

2011-08-08T18:46:00.000-07:00

Reprinted from Temasek Review Emeritus

Ladies and Gentlemen,

My name is Paul Ananth Tambyah, I am an academic infectious diseases physician working at a major teaching hospital. I would like to state from the outset that I am speaking entirely in my personal capacity.

Historically, Singaporeans, especially those in public sector jobs have been very reluctant to speak at major political events except for those organized by the ruling party for fear that it would adversely affect their careers. I am pleased to share that after speaking at the SDP rallies at Boat Quay and Sembawang, my career has not taken a dive, I am not in exile on some island feeding seagulls off Pedra Branca and I am not walking the corridors of Mt Elizabeth Hospital looking for a job.

Since the SDP rallies at Sembawang and Boat Quay, I have received countless messages from all ends of the healthcare spectrum. Allow me to share a few of these actual quotes:

“I am a current Houseman. I just wanted to thank you for speaking out for our state of healthcare in Singapore. Many of us echo your sentiments, but are too timid or too selfish to speak out for our patients. As Singaporeans, we have often been taught to take the pragmatic approach and very often that means to be silent and let the underprivileged fend for themselves, I pray that the day will come when the sole aim of our healthcare system is to serve our people and not fill the coffers.“

From a cancer specialist, “I saw your impassioned speech on the internet and I would like to thank you for voicing the concerns of thousands of doctors in the public sector. I often see patients making treatment decisions based on whether or not they can afford them. This one patient I am looking after decided to stop cancer treatment the moment his medisave account ran dry. He did not want to burden his children. He knew that he was not eligible for additional funding as he had dependents. The only way for him to continue treatment was to tap on his daughter’s medisave accounts. I ask myself if there is indeed fairness in the world. I worry for my 11 month old child’s future. I need to think hard this elections, not for myself, my career but for his future”

From a SPH journalist, “I read your rally speech online, agree with you on many points. Healthcare and education are two major areas that need seriously to be re-looked if we want to build a truly inclusive society. Also, our social safety net…”

These are just a sample of the heartfelt feedback that I have received after the SDP rally speech. It has been very heart warming and encouraging to me to recognize that not all Singaporeans care only about making money.

On the other hand, there have been rumors going around that I was sacked or demoted or reprimanded. I would like to state categorically that this is NOT true. In fact, in the last few weeks, I have received nominations for awards and important administrative appointments.

More importantly from a pragmatic Singaporean point of view, I received my bonus letter last week telling me that I got a thousand dollars more than last year. I also received a letter from NS PC telling me that I was now eligible for a responsibility allowance and I received an award from MINDEF for my service as a volunteer.

Although I have enjoyed working with the SAF in research, education and clinical care in my field of Infectious Diseases, I am also still serving with an infantry brigade as a BMO. In fact, last week, I broke my elbow walking out of the cookhouse to a bus en route to a training visit!

Many in authority in Singapore are trapped in a system which says “Do not rock the boat”. Like the SPH journalists who privately support alternative points of view while publicly producing official spin, many in public sector institutions set aside their own personal beliefs and convictions to “toe the party line”, make minor tweaks to official policies without really addressing the fundamental flaws or unintended consequences of policies which come from above.

I believe that the fundamental flaw in our current system lies in the corporatization of our country and society. In healthcare, we have seen how restructured hospitals are expected to recover costs as far as possible.

I have tried to explain to many in authority that I do not believe that anyone chooses to get sick. There is always the fear of abuse when subsidies are provided liberally. I once asked a panel of senior parliamentarians, which individual would say “Aha, the government is providing free healthcare for children with leukemia – let my child get leukemia so I can enjoy that benefit”.

Healthcare, like education, public transport and defence and security are public goods. Singapore has an outstanding record in maternal and child mortality. That is the result of a massive investment in maternal and child care from the 1950s onwards.

My generation are beneficiaries of that investment, today’s parents are often afraid to have children in case the medical costs bankrupt them especially since the state health insurance policy specifically excludes congenital illnesses.

A corporation is concerned about the bottom line, about maximizing shareholder value while on the other hand, a country or a society is concerned primarily about the wellbeing of the people. The key indicator should not be GDP growth, it should be whether all people – young and old, rich or poor, able bodied or disabled are allowed to reach their fullest potential. There are corporations like Google which believe in “Doing No Evil” and perhaps we can start by being less of a Microsoft and more of a Google!

Investments are based on trust. Singaporeans do have a high degree of trust in the government although recently there have been many questions raised about policies and practices. It is time for the government to trust the people. Philip Yeo who is one of the most outspoken voices of the establishment has said “My greatest fear now is that the Government is terrified of the people.”

That is a fantastic position to be in. The ministers need to recognize that the only reason that they are in their jobs is because we the people put them there. We can dismiss them if we think that they are not performing. Singaporeans are an educated people, a first world society who are savvy enough to know what we want rather than being told what is best for us.

The fundamentals of a society can be changed from the ground up and the online social activism that has demonstrated its vibrancy during the elections is a good start. My rally speech was ignored by the mainstream English media and rebutted partially in the Zaobao but it was widely circulated online among the medical and healthcare community.

The internet has provided an unprecedented level of accountability with ministers being forced to justify to their employers – that is us – the citizens why they have implemented various policies. This is good for Singapore. But change can also come from above.

The highest office in the land is the Presidency of Singapore. The President and his wife look down on us from every school and government office. That is an extraordinary position for someone with moral courage and leadership like Mr Tan Jee Say or someone with guts and an independent mind like Mr Tan Kin Lian. Jee Say sees himself as the conscience of the nation. Kin Lian is someone who will speak for the people. Both, like the SDP, have a clear stand on the issues that matter – on how our money should be spent and how our citizens should be valued.

One person who speaks up can be safely ignored. I think that perhaps is what many hope will happen to me. Ten thousand people speaking up at many different fora, at different times and in different places cannot be ignored.

This is the new era in Singapore politics when more and more citizens start asking questions about justice and equality, about our reserves and about our jobs, about our healthcare and our education. We cannot “sit down and shut up”. We will be heard. Start by choosing a President who puts the people first. Vote for either of them.

Happy National Day. Majulah Singapore!

Who cares about the f***ing F-word?

2011-07-31T19:53:00.000-07:00

NTU does it again!
http://news.asiaone.com/News/AsiaOne%2BNews/Singapore/Story/A1Story20110801-292019.html
But who really cares about the f***ing F-word nowadays, apparently?

What we care about is the education of an elite crop of graduates who feel that vulgarities are a way of life, and whose vocabulary is so limited that joy and exhilaration is best expressed with a profanity.

So what if she apologises. Shame on you, NTU!

Hoisted by the presidential petard

2011-06-14T17:05:00.001-07:00

The petard was apparently a small bomb that the French used in the 16th century to blow up fortifications etc. The problem is that, like many such munitions, they can behave quite tempermentally and blow up at unexpected moments. Much like the situation of the terrorist who blows himself up accidentally in the comfort of his bomb factory. So one can easily be "hoisted by his own petard". Funnily, a related word to petard is 'peter' or 'petar' meaning 'to break wind', or fart. Seen in the light of this alternative meaning, one conjures up the comical imagery of someone being 'hoisted' by his own fart. For a guy, I suppose, it's like trying to pee against the wind.

