H1N1 (aka American flu) - time to end the confusion, MOH

I have been trying to give the MOH the benefit of the doubt with regards to the H1N1 thingy because it's just been such a difficult position for the Ministry to be in. But day by day, its indecisiveness is getting more and more disappointing and frustrating. And the growing public confusion is worrying.

Where are we now, and what is the real strategy with regards this infection? Do we take this seriously not not?

The MOH website doesn't contain much more than the latest stats, and an uninformative statement - "Though the number of infected cases has increased, the severity of the disease remains relatively mild. .... Singaporeans should carry on with their usual activities whilst observing good personal hygiene at all times. If unwell, they should see a doctor, stay away from work, school or crowded places, and rest at home."

Ummm...so helpful lor. If it's 'relatively mild' why this concern about staying away etc etc...?

The Straits Times today quotes an unidentified spokesman as saying "We are now preparing to manage the disease in a more targeted and risk-stratified manner".

Ummmm....that's even less helpful I am afraid.

And neither is the ST report from that interview, that Singapore is preparing to switch to the mitigation phase of dealing with the H1N1. Whatever that means. I mean, we are either containing or mitigating... being told that we are preparing to move to mitigation is like saying we want to be there, we should be there and we are going to be there. But where are we exactly?

Clearly the public is confused. And I really don't blame them.

Do we need to still control movement / contact and do voluntary home quarantine? Are all these temperature monitoring really necessary? There is just such a confusing array of containment strategies out in the schools and workplaces, that even more puzzling when you consider we are actually moving (preparing to switch?) to mitigation.

If we are not going to treat all H1N1 cases, and we are not going to swab all flu cases, why do we need, as the spokesman said, to "call 993 for an ambulance" if travelers get flu-like symptoms within a week of return from affected countries?

If the MOH wants the public to be participatory and to be engaged in the management of epidemics/pandemics such as this, information and instructions must be clear and unambiguous. Why do we keep fueling this paranoia if we are really not going to do anything substantive about it?

And we are really not having that clarity of mission at the moment.

Cat poisoning in Bayshore? Get those pest busters.....

So we are getting closer and closer to the answers behind the mystery of the poisoned cats in the Bayshore area. We are now told the the poison has been identified by HSA as alpha-chloralose.

No great mystery here. No cat hating vandals at work, I don't think.

Alpha-chloralose is a kind of anaesthetic that has been used for pest control. It is found in rodenticides (includes some moles, unsavoury relatives of mine) and pest baits for bird control.

In all likelihood this is the work of an overenthusiastic pest controller trying to get rid of rats (maybe after the Geylang Serai food court hysteria) or crows, mynahs and starlings in the vicinity.

I suggest the police follow up on the people in the neighbourhood who may have an interest in pest control.

Meanwhile, it will be interesting to find out who actually controls the import and use of pest control chemicals such as chloralose. I imagine it must be the AVA.

How about viromorphising ourselves?

Prof Paul Ananth Tambyah's anthromorphic view of the H1N1 virus got me thinking.

We are really no different from those wretched viruses are we? I mean after all it is the same evolutionary mechanism that drives us. We have to adapt and change to spread our genes across the globe.

In fact, if we think of ourselves as viruses, we are probably the most virulent and lethal organism responsible for the world's worst pandemic ever. And in that regard, we are really not a smart virus at all... so let us not run down H1N1 too soon. No, we are one of the most stupid viruses ever, because we are on the verge of totally destroying our only food source. Mother earth.

So shall we save Gaia?

Anthropomorphising the virus - Prof Tambyah's view

NUS' Prof Paul Ananth Tambyah's opinion piece in the Sunday Times today, about H1N1, entitled 'Understanding the 'mind' of a virus' provided an interesting and useful insight into evolutionary virology. He makes some interesting points - such as that among other things, if you want to be a successful virus you should try and avoid the host immune system, and not do silly things like killing off your food supply. By his reasoning through this anthropomorphising of the virus, he reckons this virus will not turn lethal.

It is an interesting model. But he is wrong.

This novel H1N1 should not be considered an separate entity from the other H1N1 viruses,or indeed the othe Influenza A viruses. It is more correct to view the entire family of like viruses as an entity - much like the cybernetic borgs in Star Trek. These viruses seek to propagate themselves, find a utilizable biological niche to occupy and as Prof Paul Ananth points, need to stay ahead of host immune systems by a constant changing of their disguise. If they remain genetically static,develop either useless non-infective characteristics, or virulent ones which may overdo their virulence and kill off the host. These are random events. There is a balance that a successful virus strain strikes, but it cannot keep that position indefinitely because the host immune system will eventually hunt it down, and destroy it.

