Singapore Health Care: NHS to learn from old Colony!!!

Singapore ©2013 Am Ang Zhang

The Cockroach Catcher recently visited Singapore and is most impressed with how a city state emerged from British Colonial rule to become a shining example to the rest of the world both in terms of Employment, Education, Rule of Law and most importantly Health Care.

Until now, most health care in England has been “free” at the point of delivery. This indeed may be where the trouble really is.

When I was growing up in Hong Kong, education was not free nor was it compulsory. Yet most of us valued it. Every single bit of book, pencil and paper were paid for by hard working parents. There was no abuse of any of those items. Primary education became compulsory (and free) from 1979, yes, late.

Well, one thing I have to admit about British Colonialist is that they generally leave a good government behind. How that is achieved is a mystery to many but in general a stable government with a single policy for 150 years or so may well be one of them. In recent years, the Civil Service in Hong Kong and Singapore had been very efficient and whatever corruption there may have been had been contained or controlled.

Old Singapore Today©2013 Am Ang Zhang

Citizens of England might be surprised to hear that for most of us, health care is not free.

No, not for those of us who pay national insurance and taxes and if we include VAT, that is just about everybody.

Singapore: NO! NOT FREE!

Singapore’s health delivery is not free at any point. This has the singular advantage of preventing the over-utilisation of any of its healthcare services. As England struggled to stem the flow of new EU citizens from coming to use (or abuse) our NHS, Singapore’s system simply see to it that it would not happen. Yet there is a safeguard in public health for what is known as a catastrophic situation which happened during the SARS outbreak.

Singaporeans are considerably healthier than Americans, yet pay, per person, about one-fifth of what Americans pay for their healthcare.

So how does Singapore achieve such impressive results?

The key to Singapore’s efficient health care system is the emphasis on the individual to assume responsibility towards their own health and, importantly, their own health expenditure.

The state recovers 20-100 percent of its public healthcare outlay through user fees. A patient in a government hospital who chooses the open ward is subsidized by the government at 80 percent. Better-off patients choose more comfortable wards with lower or no government subsidy, in a self-administered means test.

I've heard a lot of smart people warn that co-payments are penny-wise but pound-foolish, because people cut back on high-benefit preventive care. Unless someone is willing to dispute Singapore's budgetary and health data, it looks like we've got strong counter-evidence to this view: Either Singaporeans don't skimp on preventive care when you raise the price, or preventive care isn't all it's cracked up to be.

More details on how Singapore's system works:

• There are mandatory health savings accounts: "Individuals pre-save for medical expenses through mandatory deductions from their paychecks and employer contributions... Only approved categories of medical treatment can be paid for by deducting one's Medisave account, for oneself, grandparents, parents, spouse or children: consultations with private practitioners for minor ailments must be paid from out-of-pocket cash..."
• "The private healthcare system competes with the public healthcare, which helps contain prices in both directions. Private medical insurance is also available."
• Private healthcare providers are required to publish price lists to encourage comparison shopping.
• The government pays for "basic healthcare services... subject to tight expenditure control." Bottom line: The government pays 80% of "basic public healthcare services."
• Government plays a big role with contagious disease, and adds some paternalism on top: "Preventing diseases such as HIV/AIDS, malaria, and tobacco-related illnesses by ensuring good health conditions takes a high priority."
• The government provides optional low-cost catastrophic health insurance, plus a safety net "subject to stringent means-testing."

                                                             The Undercover Economist

So in Singapore private clinics are responsible for 80% of primary care but public hospitals cover 80% of hospital care!

 

Singapore has some of the best public hospitals in the Far East if not the world so much so that even those with private insurance often chose to have their operations in a public hospital but staying in a more private room if their insurance covers it. Public hospitals of this level of excellence become the natural competitor for the private market and helps to keep overall cost down without the need of draconian legislation. Such good public hospitals also provide some of the best training grounds for future generations of top class doctors.

 

Singapore together with Iceland has one of the lowest Infant Mortality rates in the world, a third the figure of the USA.

 Singapore: Now ©2013 Am Ang Zhang

 

Read also:

 

The Singapore health system – achieving positive health outcomes with low expenditure                                               by   John Tucci

 

Ministry of Heath, Singapore

OECD health data, 2009

Suicide: The Answer, my friend may be Lithium!

Yes, ’n’ how many deaths will it take till he knows

That too many people have died?

The answer, my friend, is blowin’ in the wind

The answer is blowin’ in the wind

                                                                       Bob Dylan.