Several years ago, the PAP, in a rare pique of insecurity, suddenly recognized that there could actually be a freak election result giving rise to an unintended opposition-led government. Quite an oxymoron here since all election results actually do reflect real decisions of the electorate, and if the opposition wins, it must be the decision of the electorate, and cannot be a freak result. Nevertheless, the PAP then petulantly declared that there should be second key to the national reserves that was to be held by an elected president; effectively the creation of a petard to be used against the opposition, should they be ever so freakish as to be voted into government. It was obviously never ever intended that the petard could be used against the PAP itself since any ruling party could easily engineer into position a pro-ruling party president.

How times have changed. Likewise the wind direction. Now, more than ever before, the possibility is very real that the opposition could swing enough votes to topple the PAP from its throne. Not only that, the sentiment among the electorate is very much in favour of a truly non-partisan elected president, who can actually serve as a check against the PAP itself. Under these conditions, there could be a very significant swing in support against any candidate viewed to be remotely linked to the PAP. In fact the support could likely swing in favour of any candidate who is capable of expressing some anti-PAP rhetoric.

So we see now the presidential petard dangerously being hoisted against the inventor of the petard. Will it actually detonate? We'll see. In any case, it is not a good time to be sitting downwind.

Black swans in Singapore?

2011-06-13T17:43:00.000-07:00

The black swan metaphor was introduced to us by Naseem Nicholas Taleb to describe a high impact outlier phenomenon that no body expects and one that takes everyone by surprise. The recent global recession related to the collapse of Lehman Brothers was such a black swan event. And like all black swans it can be rationalized after the event, when everyone kicks themselves in the backside and wonders why they never recognized it coming.

Although not global in magnitude, there have been a number of black swans seen in Singapore recently. The GE2011 results for example, caught many people in the PAP by surprise. The flooding in Orchard Road was another such event. In retrospect however, these events could have been easily predicted, and now we have the unusual situation where many people in the gahment are kicking themselves wondering how they missed the picture.

Often therefore the black swans are not the result of extra-ordinary events but of a lack of foresight, and the reluctance to think outside of mainstream and traditional ideologies. The GE2011 black swanlette was I believe, very much a consequence the failure to really look at the signs, which in retrospect, was everywhere. There was much reluctance to listen to naysayers, and everyone was happy to fuel the emperor's vanity. The flooding story hasn't quite unfolded fully, but I believe the picture will emerge that the black swan really came about because of the reluctance to deal with changing weather patterns as a result of global warming. There was I believe, too much discomfort in wanting to move outside of traditional models looking at weather and flood patterns. After all, to do so would have been to abandon painstakingly collected historical rainfall and flooding data. Yet the world has changed, and these models need to change as well.

The increasingly recognized hospital "bed-crunch" is perhaps not unlike the flooding black swan. Caught everyone by surprise, did it? What absolute crock! The numbers were there for everyone to see. The population was growing at a phenomenal rate. People were aging. Medical tourism was being encouraged. But no one appeared to want to look seriously at the numbers. Either that or there was an absolutely wrong prioritization of healthcare resources to cater for medical tourism instead of community needs.

Singapore hospital bed crunch....again....and again and again

2011-06-07T17:50:00.001-07:00

So Singapore is suffering from a hospital bed crunch? Again? Rightly it has been described as a perennial problem. Dr Jeremy Lim last year alluded to it being a 'systems problem'. Of course it is. Like the floods hitting us nowadays, it is a systems problem. When rainfall exceeds a certain rate, the drains must overflow. Likewise, if there are more patients needing beds than there a beds, there will be a crunch. And patients get to sleep in corridors.

When I was a houseofficer, this was a fairly common occurence during every admitting day.

The question is why has this problem not been solved? It is not as if the problem is unknown. Or cannot be predicted. At least for the flood problem we can always blame the vagaries of weather .... global warming etc. But patient bed demands are fairly predictable through the year. Population growth numbers are very well known...at least to government departments. Surely bed demands can be computed and modelled. To me, a bed crunch is a sad indictment of the lack of MoH resolve in tackling this problem.

There was once a model that promised to deliver at least 80% of capacity for local patients, and only 20% was to be for the servicing of medical tourists. Yet the current figures suggest that medical tourists now occupy 30% of bed capacity. Surely this discrepancy can be modelled and provided for. The problem did not spring up overnight!

Another problem relates to the unbalanced provision of beds. Bed occupancies differ in the different hospitals. SGH and NUH has much lower occupancies than TTSH and CGH, and the latter therefore suffer worse bed crunches. Has the MoH over provided for the premier hospitals and inadequately for those servicing residents.

I think MoH owes us an explanation.

Population issues....

2011-05-17T02:49:00.000-07:00

Last year when I did the facile estimates of our population breakdown, it was more for fun than anything else. I did not realize then how important it was going to be.

The 2010 census results confirmed that in 2010 there were a total of 3.23 million Singapore citizens, out of a total population size of about 5.08 million, i.e. roughly for every 3 people walking around the streets of Singapore, only 1 would be a non-citizen. That's really not so bad. But these computations do not make a distinction between local born Singaporeans and immigrants. In my previous estimates, in 2009, there could have been as much as 500,000 immigrant Singaporeans since 2000.

But how many of the 3.23 million citizens can vote? The census is not really clear about how many are above 21 years of age, but a reasonable estimate from their data might be about 75%. So that would give approximately 2.4 million. If we consider the PAP's electoral performance of about 60%, PAP supporters number only about 1.4 million, and have an electoral advantage of only about 500,000.

That's really a remarkable coincidence isn't it? Could it really be that the PAP's electoral advantage is essentially comprised of immigrants? This would not be far from the truth if we accept the argument that immigrants tend to vote conservatively for the ruling party. If that is really true, then the reality is quite horrifying. Has the PAP support among native Singaporeans eroded so substantially - that only 1 in 2 native born Singaporeans support the PAP?

If the above is true, it will only mean that the PAP's hand will only strengthen in time as our population growth for this coming electoral cycle will primarily come from immigration. Unless their popular support among native born Singaporeans continue to erode. Even so, it would be hard to see the erosion of support among native Singaporeans exceed the growth of immigrant support.

I am not at all suggesting that the PAP has adopted a cynical electoral strategy of propping up their flagging support through rapid immigration. But the reality of our population changes do suggest that the opposition cannot keep playing to the fears of native Singaporeans against the growing size of the immigrant population. It will be a losing cause. To survive and succeed they will have to reach out to and represent ALL Singaporeans, native or immigrant.

And what of the native Singaporeans? I am afraid all indications are that we will go the way of the dodo bird. We are a shrinking and disappearing entity. The new orang asli. Just like the peranakans before us who have all but disappeared, and only kept alive by 'acting cute', and support from the tourism industry.

Perhaps Singapore needs a bumiputra policy?

The problem with giraffes....

