Speech III by Mr Heng Chee How, MOS for Health

03 Mar 2008

By Heng Chee How

Venue: Parliament

Mental Health

1. I agree with Mdm Halimah that helping persons with mental illness should be done holistically.  Institutionalised care may be appropriate for some and in some circumstances, but not always.  It also comes with big social stigma.  Medication can help manage symptoms, but is also not the full answer.

2. To improve the outcomes for persons with mental illness, we must first recognise that it is not only a medical issue.  Many factors such as an individual’s home, educational and work environment, his socio-economic status and the quality of family and community support all influence the likelihood of improvement.  Thus, holistic care for mental illness should, besides institutional care facilities and medication, also include access to behavioural therapy, community facilities and social support services. We believe that this will help patients recover and reintegrate into society faster and better.

3. We are therefore expanding our efforts to inject new capabilities in the community over the next 5 years.  The inter-ministry working group on Mental Health chaired by PS Health is overseeing this.

4. Its efforts include wellness promotion, public education, early detection and treatment, and reintegration into society.   Employment and social needs are also examined. In strengthening the links between social care and medical support, we hope to reduce the need for hospitalisation and improve the chances for patients to regain their mental health, and to live and work well within the community and enjoy peace of mind.  Let me update the House on 4 specific areas of improvement.

5. First, we will strengthen mental health care in the community, with customised approaches for children, youths, adults and the elderly.  We are doing this with our partners - VWOs, and community partners in the workplace and schools.  For example the Adult Community Programme will monitor patients with mental illnesses to ensure compliance with medication and provide psychosocial support to the patient and family.  A network of interested GPs is being identified and trained to care for patients in the community, to complement the existing Community Wellness Clinics in polyclinics.

6. Second, we will press on with public education on mental health, and encourage people to seek treatment earlier.  This will help deal with the onset of conditions better.  The Mind Your Mind programme, a mental wellness programme for school children, will be expanded to cover tertiary institutions. HPB launched the Workplace Mental Health Programme, “Treasure Your Mind” (TYM) in October last year, and already 95 organizations have registered under the programme.  Last year’s National Healthy Lifestyle Campaign was centred on having a “Healthy Mind, Happy Life.”  This year, a media campaign will be conducted, with a focus on building positive relationships.

7. Third, we will invest more in manpower development for mental health.  We will train more psychiatrists, psychiatric nurses and allied health professionals such as psychologists, medical social workers, and occupational therapists by increasing specialist training places and scholarships.  This will translate into better care for the patients. 

8. Fourth, we will facilitate more research into mental health so that we are able to plan and care for our patients better.  The National Mental Health Evaluation Programme, led by researchers from the Institute of Mental Health, seeks to better define the extent of mental disorders in our population, to identify barriers to mental health care in Singapore, and to study social, cultural and economic factors associated with major mental disorders and to translate those research findings into treatment options.

Preventive Healthcare

9. Various members suggested that we increase the focus on health promotion and preventive healthcare.  Mr Zainudin Nordin asked about how we fared in our level of health in the population.  Dr Lily Neo is concerned about how we can reduce the time spent in poor health as we live longer.

10. Singaporeans are living longer.  We all want to live long and well.  Thus, it is right that we pay attention to prolonging our healthy years, and shortening the unhealthy ones.  Dr Neo noted from the recent article in the Straits Times that Singaporeans on average suffer 8 years of poor health. I wish to clarify that this does not mean that we spend 8 years of our life hospitalised or severely disabled. The figure of 8 years refers to the gap between life expectancy and healthy life expectancy or HALE. HALE is the average number of years of “healthy life” a person can expect to live. But living in less than full health might be due to illness of varying severity and duration. In other words, it is a broad definition.

11. Still, the point remains that we must continue to work at increasing our HALE years, so that we may indeed be hale and hearty for as long and as much as possible.