 Atacama where Lithium is extracted  © Am Ang Zhang 2015

Lithium: The Gift That Keeps on Giving in Psychiatry

Nassir Ghaemi, MD, MPH
June 16, 2017
At the recent American Psychiatric Association annual meeting in San Diego, an update symposium was presented on the topic of "Lithium: Key Issues for Practice." In a session chaired by Dr David Osser, associate professor of psychiatry at Harvard Medical School, presenters reviewed various aspects of the utility of lithium in psychiatry.
Leonardo Tondo, MD, a prominent researcher on lithium and affective illness, who is on the faculty of McLean Hospital/Harvard Medical School and the University of Cagliari, Italy, reviewed studies on lithium's effects for suicide prevention. Ecological studies in this field have found an association between higher amounts of lithium in the drinking water and lower suicide rates.

These "high" amounts of lithium are equivalent to about 1 mg/d of elemental lithium or somewhat more. Conversely, other studies did not find such an association, but tended to look at areas where lithium levels are not high (ie, about 0.5 mg/d of elemental lithium or less). Nonetheless, because these studies are observational, causal relationships cannot be assumed. It is relevant, though, that lithium has been causally associated with lower suicide rates in randomized clinical trials of affective illness, compared with placebo, at standard doses (around 600-1200 mg/d of lithium carbonate).
Many shy away from Lithium not knowing that not prescribing it may actually lead to death by suicide. As such all worries about long term side effects become meaningless. 

• In psychiatry, our most effective drugs are the old drugs: ECT (1930s), lithium (1950s), MAOIs and TCAs (1950s and 1960s) and clozapine (1970s)

• We haven’t developed a drug that’s more effective than any other drug since the 1970’s

• All we have developed is safer drugs (less side effects), but not more effective

• Dose lithium only once a day, at night

• For patients with bipolar illness, you don’t need a reason to give lithium. You need a reason not to give lithium  (Originally by Dr. Frederick K. Goodwin)

One might ask why there has been such a shift from Lithium.

"Many psychiatric residents have no or limited experience prescribing lithium, largely a reflection of the enormous focus on the newer drugs in educational programs supported by the pharmaceutical industry."

Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters?
Could it be the fact that Lithium was discovered in Australia? Look at the time it took for Helicobacter pylori to be accepted.

Some felt it has to do with how little money is to be made from Lithium.
Some felt it has to do with how little money is to be made from Lithium.

Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?

Bipolar Disorder: Lithium-The Aspirin of Psychiatry?

 

Fremantle: Medical Heresy & Nobel

 

Tasmania & SIDS: The wasted years!

My questions are: Will the new generation of psychiatrists come round to Lithium again? How many talented individuals could have been saved by lithium?

©Am Ang Zhang 2013

Cade, John Frederick Joseph (1912 - 1980)

Taking lithium himself with no ill effect, John Cade then used it to treat ten patients with chronic or recurrent mania, on whom he found it to have a pronounced calming effect. Cade's remarkably successful results were detailed in his paper, 'Lithium salts in the treatment of psychotic excitement', published in the Medical Journal of Australia (1949). He subsequently found that lithium was also of some value in assisting depressives. His discovery of the efficacy of a cheap, naturally occurring and widely available element in dealing with manic-depressive disorders provided an alternative to the existing therapies of shock treatment or prolonged hospitalization.

In 1985 the American National Institute of Mental Health estimated that Cade's discovery of the efficacy of lithium in the treatment of manic depression had saved the world at least $US 17.5 billion in medical costs.

And many lives too!

The following is an extract from The Cockroach Catcher:

“Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he overdosed on the Lithium?”

“No. my wife is very careful and she puts it out every morning, and the rest is in her bag.”

Phew, at least I warned them of the danger. It gave me perpetual nightmare to put so many of my Bipolars on Lithium but from my experience it was otherwise the best.

“Get him admitted and I shall talk to the doctor there.”

He was in fact delirious by the time they got him into hospital and he was admitted to the local Neurological hospital. He was unconscious for at least ten days but no, his lithium level was within therapeutic range.

He had one of the worst encephalitis     they had seen in recent times and they were surprised he survived.

Then I asked the Neurologist who was new, as my good friend had retired by then, if the lithium had in fact protected him. He said he was glad I asked as he was just reading some article on the neuroprotectiveness of lithium.

Well, you never know. One does get lucky sometimes. What lithium might do to Masud in the years to come would be another matter.