The common cold and Infuenza A have been extremely successful in this constant change and adaptation and engaging us poor humans in this biological cat and mouse game. And they will remain very successful. Influenza A will from time to time produce a virulent and lethal strain. Statistics don't lie. It's only a matter of time. This strain may arise in the most unexpected of places; as this one did. And as we will not have the immunity for it, many will die. But the survivors of the the onslaught will live to fight another day. And they will be stronger. Until the next real pandemic arrives. And so on.

But such is life. Que sera sera?

H1N1 (aka American flu) - 1 million in the US alone?

So here's a new slant on the H1N1. Dr. Anne Schuchat of the U.S. Centers for Disease Control and Prevention has been quoted as saying: "We are estimating about a million people in the U.S. or more have gotten this virus... ,"

The laboratory confirmed positives are only 27,717, meaning the pick up rate is only 2.7%. I wonder what this means with regards to the alarmist estimates of fatality rates around 0.37% that we have been fed with? With an estimated denominator of ~1 million, the death rates would actually only be ~1/10,000, i.e. 0.01% in the US - far less than the fatality rates of previous pandemics and even seasonal flu.

I think health officials need to be a bit more realistic in their communications, and help us understand this better.

Tamiflu works? Give us some proper data to believe in.

This morning's report by Bertha Henson and Salma Khalik made a somewhat grandiose claim that so far Tamiflu has been effective in all but 2 patients treated.

I wonder how they can tell, since most of the H1N1 will recover even without treatment, and Tamilfu is known to do not much more than shortening the illness by only about 1-2 days? This of course, may be important is shortening the period of infectivity, and possibly also in limiting the extent of the disease, but without a placebo controlled clinical trial no one can be certain that Tamiflu actually does any good despite what lab tests tell us.

I am all for reassuring the public in this time of anxiety, but making unsubstantiated claims like this is really not good reporting.

Disciplinary tribunals are not law courts -....errrmmmm..... so what's the point?

The President of the Singapore Medical Association was prodded out of the kinda slumbering organization to respond to the 'akan datang' move to appoint non-medical people (chiefly their nemesis, lawyers) to Chair the Singapore Medical Council.

I think it is a rather unconvincing response, almost like he doesn't quite believe it himself. Which really underscores the passivity of the profession at the moment. Same for the Singapore Medical Council.

I do however agree with Dr Chong's last point: '...what medical ethics really needs is more moral courage and leadership so that public interest can be better served.' How true. But what has the SMC done that can truly be said to have shown moral courage and leadership? So far it's been hiding behind the law, and only taking to task those who have obviously flouted the 'law'.

If that's all the SMC cares to do, we may as well have a lawyer to Chair, instead of a doctor pretending to be a lawyer.

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Disciplinary tribunals are not law courts

I REFER to the letter by Mr M. Lukshumayeh last Saturday, 'SMC post: Don't get emotional, docs'. The writer has failed to understand the objectives of the Singapore Medical Council's (SMC's) disciplinary tribunals (DTs) and has mistaken the DTs for a law court.

The law courts are responsible for interpreting the law and for enforcing punishment when the law is broken. However, whatever is not prohibited by law remains legal and permissible, but may still be unethical. This is where professional tribunals like SMC's DTs come in.

The law cannot spell out everything but sets an absolute minimum for all to observe, while ethics and professionalism demand higher levels of conduct and behaviour than just obeying the law. This is the essence of professionalism and ethics, be it for doctors or other professions.

As such, SMC's objective is to uphold high standards of professional conduct and ethical behaviour among doctors.

Furthermore, the Singapore Medical Association (SMA) does not object to lay people or lawyers in DTs. Lay people bring with them their own valuable expertise and viewpoints. Lawyers ensure that procedural matters pertaining to principles of fairness and natural justice are not overlooked, which is why lawyers are already present now at SMC disciplinary hearings. But having a lawyer or ex-judge chair a DT may bring about long-term consequences that do not serve public or patient interest, even if the move appears superficially rational.

That is because the role of the DT is to ascertain if professional misconduct has occurred in areas which the law is silent on. Legal training, on the other hand, is aimed at understanding if the law has been broken. The two are very different.

The move to allow lawyers to chair DTs will bring about a technical convergence of law and medical ethics, with DT proceedings probably becoming more legalistic, and a slow deterioration in the higher standards of medical ethics, which is against public interest.

Perhaps it is by the same reasoning that lawyers do not sit on the DTs of other professions in Singapore. Higher standards of medical ethics are not achieved by making DT proceedings more legalistic or having more lawyers if DT proceedings are conducted in a fair manner.

Instead, while it may be expedient to get lawyers to chair SMC's DTs now, what medical ethics really needs is more moral courage and leadership so that public interest can be better served.

Dr Chong Yeh Woei
President
50th Council
Singapore Medical Association