Good morning, friends and colleagues.
1. This is quite a milestone and it is really a privilege today to launch the SG100K research programme.
2. I am amongst experts today, but the media are here and there is an audience out there so we should explain the significance of today’s launch. That is why I am spending a bit more time to what SG100K is about.
3. This study is supported by the National Research Foundation and conducted by several institutions – the Lee Kong Chian School of Medicine at the Nanyang Technological University Singapore, National University of Singapore, Singapore Eye Research Institute, National Heart Centre Singapore, and other healthcare partners. I thank all of you for taking this brave step, which may be the start of a major change in the healthcare landscape of Singapore.
About SG100K
4. I will talk about three aspects today: First, what is special about the SG100K programme? Second, what are its implications to healthcare? Third, given all the implications, what are our follow-up actions? I will start with explaining the significance of SG100K.
5. SG100K is special in three ways. Number one, it is a major longitudinal study. This follows another significant longitudinal study called GUSTO – Growing Up in Singapore Towards Healthy Outcomes. The researchers track the same group of parents and their children since birth, from infancy to preschool, primary and secondary school. They have now studied the same group of participants for the last 13 years.
6. The study collected data on living conditions surrounding the children through their growing years – family medical history, socio-economic status, their sleep habits, what they eat, how they use devices etc. It also collected outcome data, such as the children’s health, their development, school performance, etc.
7. By going through the rich source of data collected over the years and examining the correlations, the researchers gain valuable insights into the factors that drive good health, or positive cognitive and physical development. It is a treasure trove of data.
8. For example, one of the findings is that if a pregnant mother developed gestational diabetes mellitus, both mother and child are also at higher risk of developing health conditions like obesity and diabetes later on in life. This finding has resulted in new clinical guidance, such as universal screening for gestational diabetes mellitus for all pregnant women under the care of public healthcare institutions.
9. Another example is that eating and sleeping habits inculcated at a very young age matter a lot to the child’s cognitive development and performance in school down the road, as the data shows. This will also have implications on our approach to healthcare and education for infants and young toddlers.
10. SG100K is another major longitudinal study in the same vein as GUSTO, to monitor the health and wellbeing of 100,000 consented adults from different backgrounds and ethnicities, for many years to come.
11. Two, is that in addition to detailed baseline health information such as health and lifestyle data, the researchers of SG100K will map the genome of all 100,000 participants.
12. What is a human genome? It is literally a blueprint of a person, made up of strings of standard chemical bases. From that perspective, we are not that very different from a computer software, which also makes the science fiction movies we watch not that far-fetched.
13. In 1990, the Human Genome Project generated the first sequence of the human genome, which cost many billions of dollars and took many years. Now, with a small blood sample, it can be done in a few hours on a laptop, costing a few hundred dollars. That is how far and how fast genomics science has progressed. Cost and productivity are still improving rapidly.
14. Under SG100K, with the blueprints of 100,000 participants, the researchers will monitor and follow their health and wellbeing through the years. Researchers will cross reference disease registries, and to health, social and environmental records.
15. Three, is diversity. Governments around the world – including the US, UK, Denmark, Finland and Japan – have initiated similar studies. While their studies have a larger base of participants, SG100K took a multi-ethnic approach, involving population segments that may have been under-represented in previous studies in other countries.
16. This will give scientists a deep understanding, in an Asian context, of the interactions between nature – the genome – and nurture – social and environmental conditions and factors.
Implications for Healthcare
17. This leads to the next topic I will address, which is what are the implications of that knowledge, especially for healthcare? In short, it will enable and turbocharge the development of precision medicine.
18. What is precision medicine? Let me give a layman explanation.
19. When we want to repair a machine or maintain a building, having a full blueprint of the subject makes a huge difference to the engineer or technician. They will know exactly where to find the problem and fix it. Similarly, if an IT specialist knows the source code of a computer virus that is causing a lot of problems, they can zoom into the specific lines of source code to neutralise it. That is the value of a blueprint.
20. In precision medicine, with this human blueprint in hand, we can fix diseases in very precise ways, at its roots, and even customise treatment and care for patients. Let me give a couple of examples of what is possible, starting with targeted and optimised disease treatment.
21. On average, only about one in four patients diagnosed with cancer or Alzheimer’s disease responds to medication that is currently available. For many other common diseases including diabetes, irregular heartbeat and asthma, the corresponding figure is in the range of 50% to 75%.