I found that people from the Indian subcontinent were very loyal once they realised they had a good doctor – loyalty taking the form of doing exactly what you told them, like keeping medicine safe; and also insisting that they saw only you, not one of your juniors even if they were from their own country. It must have been hard when I retired.

Some parents question the wisdom of using a toxic drug for a condition where suicide risk is high. My answer can only be that lithium seems inherently able to reduce that desire to kill oneself, more than the other mood stabilizers, as the latest Harvard research shows.

Lithium has its problems – toxic at a high level and useless at a low one, although the last point is debatable as younger people seem to do well at below the lower limit of therapeutic range.

Many doctors no longer have the experience of its use and may lose heart as the patient slowly builds up the level of lithium at the cellular level. The blood level is a safeguard against toxicity and anyone starting on lithium will have to wait at least three to four weeks for its effect to kick in. In fact the effect does not kick in, but just fades in if you get the drift.

Long term problems are mainly those of the thyroid and thyroid functions must be monitored closely more so if there is a family history of thyroid problems. Kidney dysfunction seldom occurs with the Child Psychiatrist’s age group but is a well known long term risk.

Also if there is any condition that causes electrolyte upset, such as diarrhea, vomiting and severe dehydration, the doctor must be alerted to the fact that the patient is on Lithium.

Could Lithium be the Aspirin of Psychiatry? Only time will tell!

Latest: British Journal of Psychiatry

Related Posts:

Chile: Salar de Atacama & Bipolar Disorder.

The Book: The Cockroach Catcher

                                                                                                                          

The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US

Review on Amazon

Readers' views.

                              

Medicine: It May Not Be All In The Mind!

Hong Kong ©2012 Am Ang Zhang

I have often wondered if it would be such a disservice to  mankind if doctors were not so understanding of the psychological side of things.

            The possibility of a serious illness being missed is of course a major concern when a patient seeks help for one reason or another.   To put psychological conditions at the top of the list of possible diagnosis is dangerous. Given the concern over cost in most health care systems, the need to restrict the use of expensive investigation is understandable. However, with clinical reliance on sophisticated investigations especially in modern medical training, the art of physical examination is perhaps lost to this generation of newly qualified doctors. Moreover, the reliance on the internet for information removes the need to make use of the still most powerful computer of them all – the brain. No more effort is made to attempt to download the information into our brain for future parallel processing.  As a result, vital and glaring clues are often missed and, worse, dismissed because of over-saturation of information.

       The idea that modern medical training requires some time spent in far-flung places where even the stethoscope is a luxury item is a neat attempt to remind future doctors of the importance of clinical judgment  based on physical examination. Unfortunately feedback from medical students that I had the good fortune to teach only confirmed my worst fears. Such attachments are more a chance for them to visit exotic places in the midst of a busy course than to hone the skills of medicine on which their seniors were brought up.

Hong Kong:

When I first started in psychiatry in Hong Kong, I was fortunate enough to work with a consultant who had a very firm grounding in General Medicine. A case I shall never forget was a thirty-five year old man presenting with very sudden phobic symptoms. At the time we had just opened in Kowloon our new District General Hospital Acute Psychiatric Unit with thirty acute beds, shared equally between Males and Female admissions. This allowed for some acute screening before the long trek to the only mental hospital in the colony, which was twenty two miles away in the New Territories. To many visiting relatives, twenty two miles is a long way, especially in the seventies. As we were all part of one big organisation, it was not really a problem to have screening and then transfer only if it became necessary.

            It was important to carry out a thorough physical examination on all patients including a thorough neurological test. This particular patient checked out normal on most things except for a positive Babinski (a reflex that can identify disease of the spinal cord and brain) .  I was totally baffled but instead of dismissing it I asked my consultant to have a look on the morning round. He carried out a full Neurological.

            “Yes, positive Babinski.”

            Now how on earth can positive Babinski be related to phobic symptoms?

            “We shall need an X-ray urgently, but whatever it is it is not psychiatric”, he declared.

            The patient was found to have a special type of very aggressive lung cancer, with extensive metastasis.

            He died within six weeks despite some very aggressive treatment at the time.

            The sad thing about the case was that being right may not in the end change the outcome.  It bore witness to how little we do know and how little we can do even when we do identify the problem.

            This case definitely established a principle for my clinical practice. Psychological diagnosis need not be the first diagnosis. Rule out organics first. 