2011-05-12T01:11:00.000-07:00

For more discussions of giraffes.... see here

The unbalanced development of the giraffe's anatomy led paradoxically to a situation where his neck became too long for his legs. Although the long neck enabled better reach of the high leaves, his neck became too long to enable easy reach of the low lying water. Bizarre but true.

This tends to happen also in organizations where there is an unbalanced over-fixation on certain parts of the KPI, and and losing sight of the original mission. It's just too easy to chase after certain KPIs. People become comfortable and predictable.

George Yeo was spot on in his observation that from time to time, it is necessary to shake the box.

The PAP's new clothes......

2011-05-11T21:54:00.000-07:00

Although Hans Christian Anderson popularized the story of the Emperor's New Clothes, the story actually did not originated from him. The story was rather, adapted from a Spanish original in the El Conde Lucanor (1335). Anderson's creative input was apparently to alter the punchline of the story to that of an innocent child blurting out the awesome truth: "But he isn't wearing anything at all!"

I couldn't help thinking of this as I read Mrs Lim Hwee Hua's comments of the recent elections:"We had spent the last five years working hard, trying to understand - in the areas where there are gaps - what the problems were, what the deficiencies were, and to address those," she recalled. "We have also, of course, been trying to engage the residents on some of the current issues."

"It is a surprise for us that the resentment is so deep and the unhappiness is so deep." In fact, it was only during the campaign, that "we began to fully appreciate the extent of the unhappiness and resentment towards the Government, hence the pledge by the PAP team led by Mr George Yeo for us to have a strong role in the transformation of the PAP itself."

One cannot really deny that the PAP MPs do work hard. And they are generally very good at what they do. But for Mrs Lim to admit so candidly they were caught by surprise at the level of resentment and unhappiness on the ground is indicative of how badly they had been betrayed by the people they surrounded themselves with. With their huge machinery and wide range of grassroot organizations, feedback channels, how can they not know?

They are not and will not be the only emperors who get be caught out by the sycophantic crowd. There will always be self-serving sucker-uppers who seek only to further their own fortunes by selectively telling their masters the 'truth' they want to hear.

Perhaps the first step in the transformation of the PAP is to weed out these self serving elements from within.

Doing the right operation..... ala Dr Vivian Balakrishnan

2011-05-10T00:56:00.000-07:00

Dr Vivian Balakrishnan provided an interesting analogy of the consultative approach he advocated for the PAP in the future.

Stressing the value of communication, he said: "It's not good enough just to do the right operation ... It's very, very important to talk to the patient - to explain these choices and the different trade-offs and make sure the people of Singapore understand this and participate more actively in the decision-making process."

Words of wisdom. Lessons learnt .... apparently.... until you note the first part of what he actually said: "....It's not good enough just to do the RIGHT operation".

So what he actually meant was that the PAP was right all along, and that the electorate had misunderstood all along. The PAP only failed in so far as it did not persuade the electorate of its 'rightness'. Informed consent to him, is to persuade the patient to agree to the correctness of the solution administered. Really?

Sodesne !.... And all the while I thought they were going to be truly more consultative.

To be fair, his boss, PM Lee had in the post-election press conference hinted at a future more inclusive relationship with the electorate: "And that means not only the Government working hard on its own with a population of passive but engaging Singaporeans in the more difficult decisions and trade-offs which governing Singapore involves. There are often no easy choices and the more we can appreciate this and grapple with the dilemmas and the trade-offs together, I think the better the answers we'll come up with, and the more we'll be able to have workable solutions."

I for one am truly hopeful that there will be a reformed PAP that will seek to lead rather than rule. They have done a magnificent job thus far as rulers, but I want much more than that. I really want to see them enter into a new social contract with Singaporeans, one that includes a greater degree of engagement and involvement in decision making with respect to critical problems. But the real deal-breaker is whether they trust Singaporeans enough to be transparent in their decision making processes. Or whether they will just continue to pretend to be consultative, but secretly (well, not so secret...) go on believing they have the only truth and only real solution, and just work harder to convince Singaporeans to be compliant.

I think that would be a disaster.

I am proud of you, Singapore

2011-05-06T18:25:00.000-07:00

For the first time in many years, I can say I am proud to be a Singaporean. Not just happy to be a beneficiary of GDP growth, but actually proud to be witnessing this exciting political awakening in Singapore, and this spontaneous outpouring of passion and nationalism around GE2011. True, the nationalism at times sounded somewhat xenophobic, but I don't believe the true emotions behind all that bluster about foreigners truly stems from xenophobism.

Specifically, I am so pleased to see

a] the relatively "clean" campaigns that all the parties have been running. True, the ruling party has had more than a moderate excess of campaign advantages on their side, but I think this has been relatively 'muted' (or not as effective) during these elections. Certainly there has been a minimum of personal attacks launched;

b] the PAP come to terms with the heart behind the cold rationality of their otherwise effective policies. True, this has been more forced upon them by the strong opposition showing than spontaneous development from with the party, but it is better this than not at all. I just hope that this is a true indication of changes within the party logic so that we will see a more wholesome PAP in the future;

c] the ability of the opposition to attract better qualified people into their fold. Particularly surprised and impressed by the ability of the SDP to re-engineer itself away from the self-destructive unnecessarily combative antics of their leader.

d] the emergence of a true-blue Singapore folk hero from the ranks of the opposition parties, such as Mr Chiam See Tong. He has so much love and respect from us all, and he will be so much missed when he finally retires. The sad reality is that he has run out of time, but this should not detract from his immense achievements on behalf of all Singaporeans;

e] the increasing confirmation and acceptability of Mr Low Thia Khiang, also Ms Sylvia Lim as clear definitive opposition voices on behalf of us all. He is another hero in the making, but not yet;

f] the public participation of professionals such as Assoc Professor Tambyah on the opposition platform. There had always been constraints for professionals within gov and quasi-gov institutions to be seen publicly consorting with the opposition, so Assoc Professor Tambyah's very visible participation in opposition politics is a significant milestone and very much welcomed. I truly hope that MoH will not be reactive and start to clip his wings. That would be a a monumental mistake, I think. Certainly the public will watch and pass judgement on such vindictiveness.

g] the emergence of online The Temasek Review and The Online Citizen as alternative voices for the mainstream media. Thank you guys. Please soldier on and do not give up.

h] and most heartwarming of all was the demonstration that the pledge taking can be such a stirring and emotional event as seen at the opposition rallies. Thank you so much to the opposition parties for making use of the pledge in that way (yes, they were making use of it, but thanks anyway). For too long, pledge taking had come across as formal, dead and uninspiring. Almost as if we were being punished.

So it is truly a watershed event, this GE2011. Congratulations Singapore. I am so proud, whatever the outcome.

The Singapore Pledge, as never heard or witnessed before

2011-05-05T18:53:00.001-07:00

The Singapore Pledge

One of the amazing and most memorable things about this GE - seeing the Pledge taken as passionately and so committedly as never witnessed before in all the years since independence.

And this coming from an opposition rally.

Where and how did the PAP get it all so wrong?

Associate Professor Paul Ananth Tambyah's speech at the SDP rally

2011-05-05T18:26:00.000-07:00

I am proud to be able to post a link and copy of Assoc Prof Paul Ananth Tambyah's recent speech here on this blog. Hope it reaches a wider audience because of this.

