Khaw Boon Wan
Singapore
“Motor vehicle dealerships and showrooms have been closed since the start of the circuit breaker. As COE bidding is done mostly by the motor vehicle dealers on behalf of prospective owners, the Land Transport Authority (LTA) suspended COE bidding for the months of April and May.”
“Though stressed by the financial pain, they press on with the immediate priority of fighting the virus and supporting essential services. Post-pandemic, we will see how public transport evolves. Will demand for public transport services simply return to the pre-pandemic level?”
“Under our rail financing framework, the Government fully pays for the cost of building new rail lines. In other words, we do not recover the cost of building the Cross Island Line (CRL) from commuters through fares. The CRL project is being implemented and the final costs will depend on tender bids.”
“There are around 5,000 private bus operators with a combined fleet of 13,500 private buses. As we do not track the number of private bus trips and passengers, we do not have data on their carbon emissions.”
“There are nursing rooms at 50% of our bus interchanges. We will provide nursing rooms at all new bus interchanges and integrated transport hubs. For the MRT network, we will provide nursing rooms at all new interchange stations. We will also explore providing such facilities when MRT stations undergo upgrading.”
“Over the last three years, Singapore carriers have reported a total of 20 incidents of food allergies on board their flights. None required the use of epinephrine or emergency flight diversions.”
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“Sir, the patients in Singapore can choose between public and private hospitals for their treatment. Both provide a high standard of clinical care, but at different prices because public hospitals are heavily subsidised. For infertility treatment, the expertise is available in both sectors. Just to give an example, last year, 2,100 patients sought infertility treatment. Public hospitals treated more than half of them. Success rates of the treatment are also comparable, with public hospitals averaging 27%, and private hospitals, 24%. The cost of treatment is generally lower in the public hospitals. My Ministry’s decision to subsidise infertility treatment in public hospitals is within the context of our policy towards healthcare subsidies. Patients are not subsidised in private hospitals, as comparable services are available in public hospitals. Our approach for infertility treatment is the same. This way, Government subsidy will focus help on those couples who find it difficult to afford treatment in private clinics.”
“Sir, we do review means test criteria not just for nursing home but generally, because with wage adjustments and cost inflation, it is necessary to do so. The key point is what is the subvention for. In the case of Medifund, we are aiming at assisting the bottom 20%-30% of the population. So, a short answer is "yes", we do review and adjust them as necessary. I think, on compassion, you cannot find a more compassionate Health Minister. ASSISTED REPRODUCTION TECHNOLOGY TREATMENT (Inclusion of patients at private hospitals) 17. Er Lee Bee Wah asked the Minister for Health whether the Ministry will review its current policy on Government's co-funding scheme for Assisted Reproduction Technology treatment to include patients at private hospitals.”
“That is why the Ministerial Committee chaired by Mr Lim Boon Heng actively promotes active ageing and there will be a series of wellness programmes being implemented at the community level. I hope the elderly Singaporeans will come and join in. It is for your own good. Second, subscribe to ElderShield and its supplements to ensure that we are better able to pay for any long-term care. Third, care for our elderly at home for as long as possible, so that they can be in the company of their families and friends.”
“Sir, there are around 8,600 nursing home beds in Singapore, of which about 4,800 or 56% are subsidised beds. Most nursing homes can take in patients with dementia. Dementia covers a wide range of disabilities and differs in different degrees of complexities. The number of patients on the waiting list for subsidised nursing home fluctuates. For example, during the past year, it ranged from 68 to 193. But at any one point in time there were about 100 vacant beds available in subsidised nursing homes for placement during the same period. Some mismatch occurs as some patients have specific preferences such as location, operator and sometimes even diet. Some waiting is perhaps also sensible to minimise nursing home admission becoming too convenient a substitute for taking care of the elderly within the family. The majority of patients on the waiting list are placed within a month. Care is generally affordable as my Ministry provides the nursing homes with an operating subvention to help the lower income patients pay for their bills. For those who are more needy, Medifund is also available to assist. That said, the demand for long-term care is growing with the ageing of our population, and this will pose a continuing challenge for us. We are investing more resources, including manpower, to expand the nursing home sector to meet the rising demand. We will also help upgrade the skills of the nursing home staff so that they can provide a higher service level and be more competent to care for patients with greater severity, particularly those with dementia. Singaporeans can also help to play a part. First, stay active to delay or avoid the onset of long-term disability.”
“The answer to her first question is yes, although I could not quite recall the figures. As to the number of patients who applied for instalments, we have the data somewhere but I do not carry it at the top of my head. SUBSIDISED NURSING HOMES (Waiting places) 16. Ms Sylvia Lim asked the Minister for Health how many persons are on the waiting list for places in subsidised nursing homes particularly those offering dementia care and what is the affordability of such care in Singapore.”
“We have also recommended that the Medifund Committees be especially flexible when evaluating the applications by elderly patients for assistance under Medifund-Silver.”
“Sir, the recent high inflation has also impacted the operating cost of public hospitals. Tender prices of medicine and other medical supplies have significantly increased. In line with market movements in wage levels, public hospitals have adjusted the wages of their healthcare workers. In addition, we have made a conscious decision to significantly raise the staff-to-patient ratio, so as to meet rising patients’ expectation for longer consultations and shorter waiting times. All these factors have increased the hospitals’ running costs. Public hospitals will continue to absorb the bulk of the increases in cost. Our subsidy policy remains unchanged. Some adjustments in patients’ co-payment quantum are therefore inevitable. As compared to last year, there has so far been no increase in the number of arrears cases. Patient cases in arrears after two months from discharge remain below 4%. Our system of heavy Government subsidies, Medisave, MediShield and Medifund has ensured that basic healthcare services in public hospitals remain affordable to all Singaporeans. But during this period of high inflation, we have reminded our hospitals to be on the lookout for needy patients who might have a problem paying their bills. Patients can continue to ask the hospitals for their medical bills to be paid through instalments. We have increased the allocation for Medifund reimbursements substantially so that needy patients can get appropriate financial assistance. Two years ago, the Medifund reimbursements amounted to about $40 million. I have raised it to $50 million last year and for this year, the budget set aside is $70 million, which is a very substantial increase from the previous years.”