22. This means that while patients may be given the same treatment, not all will experience the same expected benefits, and it must be so because every human being is different. We all have different blueprints. Precision medicine enables clinicians to move beyond this “one size fits all” approach to medication and treatment. If the clinician knows the genetic make-up of the patient, he or she can potentially understand which drugs work better for that particular patient.
23. For example, in some cancers, clinicians will examine the genetic characteristics of the tumour, and use that as a basis to identify targeted treatments that are more effective.
24. Clinicians can also use precision medicine to avoid drugs that can lead to severe side effects in a patient. The drug carbamazepine which is used for epilepsy and other conditions such as diabetic neuropathy, can result in very severe side effects. Through genetic testing of patients, clinicians avoid administering the drug to those who may develop these severe side effects. This has become the standard of care in Singapore.
25. Second possible implication is disease prevention. Precision medicine can be used to identify individuals who are at higher risk of developing certain diseases. This provides the basis for early preventive interventions.
26. For example, studies showed that familial hypercholesterolemia (FH), an inherited condition that results in very high cholesterol levels, can lead to higher risk of heart attacks, even at a young age.
27. Hence in the UK, first-degree relatives of those with suspected FH are genetically screened to determine if they are at risk, and where necessary, to start them on preventive oral medication early.
28. With the findings of SG100K, we can identify many more correlation between patients’ genetic make-up, their social and environment factors, and onset of severe diseases. These provide powerful bases for preventive care.
29. Recently we read in the news that Chris Hemsworth, the Australian Hollywood star who acted in Marvel superhero movies, did a genetic test, and found that he is at heightened risk of developing Alzheimer’s disease. This has prompted him to declare that he is changing his life goals, including to spend more time with his family.
30. But more importantly, people like him can start taking steps to reduce the risk of developing Alzheimer’s disease. Lifestyle factors such as not smoking, continue to learn and receive education, engage in physical and social activities, eat healthily, and do good and continue to be a modern superman.
The Journey Ahead
31. The last issue I want to address is the steps that we need to take now, given the profound and potentially revolutionary implications of precision medicine.
32. But we must first recognise that all major technological breakthroughs, from gunpowder, nuclear energy, to the Internet and Artificial Intelligence, are double-edged swords. They promise to deliver a lot of good to humankind, but they also inadvertently present risks and downsides. We need to ponder quite deeply and take steps to harness the good of technology, while minimising the risks and downsides.
33. Precision medicine is no different. In this regard, I think there are at least two major areas of work that we must embark on.
34. The first, and which I think is a no regrets move, is to start delivering preventive care universally to the public. This is in essence what we are doing under Healthier SG.
35. We are putting the key pieces of the preventive care system in place. We are mobilising family doctors and anchoring residents to dedicated doctors. We are developing more health protocols to manage chronic diseases through family doctors. We will be funding vaccinations and health screening fully if they are nationally recommended. We are re-shaping the social determinants of health, including putting in place the support system to encourage good diet, better sleep and more physical activities.
36. In time, when precision medicine and genetic screening are ready to play a larger role in preventive care, the policies, systems and processes will be ready too, to embrace this scientific breakthrough and put it to good use.
37. For example, you can imagine, family doctors can administer or facilitate genetic screening for their patients. Health protocols, many already developed and more can be developed in interpreting genetic test results and taking cost effective and evidence-based clinical actions for specific findings. Preventive interventions will be readily available in the community, especially when it concerns many diseases where preventive steps tend to converge on good diet, proper sleep and appropriate physical activities.
38. A second area of work requires much deeper thought, analysis, weighing of pros and cons, and even societal soul searching. Because the policy implications of precision medicine are profound.
39. We have gone through similar technological spurts before. When the Internet first appeared, it opened up all kinds of possibilities and filled the world with wonderment, with so much stuff that we can do with our computer. But then came the dot.com burst, cyber bullying, propagation of extreme ideas, child pornography, mobilisation of riots etc. So while the Internet has become an integral part of our lives now, societies all over the world are still playing catch up, putting in place policies and legislation to protect themselves against the darker side of the Internet.
40. We are likely to face similar dilemmas with precision medicine. A technological breakthrough like this opens up a broad spectrum of possibilities. At one end are those that are convincingly good, and which I spoke about earlier – more cost-effective treatments with better outcomes, targeted clinical interventions to prevent diseases or its progression, optimised medication to minimise severe drug allergies, etc.