Assoc Professor Paul Ananth Tambyah's speech video

Friends, fellow Singaporeans

My name is Paul Ananth Tambyah. I am a doctor working at a major local university hospital. I am not a member of the SDP partly because I work in a corporatized civil service organisation and as you know, civil servants cannot enter politics unless they are unemployed. I am grateful to the SDP for giving me this opportunity to be a guest speaker at this famous historical platform. I am speaking entirely in my personal capacity. I am not a politician. I am still doing my national service and in fact have two SAF 100s sitting in my inbox despite the fact that my job involves saving lives.

As a medical doctor, I come into contact with patients on a regular basis. I hear them tell me that in Singapore, you can afford to die but you cannot afford to get sick. I see people who have to sell their homes and move into rental flats to pay for their medical bills. Do you think this is right?

They are Singaporeans just like the Health Minister and his millionaire colleagues. If they need a bypass, they have to pay much more than $8/- in cash. At the very minimum, they have to pay cash for the Specialist Outpatient Clinic charges before admission. I have written letters, articles, posted on Mr Khaw’s facebook page, met him in Feedback sessions. He gives me polite answers but nothing changes. That is why I am here today - To ask you to help me to send him a message. I just wanted to send him a simple message to have a heart for Singaporeans who are sick. Now I realise that the message that you are sending is a little stronger – you want to send him somewhere.

Mr Khaw is a good administrator. He was the CEO of NUH when I was a medical student and ran the hospital with a much smaller staff than any of the current restructured hospitals. But he seems to have run out of ideas for Singapore’s healthcare. It is good that he is finally listening to the voice of the people but perhaps it is a little too late. He might need to seek alternative employment and would make a very good administrator of a nursing home in Johor Bahru.

The problems with our healthcare system are known to you all – mostly they are about money.

The major source of healthcare financing is Medisave – the first of the three Ms. Most patients in hospital are elderly. They have little in their Medisave accounts and depend on their children. Fortunately for that generation, they had many children and their children’s Medisave can cover most of their hospital bills. My generation however, is the “stop at two” generation. We have even fewer children ourselves. When we get sick, who is going to be able to pay our bills if we depend primarily on Medisave as our own Medisave is depleted for the previous generation.

Medishield is a compulsory health insurance program that we all have to pay into from the time we are born. Problem is that it excludes congenital illnesses and mental illnesses which affect 5% of the Singapore population. It is the only national compulsory health insurance in the world that practices such cherry picking.

Medifund the endowment fund is limited to those who have already sold their homes and exhausted their children’s Medisave. Every year it is not fully utilised as it is so restrictive.

These problems however, are more than just theoretical ones. They affect the lives of ordinary Singaporeans. A Patient of mine has an infection that has caused him a stroke. He needs medication that costs more than $250 a day. There is no subsidy for this medication . It is recommended in all the guidelines including local guidelines. If he does not take this medication, he will most likely have another stroke and could even die. I tried to help him by appealing to the medical social worker. We received the reply that he was unlikely to get help as he lives in a private condo with one of his sons. The other five siblings are not well off but this one son living in a condo disqualifies this citizen of Singapore from financial assistance. We even went to the extent of writing a prescription so he could buy his medications in Johor Baru but this did not work. How many people do you know living in condos with their own families can afford to pay $250 a day or $7500 a month for medications for three to six months on top of the needs of their own families??? There is something seriously wrong with our system.

The SDP has an alternative proposal. It is a well thought out document and can be crystallised into a number of key points. First, increase the investment in healthcare to first world levels. In fiscal year 2009, the Singapore government spent only 1.4% of GDP on healthcare – the lowest in the developed world. This is partly because our population is still young but it is also because such a large proportion of healthcare costs are borne by the people – you and I – mainly through our Medisave – our own money. One of the key elements in the SDP plan, their shadow budget and in their economic plan is raising the healthcare budget significantly up to three times.

Second, focus on primary healthcare by bringing care to the people using nurse practitioners and allied health professionals in void deck health centers. These do not need to be run by doctors – nurses and physiotherapists and occupational therapists can manage chronic illnesses much more responsively and cost-effectively.

Third, reduce the crunch on healthcare workers in public hospitals by allowing GPs and specialists to work in the public hospitals. Singapore does not really have a shortage of doctors (unless our population really gets to 6.5 million) – it is more a problem of maldistribution. Public hospital doctors and nurses are overworked and overstressed. Doctors and nurses are leaving the public hospitals en masse because of work conditions. Once they leave, however, many GPs end up with problems paying the exorbitant rentals demanded by the HDB and other landlords. They thus have to raise charges or are forced to do cosmetic procedures. These hard working skilled Singaporean GPs could be better deployed in our public hospitals instead of depending on overseas foreign medical staff who may not speak the local languages.

Healthcare is not the only area where a message needs to be sent from the people of Singapore. My 73 year old mother has dedicated her entire adult life to the support of disabled children because she believes that every child should be allowed to develop to their fullest potential regardless of disability. She started Singaproe’s first school for multiple disabled children and the first program to comprehensively integrate children with disabilities into mainstream schools. She was Singapore’s woman of the year in 1994. How much did she get paid for all this? Nothing! We were fortunate that my Dad worked hard and had a good job but she worked tirelessly, often late into the night because of passion and love, not for money or power. Right now, her major campaign is for disabled children to be included for compulsory education in SG. This is what the parents want, it is only fair. In fact, it will save the government money in the long term if all disabled children are educated and are less of a burden on society when they grow older. But this is something that the current government does not seem to understand. As we have seen with Jee Say’s economic masterpiece, a government that is obsessed with annual KPIs and short term gains,cannot see far enough into the future. They cannot see how an investment in people can bring Singapore up to the next stage of development in the long run.

Vote wisely this election for yourself, your children, your grandchildren, your neighbours, young , old, Sick, well, we are all Singaporeans. Do not be afraid that someone will track your vote. It is impossible. They cannot even catch a limping man in a baju kurung swimming across the sea with a rubber ducky how are they going to track down the more than one million Singaporeans who will vote for alternative parties on Saturday! Like Mr Tan Jee Say, I voted for the opposition the last time I voted. In 1991, I voted for the Singapore Democratic Party. Nobody knew how I voted. I have received several promotions in both work and even in my reservist unit. Last night, I spoke at the Rally in Sembawang. No one in authority called me up to tell me that my career was over. My Dean and Vice Chancellor are good and reasonable people and they value a diversity of views as they know that this is good for Singapore. Finance Minister Tharman has said on TV that it would be good for Singapore to have a strong opposition.

My time is running out. These are excellent people here in the SDP lineup. Like many in the PAP, they want the best for Singapore. Unlike the PAP, they do not demand huge financial rewards for serving the country. They also have a very different vision of how to achieve the best for Singapore. It is not a top down, “we know better” approach but it is all about you. Two weeks of campaigning have made the government finally listen to the people – make unprecedented apologies, take notice of the issues. Think what five years could do.