“If you want a specialist opinion, consult the specialist in NUH or KKH for a second opinion. As for parents of children who feel that they have received unethical treatment, they can whistle-blow to us. Let us know and we will investigate all such incidents. Unfortunately, for ASD, there is still no cure and parents would just have to be patient with conventional treatment practices. In our own experience in KK and NUH clinics, it used to be that 20% of the children patients will end up having to attend special schools. But, if they follow the advice of the doctors and work together with us, we have been able to half the rate, from 20% to 10%. So, only 10% of the patients now need to be admitted to special schools. There are proper ways of treating autism. Do not be taken in by promises of a “cure” which often can cost lots of money and emotional ups and downs, with very poor results. Our doctors in our specialist clinics told me that often, some of these parents would come with all kinds of medicine, costing them thousands of dollars a month, and they say, "My previous practitioner prescribes all these. Please supply all these to me now at subsidised rate." But when we look at it, those are based on unconventional practices without scientific evidence and which we do not prescribe. UPGRADING OF BUDGET TERMINAL 19. Mdm Halimah Yacob (Jurong) asked the Minister for Transport (a) why there is a need to upgrade the Budget Terminal so soon after it was opened; and (b) whether this indicates poor planning on the part of CAAS for failing to anticipate a higher passenger traffic at the Terminal.”
“Indeed, I am taking a similar approach for liposuction that the Member has talked about, which is to identify those procedures or practices which are high-risk and to regulate them. I do not regulate all aesthetic medicine practices but those which are high-risk, like liposuction, we regulate it tightly. In the case of CAM practices on ASD, for example, one treatment modality that is being promoted in the West is Chelation Therapy. But it is high-risk, so we regulate it because only doctors can prescribe chelating agents. Hence, it is not as if it is unregulated. If a non-doctor practitioner decides to provide such a treatment, he will then have to face the law. For those that are high-risk, we tightly control them. For those which are low-risk, but of questionable basis, it is hard to regulate. Like in aesthetic medicine, we leave it to the practitioners to self-regulate because while there is no hard evidence to prove efficacy, there are practitioners who swear by it. They say that some of their patients have benefited from it. If we were to regulate it, we will have to ban these practices and I am quite sure there will be objections from some parents, who will claim that their children have benefited from it. I think this differentiated risk management approach to tightly-control the high-risk practices and lighter regulation for others is the most practical way going forward. Where the practitioners involved are doctors, I am quite relaxed because they know they have to face the SMC, if they were to engage in unethical practices. But if they are non-doctors, then my hope and our public education are for the parents to help to regulate. The best way is to consult a trusted family GP. When in doubt, consult your GP.”
“Sir, there are two main levels of protection against such unethical exploitation of patients. First, the Medical Registration Act requires the doctors to practise ethically. They will be subject to disciplinary action if they use treatments which are not in the interest of their patients. Second, patients and their caregivers must exercise due diligence and consult the right practitioners. When in doubt, they should first check it out with their trusted family physician. Alternatively, they could seek a second opinion from the practitioners in the public clinics for patients with special needs, before accepting any unconventional or unusual treatment. Helping patients with special needs is often a very long journey. It is understandable why some families become anxious, embarking on remedies that promise them hope of a rapid "cure". The Internet has further promoted the dissemination of theories and practices, many of which are questionable and without scientific basis. For instance, the use of controversial Complementary and Alternative Medicine (CAM) treatment for children with Autistic Spectrum Disorder (ASD) is popular in the West, despite an absence of scientific support. My Ministry will work with MCYS and its VWOs concerned to educate the families on how to evaluate such information and not be taken in by pseudo-science and unsubstantiated theories. Meanwhile, my Ministry is also collaborating with the Academy of Medicine to formulate Clinical Practice Guidelines to assist doctors in Singapore in diagnosing and managing children with autistic spectrum disorders. The efforts will include compiling the evidence for the various treatments and to disseminate a layman's version to patients and their caregivers.”
“Over the years, a small percentage of the mothers would agree to continue with the pregnancy and to consider adoption. In such cases, the SOP will require us to get the pregnant mother in touch with MCYS (or NGOs because some parents would prefer to deal with NGOs), and arrangement is then made to match-make the couple who are interested in adopting with the pregnant mother who may then decide to continue the pregnancy to term. This is the current arrangement and we will continue with it. In fact, our experience is that the mothers who decide to keep the pregnancy often decide to keep the babies as well. So, not 100% of such babies will end up being adopted.”
“Sir, although there are four supplementary questions, there are really two because the last three are related to adoption and I will address them. First on the 24-week time limit. The Member is quite correct. As stated in my reply, this is purely based on science, and we are advised by the medical experts on the viability of the foetus outside the womb. While preparing for this Question, I decided to ask the experts again for the latest assessment on this particular issue and they gave me a statement, which I would like to read it here, and I quote: "We are quite confident that babies born after 24 completed weeks of gestation should have a very good chance of surviving intact and the most optimal care should be offered to them. Between 22 to 24 weeks gestation, survival rates dip sharply, even in the presence of the latest technologies, and the disability rates will also climb sharply, especially disabilities in the moderate and severe range. Therefore, it is recommended that the legal limit of abortion should be kept at 24 weeks at this moment. The dividing line can always be redrawn when future survival and disability statistics on children born in the threshold of viability warrant a review." So, this is the position that I take. Let us base our decision purely on science so that we take the emotion out of this particular subject. As for adoption, the current arrangement is like this: the law mandates pre-abortion counselling. These involve trained counsellors who will talk to the pregnant mothers of the various options available to them besides the risk of abortion procedures. And one alternative is adoption – to consider keeping the pregnancy to term and then pass the baby to the couple who are interested in adopting him.”