12. Mr Zainudin Nordin asked about nutrition of Singaporeans. The diet of adult Singaporeans is generally adequate. The mean intakes of energy, protein, carbohydrate, vitamins and minerals of Singaporeans met at least 70% of the Recommended Dietary Allowances levels.  Between 1998 and 2004, the proportion of Singaporeans who eat more fruits and vegetables has also increased, from 20% to 28% for fruit consumption and from 15% to 43% for vegetables.

13. The recent MOH study showed that the main causes of ill-health in Singapore are cancers, heart disease, stroke, diabetes and mental disorders. We believe that prevention is the key to reducing ill-health and disability arising from disease. We can do so by:

a. First, preventing and delaying the onset of illness and disability through day to day actions like eating well, exercising regularly, not smoking and practising mental wellness;

b. Second, by detecting illness, especially chronic diseases and cancers early, through regular screening;

c. Third, by minimising disease complications, through taking medication as prescribed and following up with the doctor promptly.

14. To help get the message across to the people, MOH and HPB have done many media campaigns.  Examples include the National Healthy Lifestyle Programme, the National Anti-Smoking Programme.  Screening programmes such as Breastscreen and Cervicalscreen (for breast cancer and cervical cancer) have also been introduced to facilitate early detection of certain cancers.

15. On the whole, Singaporeans have become healthier.  The prevalence of hypertension, diabetes and smoking has fallen.  Between 1998 and 2004, the prevalence of hypertension had dropped from 27.3% to 24.9% and diabetes from 9% to 8.2%. The smoking prevalence has also decreased from 15.2% in 1998 to 12.6% in 2004.  Singaporeans are adopting healthier lifestyles.  For example, the proportion of Singaporeans who exercise regularly has increased from 17% in 1998 to 25% in 2004.   The proportion of women aged 40-69 years who had gone for mammography at least once before has increased from 27% in 1998 to 51% in 2004. These are encouraging statistics.

16. However, much work lies ahead.   For example, the percentage of our people who exercise regularly is still too low.  More people should be exercising.  About 1 in 8 of the population still smoke. In 2004, about half of our diabetics did not know that they have diabetes, and about 40% of hypertensive people did not know they have hypertension. About 1 in 4 diabetics had poor blood sugar control and 1 in 2 hypertensives had sub-optimal control of blood pressure.  We must press on.

17. In the past, we had used mass media messaging. In recent years, we have moved to more segmented messaging. For example, we partnered community stakeholders to bring across messages about anti-smoking.  We have also customised programmes for specific target groups.  For example, we targetted young women in our anti-smoking campaign through messages about how smoking causes accelerated ageing.  As another example, “kebayarobics” was an exercise programme developed for Malay women, and. Moving forward, we hope to individualise these messages. One example is the nurse health educators programme which provides individualised health messages on diet and physical activity. In addition, HPB is developing an online health portal that specific messages to be sent to individuals based on their health details that they submit.

Managing Obesity

18. We share Dr Lam and Mr Zainudin’s concerns about obesity. The prevalence of obesity among adult Singaporeans is rising.  It increased from 5.1% in 1992 to 6.9% in 2004.  Obese people are more at risk for diseases such as diabetes and heart attacks.  Although our rates are still lower than those in many developed countries which have double-digit figures, their experience has shown that obesity rates can increase very quickly. So, it is important to act early and contain the deterioration.

19. We have been promoting healthy eating and physical activity for many years. Together with MOE, HPB has implemented school-based programmes to control obesity, such as the model school tuck-shop programme, which provides healthier food choices in school tuck-shops, targeted physical activity programmes and referring children who are severely overweight for medical assessment and management. The total proportion of overweight and obese students (that is, overweight plus worse-than-overweight) in primary and secondary schools and junior colleges fell from 11.1% in 1994 to 9.5% in 2007.  Unfortunately, within that encouraging drop, the percentage of obese students increased from 2.8% in 1994 to 3.6% in 2007.  HPB will continue to work closely with MOE to address this issue through various initiatives such as the counselling and medical referral programme for the overweight students.