Dr Vivian Balakrishnan is an excellent eye surgeon. Singapore needs good eye surgeons. You can help return him to clinical practice. I wish I could vote in Yuhua, Bt Panjang, Holland Bukit Timah or Sembawang but I live in Tanjong Pagar. I was denied the right to vote by 35 seconds., That is the Singapore of today. IT does not have to be the Singapore of tomorrow. The future is in your hands vote wisely. Thank you.

The General Elections - die die also must say

2011-04-30T17:35:00.000-07:00

These are interesting times. As some have already pointed out, this elections will prove to be a watershed one. A milestone. Whatever the outcome and no matter how much MM Lee wants to downplay it, I believe the consequences will be immense and the results will significantly shape the Singapore of tomorrow.

I am not a political commentator and generally have stayed away from directly commenting on political issues. Maybe indirectly shoot some arrows, but generally I have been quite content to just grumble from the sidelines. I am generally not a political person. Afterall am I not a happy-happy beneficiary of the stable gahment that has allowed me to be educated and trained to be able to provide for my family as a medical professional? I am comfortably ensconced in Singapore society. What is there to really complain about? When I am overseas, who do you think I root for, and defend when others criticize developments in Singapore?

So the recent outpouring of apparent wrath against the ruling party in this 2011 elections seems a bit of a mystery to me. Has not the gahment of Singapore, achieved wonders in bringing a resourceless Singapore into developed nation status? We are the envy of many around the world. The little red dot is only little on the map; we punch way above our weight in the world. By any measure, we have a fantastic gahment here in Singapore.

Yet people are unhappy. Why? Minister George Yeo, MP for Aljunied accused the opposition for imposing an emotional burden on the voters, yet paradoxically, here lies the true emotional burden - that the electorate must struggle between supporting an otherwise effective gahment, and the feeling of heaviness and dissatisfaction, that somehow things are not as good as the official statistics tell us.

People feel marginalized and neglected. It is not that Singaporeans are xenophobic or hate foreigners, even though the tone of comments expressed during hustings may suggest it. No, Singaporeans are not xenophobic. It is merely the feeling that their own gahment appears to value foreigners more than its own citizenry. This is probably not true, but the perception is very pervasive. This is where I believe, the gahment has failed. It has failed in managing public perceptions and expectations with respect to immigration, foreign labour and economic growth. It is fantastic that our economy and GDP continue to chug along at a healthy rate, but the perception on the ground is that the benefits appear to accrue mostly to the elites and the wealthy in Singapore. The gahment's reach out to the poor, the weak and the marginalized is often grudging and calculative. Paltry sums considering the size of our budget surpluses and national reserves. Can we do more? Of course we can..... and please don't tell me this is tantamount to raiding our national reserves. MM Lee's comments about the elderly working till 85 was supremely insensitive although I don't think he intended it. Choosing to work till you are 85, is really not the same as being compelled to work to survive until 85.

Being in power, unchallenged power, for such a long period of our history has bred a level of complacency so that leaders do not feel that the public needs to understand or seriously discuss issues. The most expedient way of going where you want to go is unfortunately via a top-down dictatorial approach. This approach has been over-used. Has there been enough planning and discussions?.... Not much apparently.

In the biomedical area, this lack of planning and discussions have wreaked real havoc in the system. Take for example, the hospital clusters. We have over a period of 20 years gone through various levels of clustering, and declustering, and now re-clustering. Each Minister that comes along pushes a hobby-horse position. Hardly evidence of long term planning. Medical manpower planning? Hardly any, apparently - because we have flipped-flopped from too many doctors, to the present situation of being desperately short of doctors. Suddenly we require 3 medical schools..... of 3 different educational systems? This is planning? Almost overnight, the US residency programme was foisted upon all and sundry. If there had been any long term planning, it was far from evident. Medical education is now in a mess. We have an undergraduate and a postgraduate system existing side by side. We have flirted with problem-based learning, then discarded it. We have integrated and disintegrated the curriculum. And we have the really bizarre situation where our medical students are not expected to have studied biology. Duh? And we are expected to believe there is someone somewhere who is responsible for planning all this?

No one discusses this publicly because everything is driven from the top. Very heavily driven.

Foreign talent is critically important for us to push towards excellence. But without appropriate signals that policy makers are concerned about protecting the interests of our home grown and local medical/biomedical professionals, one cannot avoid feeling that the economic pie is not really for local consumption. The mass of biomedical and life science graduates and postgraduates we produce annually find it hard to find jobs in the sectors they have trained for, despite the very rapid expansion of the biomedical sector.

Whatever the results of the elections, there is no doubt they will be important. I don't think the PAP will lose the right to govern. But I think it is vital for the ruling elite to recalibrate its way of doing things... to relearn how to communicate with the people it seeks to lead. If they truly believe they are servants of the people, they must make this evident. And stop being just rulers.

gerrymander, salamander....

2011-04-28T00:57:00.000-07:00

I was curious about the word gerrymander....thought it a bit strange and that somehow it had been derived from the salamander. True enough, it was.

According to my trusty reference for all things I would otherwise have been too lazy to go find out, Wikipedia, the word derives from a certain Gov Elbridge Gerry of the USA who, in 1812, redrew the district of Essex in Massachusetts to benefit the Democratic-Republican party in the elections. And as the shape of district was so bizarre, the press mis-characterized the cartoon creature as a salamander. Thus was born the word Gerrymander.

"First printed in March 1812, this political cartoon was drawn in reaction to the state senate electoral districts drawn by the Massachusetts legislature to favour the Democratic-Republican Party candidates of Governor Elbridge Gerry over the Federalists. The caricature satirises the bizarre shape of a district in Essex County, Massachusetts as a dragon. Federalist newspapers editors and others at the time likened the district shape to a salamander, and the word gerrymander was a blend of that word and Governor Gerry's last name."

Can you spot the salamander here?

Top down? Or bottom up?

2011-04-24T06:41:00.001-07:00

I think most organizations have a similar vertical structure.

People at the top, stern countenance notwithstanding, tend to see life as being rather rosy, and the view below them as being populated by trouble-making, poo-heads. The view from the bottom, is really quite different. When they get to see anything through the droppings, all they see are contracting orifices.

The situation is clearly made worse by group-think at the top, and the propagation of a monolithic logic down the ranks.

Selling off our heritage

2011-04-24T05:56:00.000-07:00

Some 5-10 years ago, as if at a given signal we started all this nonsense about naming buildings and institutions after dignitaries and philanthropic donors. Now, I don't really care if they name new (or even old) buildings after people who give lots of money. Nor do I particularly care if they want to name institutions and buildings after local 'heroes' and prominent figures who have contributed much to our nation building. But naming established institutions after people who just give money is, I think, way over the top.

I beilieve the NUS was one of the first to lead the charge. The School of Medicine particularly. I for one, was aghast when heard they named the grand old School of Medicine after a Yong Loo Lin. 'Yong who?' was my first response. How could they? Here was my old alma mater, 100 years old, with a proud heritage.....gone overnight. Morphing unceremoniously into the Yong Loo Lin of Medicine. "Yong-who? School of Medicine?" . No consulation with staff.....or alumni. Talk about a top down approach. Many of my contemporaries had been equally appalled. A heritage sold. No matter how the School of Medicine insists on the continued heritage, there is no doubt it had all been destroyed by the stroke of a pen.