“It would not be wise to reopen the debate and introduce into Singapore the divisive battles going on in the West, especially in the US. We will continue with the other efforts in public education, such as sex education to school children and the public, as well as in providing assistance to married couples to have more children.”
“The Termination of Pregnancy Act was enacted in 1974, to provide for the safe termination of unwanted pregnancies by trained persons in appropriately equipped facilities. It is to safeguard the health and well-being of the woman who has, for various reasons, decided to terminate her pregnancy. This is intended to ensure that all children born in Singapore are wanted children, who will be properly cared for, and will have opportunities to develop to their full potential. The Act was not introduced to curb population growth. Neither will its restriction or cancellation help to grow the population. It is simplistic to assume that one fewer abortion equals one more baby. Hong Kong and Poland do not allow abortion for social reasons or on demand, but their birth rates are among the lowest in the world, not better than that of Singapore. Among the many countries which legalise abortion on demand, there is a wide range of birth rates. So, clearly, there are other factors at play which determine the birth rate of a population. As for the time limit for unrestricted abortion, it is determined on objective medical grounds, based on the doctors' assessment of the survivability of the foetus outside the womb. The Act requires all women contemplating abortion to be counselled. The counsellors will advise the women of the full implications and the risks of an abortion, and of the alternatives available, including adoption. The issue of abortion is an emotive and divisive one. It has been debated at length and decided in Singapore. The decision respects the different views that some community and religious groups hold on abortion. It is not useful to talk about abortion in absolute terms as there are practical human, medical and social issues involved.”
“Sir, may I have your permission to take Question Nos. 6, 7, 8 and 9 together?”
“There is no formal travel advisory. But we did periodically warn Singaporeans about the risk of getting chikungunya in endemic regions. At this point in time, Johor is a major problem area. As it also coincides with the durian season and I know that many Singaporeans go to durian plantations there, my advice is that Singaporeans should protect yourself with mosquito repellants. That may help. ERP GANTRIES ALONG KPE (Rationale) 2. Mr Baey Yam Keng asked the Minister for Transport (a) if he will explain the rationale for building 16 new ERP gantries along KPE when it is not even fully operational; and (b)whether the same rationale will be applied to all new and existing expressways to build gantries at all possible junctions in anticipation of slower traffic flows.”
“My Ministry will continue to work with the National Environment Agency to facilitate rapid vector control of Aedes mosquitoes upon notification and detection of cases of chikungunya fever. We will also continue to reduce disease transmission through active case detection and measures to protect cases from further mosquito bites. The public has an important role to play in eliminating the breeding of Aedes mosquitoes and taking sufficient precautions against mosquito bites while travelling overseas. This will help minimise the risks of disease importation and transmission. We have to work together to prevent chikungunya from taking root in Singapore.”
“Sir, chikungunya is a viral disease which originated in Africa. But, with globalisation, it has now spread to different parts of the world. It is transmitted by the bite of an infected Aedes mosquito. These mosquitoes, which also spread dengue fever, are commonly found in Singapore and the region. Unfortunately, there is no vaccine yet against chikungunya. The first case of chikungunya in Singapore was reported in 2006. There were three cases then. It increased to 10 last year. All cases were imported. The first cases of local transmission of chikungunya were from the outbreak in Little India in January this year. By now, a total of 150 cases have been reported. Seventy were imported cases, and 80 through local transmission. Most of these cases occurred recently in July and August. Chikungunya is endemic in our region, including Indonesia and Malaysia. In the last few months, cases of chikungunya have been increasing in Malaysia, especially in Johor. This development, combined with the large volume of travellers between Singapore and Johor, is a major reason for the recent surge in the number of chikungunya cases here. About 80% of the imported cases had a recent travel history to Johor. The key strategy to controlling chikungunya and preventing it from becoming endemic here is better control of mosquito breeding. But this requires full cooperation by all and constant vigilance. The NEA has worked hard to control mosquito breeding for a long time. However, they continue to find mosquito breeding sites upon investigation of places of residence or work of local cases with chikungunya fever.”
“Sir, like the Member, I have also read the report in the newspaper. Here is an example of not all news reports are factual. So you have to double check and the facts are what I have presented in my reply just now – that the Ministry of Health cannot be involved, in fact it is not involved, in the disbursement of the donation fund. Every time a fund is created, they will have to set up a committee with specific terms of reference and the committee has to operate within the terms of reference. I think $600,000-odd donation was collected but what is left, I am told, is about $50,000-odd. How it will be spent will be decided by the committee within the terms of reference, which must be for the welfare of the twins. Unfortunately, Ganga has passed away, but Jamuna has survived. SINGAPORE MASS RAPID TRANSIT (Social responsibility) 16. Ms Denise Phua Lay Peng asked the Minister for Transport why is the Singapore Mass Rapid Transit (SMRT) operating as a for-profit entity instead of a social enterprise with the goal of providing cheaper, faster and better commute for the public.”