20. The figures show that obesity among adults is also rising.  As Dr Lam rightly points out, obesity is associated with higher risks of chronic diseases like heart disease and diabetes.  We must do more.

21. We will strengthen current efforts to prevent obesity through promoting regular exercise and healthy diets. We will also create a supportive environment by increasing the availability of reduced-energy and healthier foods in supermarkets and food outlets and making exercise and fitness facilities more easily accessible for all Singaporeans.

22. This year, we will mount a campaign to increase awareness that obesity is a major risk factor for diabetes, and to encourage Singaporeans to maintain a healthy weight to reduce the risk of diabetes. Next year, we will campaign against obesity directly. 

23. MOH will be forming an obesity prevention taskforce to explore strategies to address this issue among the young and adults. We will study how other countries are approaching this problem, learn from them, and adapt to our local setting.

24. Controlling obesity in the population is tough. Campaigns can only do so much, and we need to move beyond healthy eating and regular exercise messages.  As with other chronic medical conditions, improvements at the population level will generally be seen only in the medium-term. It clearly calls for collaboration amongst various agencies and stakeholders, and the individual must take responsibility for his own health.  We will study the scientific evidence to see what more can be done, and also learn from promising initiatives elsewhere.

25. There is no short cut to keeping slim.  The only sustainable way is to control our diet and do regular exercise.  However, there are some people who choose quick-fix procedures such as liposuction to improve their appearance by removing excess fat.  We do not recommend such an approach.  Liposuction carries risks and if improperly done can result in life-threatening complications such as bleeding, infection and even death. Major complications and deaths arising from liposuction have been reported in the US and in Europe.  Nearer home, a neighbouring country has recently reported on a patient who underwent an eye-bag surgery, tummy tuck and liposuction.  But she developed complications, went into coma and remains in coma.  Singaporeans should be aware of this.  Unfortunately, my Ministry has also begun to receive unconfirmed feedback of liposuction being done in some outpatient clinics leading to problems.

26. Let me stress that liposuction should be done by properly trained doctors and in properly equipped and staffed operating theatre facilities.  Doctors have a duty of care to their patients and they should practise only within their competence.  For those who insist on undergoing liposuction, they should seek qualified and experienced doctors to do this for them in accredited surgical facilities.  They risk their lives otherwise.  

Public Awareness on HIV/AIDS

27. Mr Zainudin Nordin cited some statistics from a survey to express his concern about the public awareness on HIV/AIDS.  The statistics remind us that we need to continue working hard with new strategies to address these misperceptions, improve knowledge and more importantly, change behaviours so that HIV can be better prevented and diagnosed earlier. Another area that needs to be addressed is stigma against people living with HIV and AIDS. HPB has specially targetted education programmes for youths, parents, high-risk heterosexual men, men-who-have-sex-with-men and single women. The programmes are carried out in schools, higher educational institutions, workplaces, entertainment spots as well as in the community. To support our expanded efforts, we have secured an additional $10 million for HIV education over the next 2 years.

Teenage Abortions

28. Our data showed that teenage abortions are not on the rise.  In fact, the number of abortions has declined from a peak of about 1,700 annually in 2000/2001 to about 1,300 in 2005/2006.

29. Nonetheless, we agree with Dr. Lam that it is important to educate our youth on safe sex to prevent unwanted pregnancies and sexually transmitted infections, and we will continue to monitor closely the abortion rates in teenagers. HPB works closely with MOE and MCYS in this effort.  Today, all our secondary schools offer sexuality education that teaches the consequences of sex and how to say no to sex.  Contraception and STI are included in the curriculum.  HPB complements this with an STI/AIDS prevention programme called “Breaking Down Barriers”. This programme has an interactive, multi-media mass education session that covers topics like abstinence and condom use, and a class-based component that teaches skills like responsible decision-making, assertiveness and negotiation skills on saying no to sex.