How much was the heritage worth? One hundred million bucks. Sounds big doesn't it? Until you realize how big the annual operating budget for the school is. Let me tell you one hundred million dollars doesn't really go very far. Consider for example, that the NUS operating expenditure is in the range of $1.5 billion.

And so we sold the hundred year heritage for a hundred million dollars. One million for each year. How callous, and tragic (not to even mention that the old original building of the medical school, the female asylum, had much earlier on, been bulldozed over to build a carpark!).

This was most certainly one of the straws that led to the final one for Dr Tan Cheng Bock. He finally resigned in exasperation from the board of Jurong Hospital when they decided to name the hospital after Ng Teng Fong, whose family had also donated some money.... some $125 million of it. Again while the sum may appear big, it is also small compared to the $1 billion the government is spending on the hospital.

So what gives....?

Seems to me that our idea of Total Defence includes the protection our heritage, because it is our heritage that holds us together and gives Singaporeans a sense of that common history and vision for the future. Seems to me that the selling off of our heritage for a paltry 30 pieces of silver is not working in our favour, and undermines all the effort in the building our total defence.

It is time to take stock.

Death of Physiology....and of medical education?

2011-04-19T17:44:00.000-07:00

Hot on the heels of my preceding 'rant' on groupthinks and health/education, here is an article by a leading physiologist and Emeritus Professor in King's College, London, Prof RJ Naftalin. Needless to say our medical educational system is pretty much hurtling down this road to disaster.

I reproduce an abstract here, and the full article can be read at The Scientist

Opinion: The decline of physiology
Medical schools in the UK are teaching physiology courses primarily focused on clinical applications with much curtailed practical laboratory training to the detriment of medical education. Prof RJ Naftalin.

Clinicians now take a leading role in pre-clinical teaching, largely displacing pre-clinical scientists who are more in touch with basic physiological processes. Scientific content taught in the context of clinical problems omits much basic science, which is regarded as inessential digression from the clinical problems upon which the course is centred.

Another factor contributing to the decline of physiology courses has been the loss of physiology departments as a result of their merging with schools of biological, life, health, or medical sciences. Only one or two discrete academic physiology departments remain in the United Kingdom. Resource allocation within the preclinical schools, formerly controlled by academics working at the pre-clinical faculty or departmental level, is now centralized and controlled by senior administrators and clinicians. The financial and man power resources are redirected towards the more highly prioritized needs of the medical school rather than to science departments.

Election fever!

2011-04-19T16:55:00.000-07:00

So the long awaited election date has been announced, and the main stream media has predictably been insufferably carpet bombed with stories of huffing and puffing politicians doing their rounds and making promises.

Cynically, I must say the so far the most interesting stories have been about Tin Pei Ling's feet stomping on YouTube, and Mr Lim Boon Heng being moved to tears on the suggestion that the political leadership suffered from a 'groupthink'.

Made me wonder what the definition of groupthink actually was.

According to my most reliable source of knowledge, Wikipedia, "Groupthink is a type of thought within a deeply cohesive in-group whose members try to minimize conflict and reach consensus without critically testing, analyzing, and evaluating ideas. "

Is the political leaderhip at the highest government level deeply cohesive? I believe so. Are they trying to minimize conflict and develop consensus? No reason to doubt that. So what is the problem? Really, it is about whether the consensus are reached without critically testing, analyzing and evaluating ideas. Herein lies the the difficulty. Can ideas be fully tested and evaluated behind closed doors within a small in-group, especially where there are strong ideological positions? I am not so sure. Even when discussions are taken beyond the inner sanctum, as long as they operate within party constraints, can truly critical evaluations be made? I seriously doubt it.

So while Mr Lim Boon Heng insisted and believed there was no groupthink, I am not so convinced. I for one believe that Singapore will be a much stronger and cohesive society if the political leadership could trust civil society a bit more, and would allow for more and broader public debate on critical issues.

Having said that I must qualify that I don't believe that the problems we have on the ground are fundamentally a result of any groupthink occuring at the top. In my opinion, the problems we see all over the place are largely related to the middle managers implementing extreme forms of a 'monolithic logic' derived from otherwise 'sensible' policies generated at the top. And by middle managers, I refer to that thick layer between the top echelons of political leadership and the workers.

What have these to do with Gigamole? I think health and education have been badly affected by this. Lots of giraffes.

What have giraffes got to do with this discussion? Read here.

Traditional medicine and all that Andy Ho stuff......

2011-02-24T20:57:00.000-08:00

Andy Ho did us all some service when he wrote that pretty accurate piece about the placebo-ness of traditional chinese medicine (TCM). Pity, but expectedly I suppose, he caught a lot of flak over the articulation of those truths.

What disappointed me most in the whole episode was the realization that the Singapore Medical Association was all for the legitimization of TCM, because by their response, they are signalling rather publicly their intent to maintain their role as a trade guild rather than a professional association. It's all about earning those few extra bucks peddling snake oil if necessary, since the patients seem to want it. Shame, shame.

So what is traditional medicine? Really nothing more than a primitive form of rationalized medicine based on empirical observations. No mystery. Nothing more, nothing less. The Chinese are not the only people who engaged in such practices. Our good old friend Hippocrates, whom many of us would regard as the father of modern medicine, was famous for his practice of observational medicine. Not that his theories were correct, or that his cures are still being applied today, but he based his practice on rather astute but emprical observations of the world around him at that time. So did many physicians over the years, until modern scientific theories caught up with practice of medicine.

TCM is the Chinese form of that empirical practice. It has maintained its mystique today to a large extent because in the isolation of the cultural revolution, TCM was pretty much all that was available in rural China. Now that mystique is carried by the sentimentalities of the very (very) large Chinese diaspora.

One can predict, very legitimately, that traditional or TCM when brought to its logical conclusion will very much resemble modern medicine. Useful herbs are of limited utility until the active ingredient is identified, purified and proved in clinical trials. Until that happens, TCM will remain a fairly emirical practice. Placebo effects? Perhaps.

So let's be very clear about it. TCM is a stunted version of rationalized medicine. There may be some limited utility to the herbs being used, but it will remain stunted because of the empirical environment it remains locked within. Much research is required, and much willingness to move out of the box of traditional sensitivities.

The SMA needs to get back to basics and hold on to the truths and defence of science and professionalism.

Miracle of birth

2010-12-23T06:58:00.000-08:00

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...

2010-12-20T13:33:00.000-08:00

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.....

2010-12-19T14:18:00.000-08:00

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

2010-12-10T00:20:00.000-08:00

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?

2010-11-29T22:39:00.000-08:00

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

2010-11-29T17:44:00.000-08:00

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?

2010-11-29T16:45:00.000-08:00

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?

2010-11-29T16:37:00.000-08:00

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"

2010-11-23T18:21:00.000-08:00

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

2010-11-17T16:23:00.001-08:00

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.

2010-11-16T17:44:00.001-08:00

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?

2010-11-14T01:18:00.000-08:00

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?