“Sir, this question is not for the Singapore General Hospital or the Ministry to assess or to decide. The donation fund is managed by the Nepalese Twins Fund Disbursement Committee which includes the Nepalese Honorary Consul General. The fund is intended for the twins' medical expenses, not just the separation surgery which has already been done, but also post-surgery long-term treatment required as they grow up in Nepal. I assume the Fund Disbursement Committee will want to preserve the fund for as long as possible, and not to allow it to be prematurely depleted. For instance, if any treatment can be competently carried out in Nepal at lower cost, I assume the Committee will prefer that the treatment be carried out there. But this is really something for the Committee to decide. I am told that the Committee has not received any recent application from Dr Keith Goh or any other doctor for the use of the fund.”
“So, their job is to try to make a judgement. But we know that in real life, if a person is determined to lie through sworn statements, it is not easy to pick up there and then. But dishonesty will be exposed, not immediately, but after a while. NEPALESE TWINS' MEDICAL EXPENSES (Utilisation of balance of funds raised) 15. Mr Baey Yam Keng asked the Minister for Health how will Singapore General Hospital assess Dr Keith Goh's request to utilise the balance of $58,000 in funds that were raised for the Nepalese twins' medical expenses.”
“Sir, I will take both supplementary questions together. Indeed, the system we have here is not uniquely Singapore. It is a very common system adopted in practically all countries where we leave such decisions to the local hospital ethics committee. And, while there is potential conflict of interest, it can be managed. That is why the composition of the ethics committee is important. We have included members who are outside of the hospital and the individuals who are appointed include not just doctors but also non-doctors. It is not a system which must lead to conflict of interest as it can be managed properly. As I have said, when we have fully wrapped up the current case, we will see whether there are better ways of doing it. There are options like whether we can have, say, a national ethics committee, which reviews all such cases. But this committee will then be inundated because today, I think, we are doing more than 120 transplants a year. Each case will require many rounds of interviews. The workload is already quite severe and we expect the transplant rate to rise, and we hope the transplant rate will continue to rise. I think the most practical way, as adopted in practically all other countries that I am aware of, is to leave the decisions to the local level but constitute the ethics committee properly. The ethics committee members do not report to the hospital. They report to their own conscience because, if I volunteer as a member in this committee, I know I have to discharge my responsibilities. In this case, it is quite straightforward – have the donors been properly informed, do they know the risk, and have they taken a decision purely based on altruism or is it under duress or being induced by financial compensation?”
“Sir, in my many years in the health care industry, I have yet to hear of live donations of the heart. But I certainly have read the article about this village, I think in Medan, of people who sell parts of their bodies in exchange for money, and quite pitiful cases. In fact, next month, because I have to go to Manila for a WHO meeting, I am also planning a side trip to one of those villages, where there have been quite a number of those donors. The recipients may not necessarily be in Singapore but these are donors who, for various reasons, were financially desperate enough to have to part with their kidneys. I intend to have a chit-chat with them to find out what happened after surgery. I had shared with Members in this House last month that I intend to set up a proper donor registry so that we can focus on how to protect the welfare and also monitor the health of live donors, including family members of cadaveric donors, where donation is altruistically made. These are some of the most wonderful people on earth and I think society ought to find ways and means to protect the interest of them and their family members. As to our own Singapore hospital ethics committee, whether it is robust enough, as I said in this House last month, the case is still before the court. Once it is fully wrapped up, we will see whether there are loopholes and, if there are weaknesses, definitely I will fix them. But I do not think we should be recalling cases just because there has been one case and conclude that every past decisions were flawed or wrong. Many of these volunteers are very experienced individuals and they volunteer their time to do a proper job, and I do not think we should assume that all of them have been negligent or there has been misconduct.”
“Sir, the Transplant Ethics Committee's primary function is to ensure that a living donor has been fully informed of the nature and the risk involved in the proposed transplant surgery, and that his consent is given freely and not under duress or for any financial gain. They discharge this function through a thorough review of the medical and social history of both the donor and the recipient, the submitted personal documents and statutory declarations. They would also conduct separate interviews of the donor and the recipient, before they come to any conclusion on the application. If the Committee has any doubt, they should not approve the transplant. If there is evidence of misconduct by any Transplant Ethics Committee, my Ministry will investigate. As the current cases are still before the courts, I should not comment further on them.”
“There are 18 polyclinics in Singapore. Dental services are provided in nine of these polyclinics staffed by 36 dental officers. In addition, dental services are also available in all the public hospitals and the majority of Government schools. A total of 75 dental officers are currently deployed for this purpose. HARASSMENT BY LOANSHARKS 52. Mrs Josephine Teo asked the Deputy Prime Minister and Minister for Home Affairs (a) how many cases of harassment by loansharks were reported annually in the last three years; and (b) what is the average time taken to resolve such cases.”
“Mrs Josephine Teo asked the Minister for Transport if there are plans to improve (i) the Park and Ride Scheme to enable more vehicle owners to use public transport as an alternative mode of transport into the Central Business District; and (ii) the feeder bus services as these contribute significantly to the overall travel times of commuters.”
“I applaud Dr Lim Wee Kiak as an enlightened employer and I will pass the message down to the employers of nurses. But, as I said in my reply, it is really something for the employers to decide and it is up to them how they want to show it. My preference is to show gesture throughout the year and not just for that one day, which means showing respect, treating your nurses with dignity and recognising that theirs is a worthy profession – recognising nurses who are doing their best to treat their patients and serve them well. In fact, going forward, with ageing, the role played by nurses and highly-skilled nurses will become even more important because we will always be short of specialists and doctors. I have just had a discussion with the Ministry of Health colleagues on how to ramp up trained oncologists, orthopaedic surgeons, and so on. And the conclusion is that the world is so short of such specialists. While we will still try to ramp up the numbers, it can never be enough and, increasingly, we have to look at alternative allied health professionals, of which nurses are a big part, to try to help out. If you train them well, they can take on many of the routine stuff from the specialists. Collectively, as a team, they can then serve our patients much better. SWITCH TO PUBLIC TRANSPORT (Measures) 11. Dr Lim Wee Kiak asked the Minister for Transport (a) what measures are being considered to encourage drivers to switch to public transport and reduce usage of their private vehicles; (b) what is the current usage of the Park and Ride Scheme and whether there are plans to enhance the Scheme; and (c) whether the Ministry will consider setting up platforms to encourage car pooling. 12.”