30. HPB is also taking the fight beyond the schools.  It recently developed the "Love Them. Talk about Sex" Programme, in collaboration with MCYS.  This is conducted in workplaces, schools and community venues and provides information and tips on how to broach and discuss sexuality issues with their children.  The programme is supported by a toolkit, helpline and website.   HPB is also working with Family Service Centres and other youth organisations to reach out to youth-at-risk and equip them with life-skills.

Living Will

31. As Dr Lateef has pointed out, in our society, people are generally reluctant to think and talk about death or issues related to death. In view of this, my Ministry has thus far adopted a cautious approach in promoting AMD. We acknowledge that making an AMD is a very personal decision.

32. Although medical technology can sometimes struggle to delay death in the final stages of a terminal illness by very invasive and intrusive treatment, it remains true that death cannot ultimately be avoided.  The aggressive methods may also cause the terminal patients to suffer more rather than less. The Living Will or Advance Medical Directive (AMD) gives terminal patients with no prospect of recovery the ability to pass on in peace and dignity.

33. Although my Ministry has undertaken public education about the AMD since its introduction in 1997 to explain its value for both individuals and their families, to reassure about the treatment safeguards and to allay fears about the process, to date, fewer than 9,000 people have made an AMD.  We will increase our education efforts to improve social awareness and understanding of AMD and end of life issues, especially when our population is rapidly aging.  We will also be reviewing and simplifying the administrative processes to reduce the difficulties for those who choose to make an AMD.

Skin Donation

34. I would like to thank Mr Sam Tan for bringing up this subject to help increase public awareness about skin and organ donations.

35. Currently, the Human Organ Transplant Act (HOTA) only allows for kidney, heart, liver and cornea donations. When the HOTA was enacted in 1987, it only included kidney donation. In 2004, the Act was amended to include liver, heart and cornea donations, after extensive public consultations showed that the majority of Singaporeans support such inclusion. Because organ donation under the HOTA runs on an opt-out system, we have ensured that the inclusion of organs in the Act has public support and address the more urgent transplant needs of Singaporeans.

36. Although skin donation is not covered under the HOTA, Singaporeans can pledge to donate their other organs including skin through the Medical (Therapy, Education and Research) Act (“MTERA”).  This does not affect their decisions under HOTA.

37. Skin donations are no less important than kidneys in saving lives. From 1998 to 2007, the National Skin Bank managed to receive over 100,000 square centimetres of skin grafts from 50 donors after their death. This has benefited more than 100 Singaporeans patients, mostly suffering from extensive burn injuries.

38. Mr Sam Tan thought that each year, up to 20 burn victims die because there is not enough skin to cover their burns. Over the past 5 years, an average of 8 deaths per year from severe burn injuries. This figure includes both Singaporeans and foreigners. Most of these patients die not because there is not enough skin grafts available but because of their severe injuries.  Our Skin Bank maintains a good reserve of skin grafts.  However, in exceptional situations, we tap the assistance of overseas Skin Banks for additional grafts. 

39. As we intensify our public awareness efforts on organ donation over the next few years, we hope that more members of the public will consider pledging their skin and other organs. 

SingaporeMedicine

40. Dr Lam Pin Min was concerned about the impact of medical tourism on healthcare for Singaporeans.  My Ministry remains committed to ensuring that Singaporeans have access to good and affordable healthcare.  My Minister has earlier explained how we will be investing to further improve the quality of our healthcare for our citizens.  Indeed, it is the high quality of our healthcare that attracts foreign patients to our shores. 

41. Although foreign patients can choose to go to our restructured hospitals as unsubsidised patients, they make up less than 2% of admissions in our restructured hospitals there.  That said, MOH understands the concern that Dr. Lam has described.  This is why we have put in place measures to ensure that Singaporeans are not disadvantaged as foreign demand for healthcare services here grows.

42. First, we are building new restructured hospitals and adding more beds to serve Singaporeans’ healthcare needs.  Next, we are facilitating the private sector’s building up of medical infrastructure to meet increased foreign demand. Third, we are strengthening our healthcare manpower pipeline – both local and foreign.  Together, these measures will increase our capacity to meet the anticipated healthcare needs in Singapore.