41. At the other end are possibilities that are undeniably bad – for example, organisations that hire based on genetic profiles, which could be possible; couples testing for genetic traits of a foetus before deciding whether to keep it. Today, the Ministry of Health already imposes a moratorium on the insurance industry against genetic discrimination in health insurance coverage. At some point, it would probably need to become law.
42. In between the convincingly good and undeniably bad are many shades of grey, possibilities with pros and cons, or benefits that we can realise provided we address the key concerns.
43. You might have read recently, a news report concerning Alyssa, a 13-year-old girl in the United Kingdom who has leukaemia. She participated in a clinical trial using genetic ‘base editing’ technology, where she received T-cells from a healthy donor that were genetically modified to attack the cancerous cells in her body. Today, she is in remission.
44. This is great news. But we also need to understand the context, the implications and issues it has raised.
45. Alyssa is likely a unique case – someone who did not respond to traditional treatments and found to be suitable for gene therapy. So ‘gene editing’ technology is yet to be a mainstream treatment that is suitable for most people.
46. Even amongst those found suitable for the treatment, it may not work well for everyone as it did for Alyssa. As of now, there are simply not enough patient cases for scientists to ascertain the overall effectiveness of such treatments.
47. And even if it is effective and patient is suitable, there is the issue of cost. Novel treatments like this is in the range of multiple millions of dollars per patient. Unlike traditional treatment, the cost is not in research and development, but in the customisation and delivery of the therapy.
48. Hence, if and when this technology is proven to be efficacious enough to become mainstream, we must ensure that it can be accessible to the patients who need it clinically, and not just those who can afford it. This will require a major rethinking of healthcare financing policies and healthcare safety nets. No healthcare financing policy in the world is now designed for this.
49. Similarly, in the area of preventive care, while genetic sequencing of an individual can provide useful signposts for future possible diseases, we also don’t want a population of hypochondriacs and unnecessary medical interventions all over the place. The benefits therefore, are not straightforward, in the absence of proper rules and clinical protocols.
50. We need to decide: to what extent will we allow the extrapolation and interpretation of genetic test results? To what extent will we allow the results to be translated to clinical actions?
51. Hence, for us to fully benefit from precision medicine, much work needs to be done, in clinical development, ascertainment of cost and medical effectiveness, healthcare financing policies, legislation, and determining what is encouraged, allowed and proscribed.
52. These issues will cut across clinical, economic and moral considerations. We need to conduct a great deal of studies, consultations and engagements with policymakers, physicians, economists, regulatory bodies, bioethicists, the public and patients.
The Moon Shot
53. Let me conclude. From time to time, we hear about the medical moon shot – a major breakthrough like curing of cancer, that is as significant as sending a person to the moon. Indeed, we are on the cusp of witnessing the medical moon shot, because of precision medicine.
54. But there are important differences and similarities between sending a person to the moon and precision medicine.
55. The moon shot and precision medicine differ in in one key aspect – which is that very few people are astronauts, while healthcare touches the lives of almost everyone, directly or indirectly. For the Apollo 11 landing, we witnessed it on TV and we cheered in our homes; for the medical moon shot, each of our lives can be affected.
56. The promise of better treatments is always good news, but it always comes with many uncertainties, and moral, ethical and policy dilemmas. The work starts now, in fact yesterday, to address these issues.
57. There are however powerful similarities between the two as well. First, they are both not about advancement in just one technology. Many strands of breakthroughs come together to make the moon shot possible, from the propulsion system of the rocket, the launching pad, materials science, down to the design of the space suit, the food the astronauts eat while in space.
58. All need to be ready and come together to make the endeavour successful. Similarly, for precision medicine to serve humankind well, technology, delivery systems, legislation, clinical protocols, ethical standards, patient education, etc, have to be concurrently in place.
59. The most important similarity is the human spirit driving such advancements. Human beings are always determined to march forward, venture into the unknown, to embrace scientific advancement for the benefit of our present and future generations. Each society and country will do its part. SG100K represents such a step forward, to help us learn more, improve and seek answers, in Singapore.
60. That is why in my own little way to support this research programme, and more broadly the human spirit that we want to celebrate, I have enrolled myself into the study, as one of the 100K participants.
61. I wish the SG100K investigators and their teams every success in this brave, unprecedented step forward, as we continue our quest towards a future of better health. Thank you.