“Increasing the nurse to population ratio is part of this strategy to enhance the working condition for our nurses so that they have more time to look after their patients and also enjoy better worklife balance as well. Our efforts have seen result, both in terms of increased student interest in nursing and the reduced attrition of nurses from the healthcare sector. But we must not relent in our effort to compete for our fair share of talent. In this regard, we are grateful to the President for honouring nurses by hosting an annual reception at the Istana every year on Nurses' Day which is 1st August. As employers, healthcare institutions will make the effort to show their appreciation for their nurses on this day. Their gestures take many forms, ranging from awards to celebrations. Whether it should also include a day off on or in lieu of Nurses' Day is something for the employers to decide.”
“Sir, there are currently 18,400 nurses actively practising in Singapore, comprising 13,500 registered nurses and 4,900 enrolled nurses and midwives. This gives a nurse to population ratio of one to 249, a significant improvement as compared to, say, 2001, when our ratio was one to 306. But we aim to further improve on it and are working towards a ratio of one to 220 by 2015. And this would mean an increase in the nurses' population by 40%. The bulk of these nurses, 67%, work in the public sector. The turnover of public sector nurses has improved over the years from 14% in 2001, to 9% last year. But we want to reduce it further. To meet the projected demand for nurses, we are working on several fronts. First, we have progressively stepped up the local training of nurses. Our current local training capacity is 1,875 intake per year, which is more than double the intake of 728 in 2001. We are raising it to 2,000 per year and will consider further increases in due course. Second, we will continue to recruit foreign nurses to supplement our local supply. Currently, foreign nurses make up 15% of our total nurses population. Not too long ago, we have foreign nurses accounting for almost 25%, so we have been able to reduce it to 15% because of increased interest among Singaporean boys and girls. But 15% is low compared to our peak of 25%, so there is scope to raise this proportion further, if necessary, and I think it is necessary. Third, we will continue to enhance the image and the value of nursing as a desirable profession. This requires the employers to provide challenging career opportunities and favourable working conditions to attract and retain the talented to join the profession.”
“Dr Lim Wee Kiak asked the Minister for Health (a) what is the current strength of qualified registered nurses and the shortfall against actual demand; (b) what is the current turnover of nurses in the Government sector; (c) what is being done to ensure a sufficient supply of trained nurses to cope with the advent of new hospitals in the next 10 years; (d) what is being done to further enhance the image of nurses to attract more to the profession; and (e) why are nurses not given a day off on or in lieu of Nurses’ Day.”
“Sir, the epidemic level and where it is pegged is a technical exercise. We would look at past records, and this is done by the experts. We exceeded that level in April, during the recent outbreak. Currently, we are close to that level. So, let us be careful. The solution to it, which is in reply to the second question, remains the same. Until a vaccine is found, we have to rely on basic grandmother advice, which is frequent hand washing, thorough handwashing with soap, and maintain high personal and environmental hygiene standard. The solution is well-known, easy to explain, but execution is a problem. When I first had to deal with this public health issue years ago, I was naively ambitious. I thought in modern Singapore we should be able to eliminate this. We know the Japanese are legendary in their personal hygiene standard – how to wash hands, and they teach their kids from young. So I told my colleagues in the Ministry of Health, "You go and check. I am sure in Japan they do not have Hand, Foot and Mouth disease, given their high standard of personal hygiene." I was personally quite disappointed when I found that even Japan has HFMD outbreaks, not throughout the year, but during the hot season. Unfortunately, we have hot seasons throughout the year, so we have a problem. SUPPLY OF QUALIFIED REGISTERED NURSES 10.”
“Sir, Hand, Foot and Mouth Disease (HFMD) is a common childhood infection. The infections are usually mild. Nevertheless, when the virus involved is the EV71 strain, it can affect the brain or even result in death, although such a complication, fortunately, is rare. This year, we experienced a surge of HFMD cases involving EV71 as the predominant circulating strain from late March to early July. The total number of HFMD cases this year has already exceeded 18,000 cases. The number of cases peaked in April, with more than 1,400 cases a week, and thereafter it declined steadily to around 500 cases a week now. But, then, there is usually a second though much smaller peak outbreak in September, which is just around the corner. So we have to be careful. During the April outbreak period, a total of 35 preschools and childcare centres were ordered to close while 95 were advised to close so that the premises could be cleaned thoroughly and the chain of transmission within these centres broken. The way to reduce the transmission of HFMD, including EV71, is to continuously maintain a very high standard of personal and environmental hygiene and also to seek medical treatment early when the child is unwell. Parents should also ensure that their children with HFMD have adequate rest and, very important, to remain at home for the duration of the illness as advised by the doctors. We have worked closely with MCYS and MOE in educating all childcare, kindergarten and preschool operators on hygiene measures. My Ministry has also alerted doctors to be vigilant for complications from HFMD as the predominant strain this year is the EV71 strain.”