2010-11-12T17:04:00.000-08:00

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!!!

2010-11-05T00:04:00.001-07:00

Organ trade tenesmus in Malaysia

2010-11-04T23:38:00.000-07:00

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

2010-11-04T23:15:00.000-07:00

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?

2010-11-03T21:05:00.000-07:00

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

2010-11-01T18:17:00.000-07:00

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

2010-11-01T17:17:00.000-07:00

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

2010-10-18T17:23:00.000-07:00

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

2010-10-18T16:36:00.000-07:00

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

2010-10-03T17:32:00.000-07:00

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

2010-10-03T17:00:00.000-07:00

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...

2010-09-23T15:01:00.000-07:00

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??

2010-09-21T22:06:00.000-07:00

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?

2010-09-10T19:42:00.000-07:00

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

2010-09-10T19:20:00.000-07:00

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

2010-09-09T17:01:00.000-07:00

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

2010-09-09T16:33:00.001-07:00

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

2010-09-03T18:14:00.000-07:00

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.

2010-09-03T08:41:00.000-07:00

Does YLL SOM have anything to worry about?

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

2010-08-18T01:08:00.000-07:00

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?

2010-08-17T23:51:00.000-07:00

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?

2010-08-10T08:35:00.000-07:00

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!!!

2010-08-09T06:07:00.000-07:00

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

2010-07-24T18:13:00.000-07:00

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?

2010-07-22T21:39:00.000-07:00

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...

2010-07-16T18:24:00.000-07:00

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?

2010-06-25T23:16:00.000-07:00

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.

2010-06-25T20:30:00.000-07:00

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?

2010-06-22T22:59:00.000-07:00

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.

2010-06-22T17:26:00.000-07:00

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...

2010-06-15T02:57:00.000-07:00

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....

2010-06-04T19:15:00.000-07:00

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

2010-05-30T15:25:00.000-07:00

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?

2010-05-27T17:15:00.001-07:00

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

2010-05-26T23:35:00.000-07:00

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.

2010-05-26T21:53:00.000-07:00

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?

2010-05-25T20:41:00.000-07:00

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

2010-05-18T01:06:00.000-07:00

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.

Ethics of prophylaxis

2010-05-17T16:42:00.001-07:00

Recently the issue of the fluoridation of our drinking water was raised in parliament, to which Minister of Health Khaw gave a written defence.

We have had fluoride in our drinking water since 1954, and it is without doubt the most effective way to protect growing teeth against caries. But it's been more than 50 years, and we are now no more a backward rural third world community with poor dental hygiene. Do we still need that paternalistic hand of protection shovellings fluoride down our throats?

It just made me wonder about what the ethical issues are with respect to governments forcing public health prophylaxis upon citizens. De we have a choice or say in the matter?

No doubt the government has a responsibility to impose public health measures on the population for the public good. I can think of compulsory seat belt laws, or crash helmet laws.... but then these are to protect against serious potentially fatal risks. Compulsory vaccinations at birth.... but these may be defended because they protect the vaccinated and people around them against serious diseases.

Fluoridation does not much more than protect against dental cavities.... an almost trivial concern by comparison. Plus, there are alternative ways to protect the teeth.... good hygiene, fluoride in toothpastes, etc. The public does have a choice in the matter.

How about fortification of milk or beverages with all sorts of vitamins and good-for-you kind of stuff, you say? These are not mandated by law.

So how ethical is it for a government to spike the drinking water with fluoride and force its citizens to consume excessive fluoride? I wonder.

Good leader, or a bad follower....?

2010-05-14T17:25:00.000-07:00

Dr Goh Keng Swee's passing made me ponder a bit about what set him apart so clearly from his contemporaries, and identified him, for me at least, as one of the truly great leaders of his time.

I think it was for me, his clarity of vision and firmness of conviction, and his ability to translate that into down to earth policies that were able to galvanize his followership into achieving wonders for our small island state.

And I think of so much of what's happening in the medical community and our main medical school that disappoints because so much of our 'leadership' appear unable to see beyond blindly following an 'American model'. Where is the vision and self belief that can galvanize our community into achieving true greatness? Instead, the lemming-like dash towards an US residency system continues to baffle everyone about what it is supposed to be achieving. The medical school has been similarly impressive with respect to its pig-headed commitment to policies and pedagogical fads that now is threatening to unravel the very core of medical training.

So here I am wishing instead, that a true leader like Dr Goh can step forward within the medical leadership (MOH or NUS or MOE, or whatever...) and remove the blinkers from their eyes and see the destruction their poor followership has been wreaking on the medical community.

Dr Goh Keng Swee - Requiscat in pace

2010-05-14T17:17:00.000-07:00

Dr Goh Keng Swee, Robert, 吴庆瑞

6 October 1918 – 14 May 2010

The passing of a great Singapore leader. Requiscat in Pace, Sir.

Ineffective screening for breast cancer?

2010-03-29T06:37:00.000-07:00

A new study published in the British Medical Journal has raised new questions about the effectiveness of large scale breast screening programmes.

The report in Times Live can be found here. The abstract of original paper in the BMJ here.

The Danish study reports that they were "unable to find an effect of the Danish screening programme on breast cancer mortality. The reductions in breast cancer mortality (they) observed in screening regions were similar or less than those in non-screened areas and in age groups too young to benefit from screening, and are more likely explained by changes in risk factors and improved treatment than by screening mammography."

Late last year the U.S. Preventive Services Task Force (USPSTF) revised the recommendations for screening mammograms in women between 40-50 years of age.

Methinks it's about time our breast oncologists did some serious and honest review of the situation, though I seriously doubt they will say anything other than to defend the need to do lots more screening.

Climatology - Post-Normal Science

2010-03-21T02:06:00.000-07:00

Some might wonder why discussions about climate change often sound as if it was more of a debate about religion than it were about science; and fret about how political the whole issue has become. All this has apparently been because Climate Science is typical of a 'new' kind of scientific process called post-normal science (PNS).

Actually post-normal science (PNS) is not that new. It was first proposed by a pair of academics, Silvio Funtowicz and Jerome Ravetz in 1992 to characterize that type of scientific process that dealt issues of some urgency and where facts are sparse and uncertain. It is in effect, a kind of problem solving approach to complex science related issues. Because of the unavailability of good accurate data, all kinds of data from non-traditional sources can be used in finding urgent resolution to the problem. much of which did not require validation or proof. Much of medical science can be of this sort, where significant uncertainty exists in the management of critical and urgent clinical problems.

The Wikipedia entry reads: "According to its advocates, "post-normal science" is simply an extension of situations routinely faced by experts such as surgeons or senior engineers on unusual projects, where the decisions being made are of great importance but where not all the factors are necessarily knowable. Although their work is based on science, such individuals must always cope with uncertainties, and their mistakes can be costly or lethal. Given the greater importance of climate systems and the fact that less is known about them, conventional methods of inquiry, based on determining all relevant information before proceeding, are too slow and uncertain to deal with an issue too complex to be fully understood and too important to wait for confirmatory results."