“6 & 7 - Comparison of M&P benefits and taxes MP Name: Mr Wong Kan Seng”
“Year 2004 2005 2006 2007 Number of Employment Pass (EP) and S Pass holders 80,000 90,000 110,000 143,000 Number of dependants of EP and S Pass holders on Dependant Pass/Long Term Social Visit Pass 53,000 59,000 60,000 69,000 Number of Long Term Social Visit Passes issued 51,000 58,000 62,000 64,000 The stock of Employment Passes (EP) and S Passes has generally increased in the last few years in tandem with the robust economic growth and job creation. As of December 2007, there were about 143,000 EP and S Pass holders. Foreigners on EP and selected S Passes may apply for Dependant Passes or Long Term Social Visit Passes for their dependants, such as spouses and children below 21 years of age. As of December 2007, there were about 69,000 dependants on Dependant Passes or Long Term Social Visit Passes. Long Term Social Visit Passes are also issued to other groups of foreigners such as family members of Singapore Citizens and Permanent Residents. In 2007, there were about 64,000 Long Term Social Visit Passes issued. Long Term Social Visit Passes can be issued for up to five years. Long Term Social Visit Pass holders and Dependant Pass holders must apply for work passes to work in Singapore. The number of these pass holders working in Singapore is not high. As of December 2007, there were about 6,600 Long Term Social Visit Pass holders and Dependant Pass holders with work passes. APPENDICES Section Name: ORAL ANSWERS TO QUESTIONS Title: NEW INCENTIVES FOR MARRIED COUPLES TO HAVE MORE CHILDREN Filename : Handout to Question Nos. 6 & 7 - Statistical trends MP Name: Mr Wong Kan Seng Section Name: ORAL ANSWERS TO QUESTIONS Title: NEW INCENTIVES FOR MARRIED COUPLES TO HAVE MORE CHILDREN Filename : Handout to Question Nos.”
“The TCM Practitioners Board was established in 2001 to regulate and register TCM practitioners. The transitional period for the registration of TCM practitioners ended on 31st December 2003. From 1st January 2004, only those who are registered with the Board can practise TCM. From 2004 to 2007, the Board received a total of 55 complaints: 19 (2004), 9 (2005), 17 (2006) and 10 (2007). There were currently 2,232 TCM practitioners registered with the Board, a significant increase from 1,910 in 2004. The increase matched closely the number of graduates from the two local TCM schools approved by the Board. TCM is a complementary form of healthcare and the market determines its supply and demand. MOH and the TCM Practitioners Board monitor the standard and quality of TCM training to ensure public safety. ISSUANCE OF EMPLOYMENT PASSES, S PASSES, DEPENDANT'S PASSES AND LONG TERM SOCIAL VISIT PASSES (Statistics) 7. Mr Siew Kum Hong asked the Acting Minister for Manpower for each of the past five years (a) how many Employment Passes and S Passes have been issued; (b) how many Dependant’s Passes have been issued to dependants of Employment Pass and S Pass holders; (c) how many Long Term Social Visit Passes have been issued; (d) what is the average duration of the Long Term Social Visit Passes issued; and (e) how many Long Term Social Visit Pass holders have been issued with work passes. Mr Gan Kim Yong: See Table below for the detailed statistics.”
“HFMD is endemic in Singapore and it cannot be eliminated as there is as yet no vaccine. However, we can minimise its spread through maintaining continuous high standards of personal and environmental hygiene. We all can play a part to maintain good personal hygiene such as washing our hands after going to the toilets and washing our hands before we eat. Parents should set good personal examples and get their children to adopt these simple hygiene habits. Together, we can reduce the spread of HFMD. CASE OF MR CHAN MUN CHIONG (Charge under section 377A of Penal Code) 60. Mr Siew Kum Hong asked the Deputy Prime Minister and Minister for Home Affairs what was the rationale for charging Mr Chan Mun Chiong under section 377A of the Penal Code in view of the Prime Minister’s statement to Parliament last year that the provision is not proactively enforced.”
“We know quite a lot about the hand, foot and mouth disease (HFMD). It is a common illness that affects infants and children worldwide. Many different viruses cause HFMD. Coxsackie A16 is the most common but Enterovirus 71 (or EV71) can also cause HFMD. I mention EV71 because its infection has been associated with severe complications, including death, in young children. Infection by one virus does not confer immunity to other viruses causing HFMD. That is why a person who has recovered from HFMD may still come down with the disease again. In temperate countries such as Japan and Australia, HFMD outbreaks occur most often in the warmer months. In Singapore, HFMD occurs throughout the year but it generally peaks during school terms and decline during the school holidays. This suggests that nurseries, childcare centres, kindergartens and primary schools are major sources of transmissions. Locally, EV71 has also been observed to be the predominant circulating virus every two to three years. There is no evidence to suggest that HFMD outbreaks are becoming more frequent. The disease is spread by direct contact with nasal discharge, saliva, faeces and fluid from the rash of an infected person, or with droplets from coughing or sneezing. A person who touches a contaminated surface will be exposed if he does not wash his hands properly before eating his food or touching his mouth. The virus can survive in the environment for a few days. Since children can be infectious even without symptoms, the virus can potentially be found in any public place, including playgrounds and public libraries. But as noted earlier, the main sources of transmissions are in childcare centres, nurseries, kindergartens and schools.”
“Early detection and good management of chronic diseases like diabetes, high blood pressure and high cholesterol also reduce the risk of developing coronary heart disease. For the younger age group, diseases of the heart muscles, although uncommon, may play a role in some cases of SCD. Some examples are enlargement of heart muscles and viral infection of the heart. Screening may be useful to detect some of these conditions so that precautionary measures can be instituted to prevent exercise-related deaths, but no test can identify all individuals at risk. Despite our best efforts at prevention, SCD will still occur. In such cases, survival can be improved if the patient is treated as soon as possible with cardiopulmonary resuscitation (CPR) and defibrillation. There are programmes in place to teach and encourage CPR and use of defibrillators for the public and appropriate personnel such as policemen, and staff at sports facilities and airports. All our SCDF ambulances are equipped with defibrillators. We also support efforts to improve access to defibrillators at public locations with high human traffic and at mass participation high intensity sports events. 3.10pm”
“Mr Speaker, Sir, as explained by the Minister for Defence just a while ago, SCD is a sudden and unexpected death due to cardiac causes. A common cause of SCD is abnormal heart rhythm, resulting in the heart stop pumping. In Singapore, about 16,000 deaths occur every year, of which 23% are from cardiac causes, almost one in four. SCD is a subset of cardiac deaths and in Singapore accounts for about a third of deaths due to cardiac causes. Over the past 10 years, our incidence of SCD has increased steadily from 26 per 100,000 population in 1998, 10 years ago, to 34 in 2007. This is largely due to the steady increase in the proportion of the elderly in our population as the incidence of SCD is highest among the elderly, eg, last year, the incidence of SCD ranged from 2 per 100,000 for those below 35 years old to 211, 100 times more, for those above 60. Of the 1,538 cases of SCD last year, 67% were above 60 years of age. Less than 3% were below 35. In fact, the incidence in younger persons under 35 has declined from 4 per 100,000 in 1998 to 2 last year. There is a gender difference in the SCD incidence, with men having more than double the risk as compared to women. Overall, our SCD incidence of about 1 in 3,000 is low as compared to other developed countries. Studies from the US and Europe have reported higher rates, of 1 in 600 and 1 in 1,250 respectively, although there are some variations in defining SCD in these studies. How to reduce SCD incidence? More than 80% of SCD is due to blockage in the coronary arteries. So the key to prevention lies in adoption of a healthy lifestyle: eating wisely, not smoking, staying active and maintaining healthy weight.”
“Dr Lam Pin Min asked the Minister for Transport if his Ministry will defer the erection of additional ERP gantries and further ERP rate increases in view of the escalating fuel prices which may have already deterred some drivers from driving or caused them to switch to public transport.”
“Sir, as I said in an earlier reply, I have occasionally received requests from religious bodies and some charities which wanted to promote altruistic donations. They said, "Can we be allowed to compensate the families, in the case of cadaveric donors, including in dollar terms?" These are cautious people and they worry whether they will be flouting any HOTA rules. I am studying this idea. I think we should encourage such third party, particularly if they are charities and religious bodies who want to promote altruistic donations. I think the more you can break the direct relationship between the donor and the donee, a lot of the unethical considerations can be minimised. This is a possible option that we should explore, and I am studying it carefully with a view to doing so. As for research on how to eliminate or reduce the impact of this problem, that is ongoing globally, including to a certain extent, in Singapore. I remember the early days when I first joined the Ministry of Health when dialysis machines reminded me of mainframe computers, big machines, but they have shrunk over the years and now there are a lot of efforts to shrink it further. In parallel, there is also research ongoing to look at other non-human organ possibility and substitutes. We wish such researchers early success but, meanwhile, the problem exists and I think the practical problem of this has to be resolved one way or the other. ELECTRONIC ROAD PRICING CHARGES (Freeze increases) 4. Mr Lim Biow Chuan asked the Minister for Transport whether he will consider a freeze on further increases in ERP charges until the cost of living for the average Singaporean is more stable. 5.”
“Sir, over the past three years, there were 228 kidney transplants involving Singaporeans, and 63% of these were from deceased donors. During the same period, there were 33 liver transplants, 64% from deceased donors. There were 271 cornea transplants, all of course from cadavers. Currently, the numbers of patients waiting for cadaveric organs are 563 for kidney, nine for liver and 25 for cornea.”
“I spent many years running hospitals and I am used to listening to the talks in the doctors' lounge or in the corridors, and often you get better information at the hospital grounds than far away at the Ministry headquarters. So whether there are unethical practices happening on the ground, if you bring the committee to a level which is much more remote from the ground, I do not think we are improving the situation. ORGAN TRANSPLANTS PERFORMED IN SINGAPORE 3. Dr Lam Pin Min asked the Minister for Health if he will provide (i) the number of kidney, liver and cornea transplants performed in Singapore over the past three years and their breakdown into cadaveric and live donor organs; and (ii) the average waiting list for each organ type.”
“Sir, the lifting of age limit is something that is common in many countries. Our setting this arbitrary limit of 60 is quite unique. I remember the history to this. We were breaking new grounds with a presumed consent legislation, so for conservative reasons, my predecessor decided to set this age limit of 60. We can certainly study the survivability or success of kidney transplants in other countries where elderly donors are involved. But the fact that in Norway and Spain, for example, many donors are above 60 and their population life expectancy is not worse than ours suggests that this is a very viable and practical option, going forward. As for employer support, this is not covered under HOTA. My understanding is that employers are generally supportive of employees who are donors, including insurers. I have checked on this point before, for example, whether insurance premiums of donors will be affected, and the answer is "No". I think I missed an earlier question from Mdm Halimah, which was on hospital Ethics Committee, and whether we should set up other ethics committees to just look at unrelated organ donors. Our system is not unique. We have a National Ethics Committee which provides guidance to the various hospital ethics committees, but we leave the decisions at the ground level to the hospital ethics committee. It is their job to assess carefully the donors. There are two things they have to look out for: (1) Are the donors well informed about the risks that they are going into; and (2) Are they being pressured by financial considerations? That is the arrangement we have in Singapore, which is also the system elsewhere. If we bring it to the Ministry of Health to perform such a role, can we do a better job? I am not so sure.”
“But if we apply our minds, if we do not shut off our minds to options like this, I hope to be able to find practical solutions that can minimise or even eliminate the exploitation. Is that not a better outcome than the current situation?”