Because this form of scientific approach cuts short many of the processes required to generate accurate and detailed data, it is important that the process relies on an 'extended peer community' (EPC) to provide quality assurance for the proposed solutions. This EPC consists "not merely of persons with some form or other of institutional accreditation, but rather of all those with a desire to participate in the resolution of the issue."

Funtowicz and Ravetz further point out that "Statistical theory tends to undervalue another sort of error, ironically called Type III, when the whole artificial exercise has no relation to the real issue at stake. Type III errors are a characteristic pitfall when the ‘normal science’ approach is deployed in post-normal situations. Modelling exercises are particularly prone to this sort of error, as when the gap between the available data and a manageable model on the one hand, and the real policy situation on the other, cannot be bridged."

The PNS approach is without doubt effective and necessary. However it does have a tendency, because of its relative lack of traditional scientific rigour and objectivity, to drift into an approach that is resembles activism or advocacy. Without checks and balances, the solution soon becomes orthodoxy. That is why the 'extended peer community' is essential to keep this paradigm 'honest'

The science of climate change fits exactly into this form of a scientific approach, being complex, urgent and bereft of good accurate data and understanding. The problem with it has been that the protagonists in the story got carried away with their zeal and lost their objectivity. The solution became orthodoxy. They proclaimed the science settled, and excluded the EMS, branding them deniers and skeptics etc. In so doing, they became advocates and activists. Some might say priests of a new religious order.

Ravetz's own critique of climate change as PNS is recommended reading.

He writes: "We can understand the root cause of Climategate as a case of scientists constrained to attempt to do normal science in a post-normal situation. But climate change had never been a really ‘normal’ science, because the policy implications were always present and strong, even overwhelming. Indeed, if we look at the definition of ‘post-normal science’, we see how well it fits: facts uncertain,values in dispute, stakes high, and decisions urgent. In needing to treat Planet Earth like a textbook exercise, the climate scientists were forced to break the rules of scientific etiquette and ethics, and to play scientific power-politics in a way that inevitably became corrupt. The combination of non-critical ‘normal science’ with anti-critical ‘evangelical science’ was lethal. As in other ‘gate’ scandals, one incident served to pull a thread on a tissue of protective plausibilities and concealments, and eventually led to an unravelling. What was in the e-mails could be largely explained in terms of embattled scientists fighting off malicious interference; but the materials ready and waiting on the blogosphere provided a background, and that is what converted a very minor scandal to a catastrophe."

An early post by Elizabeth Bury (before Climategate broke) on this issue is also a good read.

Impact of climate change in Singapore??

2010-03-19T18:31:00.000-07:00

In 2007, Environment and Water Resources Minister Yaacob Ibrahim announced a 2 year research programme to "gauge the impact of global warming". Implicit in that announcement was that global warming was already a given. The study was merely to look at the impact of such a certainty.

Recently, Minister Yaacob announced some findings of that study by the NUS Tropical Marine Science Institute that "by 2100 the average daily temperature here could increase by between 2.7 and 4.4 degrees Celsius from the present average of 26.8 degrees Celsius. In the same time-frame, sea levels could rise by between 24 and 65 cm". This is quite a substantial effect.

No mention here that climatology has recently been hit by a roiling wave of scandals which have threatened the very credibility of climate science altogether. The term "climategate" has been applied. Even the credibility and authority of the much vaunted IPCC’s 2007 Fourth Assessment Report (AR4) has been called into question. A considerable amount of the raw data that had been generated by the University of East Anglia Climate Research Unit has been called into question, and review of the data has been directed by Britain's Met Officer. And since it now appears that this set of data has been the main data set that other agencies have used as the raw data for the predictions, conclusions previously thought to be unquestionable, must now be questioned.

It is unclear what assumptions have gone into the NUS Tropical Marine Science Institute's computations. These assumptions are important, as is the raw data used to model the bold predictions the TMS Institute made for Minister Yaacob. Since, the report is not available for public scrutiny, either on NEA's website, or at the Institute's website, we cannot at the moment form an independent opinion of the validity of those predictions, and must depend on Minister Yaacob's summary presentation of those findings.

Assumptions are critically important in any predictions of future outcomes. Hopefully, the TNS Institute and the NEA will release these study report soon, so that the methodology and assumptions that were used in estimating the impact of any climate change of Singapore's environment impacclimate change can be understood by the public.

Cord blood banking - should you, or shouldn't you?

2010-03-17T01:10:00.000-07:00

There was some recent publicity (see here and here) about this issue, provoked by a comment made by Dr Irving Weissman on this issue. As the Director of the Institute of Stem Cell Biology and Regenerative Medicine at Stanford University, his comments are taken seriously. He was quoted as saying that parents were being fleeced by stem cell bankers, and likened them to fraudsters.

The International Society for Stem Cell Research (ISSCR) of which Dr Weissman is also head, was quick to point out that his comments referred to the sale of stem cell therapies rather than the banking of stem cells.

Nevertheless the issue of cord blood banking needs to be clarified.

Cord blood blanking promises to store cells from the cord blood of babies, with a hope that these cells can be used in the treatment of various diseases later on. The idea is that these cells have some potential to differentiate into various mature cells. However it is not usually pointed out that this potential is limited and that these cells cannot form organs or tissues, and cannot replicate adequately to populate an adult body.

It should also be recognized that cord blood cells are banked in two possible ways, as part of a public bank, where the cells can be used by anyone with the appropriate need, or as a private bank where only the donor uses the cells. This latter form of transplant is called an autologous transplant.

While the former has considerable merit, because kids with various diseases can potentially benefit by tapping into this bank, the latter autologous bank has very little to offer.

There are relatively few proven indications for autologous transplants using cord blood, as compared to the heterologous use of cord blood. Furthermore the chance that a child will be able to use his own stored cord blood is very small.

The American Academy of Paediatrics (AAP) produced a policy statement on this issue in 2007. Their position hasn't changed since then. In the document they say: "Because there are no scientific data at the present time to support autologous cord blood banking and given the difficulty of making an accurate estimate of the need for autologous transplantation and the ready availability of allogeneic transplantation, private storage of cord blood as “biological insurance” should be discouraged."

Singapore has a public cord blood bank, called simply the Singapore Cord Blood Bank. They are doing good work and should be supported.

There are two private cord blood banks, Stemcord and Cordlife.

Their claims are that the cord blood can be used to treat an extremely wide range of diseases. Read their claims for yourself : for Stemcord, and for Cordlife.

Read the above for yourself, and take into consideration the AAP's policy statement: "Cord blood donation should be discouraged when cord blood stored in a bank is to be directed for later personal or family use, because most conditions that might be helped by cord blood stem cells already exist in the infant’s cord blood (ie, premalignant changes in stem cells). Physicians should be aware of the unsubstantiated claims of private cord blood banks made to future parents that promise to insure infants or family members against serious illnesses in the future by use of the stem cells contained in cord blood. Although not standard of care, directed cord blood banking should be encouraged when there is knowledge of a full sibling in the family with a medical condition (malignant or genetic) that could potentially benefit from cord blood transplantation."

One wonders why the Ministry of Health and the Singapore Medical Council does not come down firmer on these unsubstantiated claims by private cord banks.