“Sir, I thank the Member for her support in advance of the proposed HOTA Amendments which I will bring to this House. I agree totally with the Member on prevention as the best approach, going forward. But no matter how hard we try on this front – and we will push it to the limit – patients will still fall sick and there will be kidney-failure patients. Our end-stage renal failure rate is high, as compared to other populations. So there is scope for us to bring it down further. But no matter how hard we try on this front, there will still be patients with kidney failure and we have to seriously think about how to manage those kidney-failure patients. On the existence of a black market in Iran, that is a model that we will study because, currently, this is the only country that legalises it. They themselves admit that their solution is not perfect. That is why this topic needs a fairly deep study. It is not something that I will bring to this House immediately, certainly not this year, but the more we discuss the practical difficulties of pushing this front, the more we may be able to find better solutions out of it. The stark reality remains that a black market exists in this part of the world and, as I have said, not only this part of the world but in Europe as well. I was having a conversation with a transplant surgeon from the UK who knows this business very well, so I asked, "Where do desperate British patients with kidney failure go to?" He said, "There are many countries in Europe where such things are happening." Ethical concerns, I can understand. To me, the biggest concern about the ethics of this activity is the exploitation that is going on.”
“Becker won the 1992 Nobel Prize in Economics and he studied the applications of economics to social policies. I would suggest to our media to publish this article of his so that more Singaporeans can be informed of this school of thought. The academic ethicists and medical doctors may be against the sale of organs, but the economists have analysed the problem from a practical perspective, which deserves to be considered. In the article, Prof. Becker carefully weighed the pros and cons and came to this conclusion: "My conclusion is that markets in organs are the best available way to enable persons with defective organs to get transplants much more quickly than under the present system. I do not find compelling the arguments against allowing the sale of organs, especially when weighed against the number of lives that would be saved by the increased supply stimulated by financial incentives." On the part of my Ministry, even as we take action against those involved in illicit organ trading and unscrupulously exploiting the desperate and the vulnerable, we will take a sympathetic approach to the plight of the exploited donors and the basic instinct of kidney failure patients to try to live.”
“While countries and ethicists proclaim that organ trading is illegal and immoral, a black market of illegal transplants flourishes in many countries, and not just in Asia, with poor clinical results for many patients and exploitation of many in poverty. This is the stark reality and the human dilemma confronted by many in such desperate situations. We must therefore take a practical approach. Criminalising organ trading does not eliminate it. But it merely breeds a black market with the middleman creaming off the bulk of the compensation which the grateful patient is willing to offer the donor. Prof. Arthur Lim, a senior doctor and a past President of the Singapore Medical Association, argued eloquently in a letter to the Straits Times just last week that organ-trading "laws should be removed or amended to take into account the desperate circumstances of dying kidney patients." While they have breached the technical aspects of the law, Prof. Arthur Lim argued that "It is wrong to consider them criminals ..... ­In the same way, kidney donors should be supported and not regarded as criminals." He appealed to Singaporeans to think over this important issue carefully, knowing that it is complex. He hoped that Singapore "will not go down in history as a nation with no support and empathy for those who are dying from kidney failure.". As the practical problem of organ shortage grows, attitude towards com pensating kidney donors is gradually changing, and not just in Singapore. Prof. Gary Becker, Professor of Economics and Sociology and Senior Fellow at the Hoover Institution, published an article recently, entitled: "Should the purchase and sale of organs for transplant surgery be permitted?" Prof.”
“With or without legalising kidney trading, HOTA and living-related kidney donations must be the predominant sources of kidney transplantation. But if altruistic kidney donations cannot fully meet demand, we should continue to search for good complementary solutions. We should not reject any idea just because it is radical or controversial. By forcing ourselves to think about unconventional approaches, we may be able to find an acceptable way to allow a meaningful compensation for some living-unrelated kidney donors, without breaching ethical principles or hurting the sensitivities of others. Occasionally, I receive requests from some charities and religious bodies which wish to provide some compensation, in kind and in cash, for the organ donors and their families, to acknowledge their altruistic act. But they worry that this may be construed as organ-trading and they may be breaching the HOTA rules. My view is that we should encourage third parties, especially those from the charity and religious sector, to help promote altruistic organ donations, and that we should consider how they can be allowed to provide some financial compensation to the donors and their families after the transplants have taken place. My Ministry will study whether such an idea is feasible and, if so, whether HOTA needs to be amended to facilitate its implementation. Meanwhile, the reality is that we have not fully met the demand for kidneys and there are desperate patients out there wishing to live and desperately poor people willing to exchange a kidney for a hopefully improved life.”
“This means matching a donor whose tissue is incompatible with the intended patient with another pair or even pairs in a similar situation. This has not yet been done in Singapore. My Ministry is working on this idea so that we can meet the altruistic wishes of such living-related donors. We will set up a live-donor registry to facilitate this. This may require the legal backing of HOTA and, if so, we shall amend HOTA accordingly. With these two additional initiatives, we can aim to raise our sufficiency level from 50% to 70% in the medium term. Dr Lam Pin Min asked whether we will consider legalising the ethical sale of organs in the near future. This is controversial and the current public debate shows that Singaporeans hold strong views both for and against. Moral and ethical issues aside, there are major practical concerns over legalising the sale of kidneys. Would it result in more or fewer kidney transplants? Would it shrink the current cadaveric and living altruistic donor pool of organs? Some studies have shown that with a system for paying organs in place, the altruistic donations may simply dry up. In Iran, where trading of organs is legalised, the transplant rate remains low and the claim, that it has eliminated its kidney waiting list, has not been substantiated by independent studies. According to the WHO, the only two countries almost self-sufficient in kidneys are Spain and Norway. Both of these countries have successful altruistic organ donation systems built up through years of sustained public education. In Singapore, we have not yet maximised the yield through altruistic organ donations. Let us emulate them and push altruistic organ donations to their maximum potential.”