            Modern medical schools on the other hand pride themselves in concentrating on the role of psychology in bodily dysfunction. It is arguably true that most family doctors do not get to see all the obscure cases we spent so much time studying as a medical student. Yet in time these cases do get to the hospital to be seen by the specialists. Where indeed do they come from?  Are they not referred by the family doctors, or are they simply missed and then picked up by the specialists?

            Do we as psychiatrists think that it is such a brilliant idea to think “psychology” all the time? Do we really think that people want to see their doctor even when there is fundamentally nothing wrong with them?  Is there a grave danger in that assumption?

            Health planners seem to assume that most who turn up at Family Surgeries have nothing seriously wrong, and similarly those who turn up at A & E. The latter group are just there because they could not be bothered to see their Family Doctors earlier.

            Do we need to apply the money test? Charge a small fee for every consultation for any new condition to exclude malingerers, a sort of “deductible”, in insurance terminology?

            Would it not be safer for all concerned that we should remember:  “It may not be all in the mind!”

                          From:  The Cockroach Catcher     Chapter 40  It May Not Be All In The Mind

England:

Daily Telegraph:

Professor dies of lung cancer after doctors dismiss illness as 'purely psychological'Or HERE.

                                                                          

Lisa Smirl, 37, saw three different doctors after she began experiencing a range of symptoms including shortness of breath, wheezing and pain in her arm over the course of a year. But they were all dismissed as anxiety and depression.

By the time the cancer was finally diagnosed it had spread into her brain, bones and liver and was terminal.

In a blog written during her treatment, Cambridge-educated Dr Smirl wrote: "How is it possible that a 36-year-old, health [obsessed] conscious, occasionally social smoking, middle class, fiancée of a doctor can develop metastatic lung cancer unnoticed. How?!?"

"For the last year I'd been battling a range of bizarre and seemingly disparate symptoms that had forced me in September 2011 to go on sick leave from my job as a lecturer (assistant professor).

"The diagnosis at the time was anxiety and/or depression. And while I was both anxious and depressed, this was due to the increasingly disabling symptoms that my doctor kept insisting were purely psychological.

"So I was actually grateful for a medical diagnosis that confirmed there were objective, physical reasons behind my illness.

"While in some ways this was a terrible surprise, in another it was a huge relief."

Dr Smirl, who is originally from Canada, first experienced shortness of breath and wheezing in late 2010, which was wrongly diagnosed as asthma.

By September 2011, after developing shoulder and arm pain and experiencing 'visual migraines' – in which she lost her vision for half an hour – Dr Smirl was forced to leave her job. She was diagnosed with depression and anxiety and put on antidepressants.

But despite a dramatic weight loss, Dr Smirl claimed three different family doctors refused to consider her symptoms in connection with each other.

In November 2011, a year after she first started having symptoms, she was finally diagnosed with cancer after a doctor agreed to send her for an X-ray.

Dr Smirl, who went on to complete the Great North Run to raise funds for a cancer charity in November 2012, wrote on her blog: "I can't prove it, and this is just my opinion, but I have no doubt in my own mind that my misdiagnosis was in large part due to the fact that I was a middle aged female and that my male doctors were preconceived towards a psychological rather than a physiological diagnosis.

"It is so easy to say that someone's symptoms are 'anxiety' related if they are a little bit complicated, unclear or unusual. Don't repeat my mistakes.

"You know when something is wrong. Find another doctor that you connect with and who takes your concerns seriously. Get referrals. Get tested. Refuse to be dismissed."

USA

My good friend told me about a case that was first thought to be a psychiatric one. It was a severe case of Trichotillomania (hair pulling disorder) that had to be admitted to a mental institution compulsorily.

This is the same friend who alerted us to the radiation dose of some routine health checks.

Trichotillomania is not a condition that requires compulsory admission, so why in this case?

"The patient was sure someone was trying to harm her."

Oh! Acute paranoid psychosis. That makes sense. Anything else? I suppose she had to be on the most up-to-date anti-psychotic and anti-obsessional drugs.

No, before they could pump these drugs into her, her friend bailed her out, against medical advice, and got my friend to see her.

Great friend!

But what could have caused the hair loss?

Polonium?

No way, she was not a spy!

Yes, it was poisoning, not by Polonium, but by Thallium. That was what my friend’s investigation showed.

Thallium has been a noted poison favoured by Secret Services and one famous Graham Young in England. He poisoned his stepmother at the age of 14 and then other members of his family. He was caught and sent to Broadmoor, a maximum security mental hospital in England.

Miraculously he was declared “cured” and released. Nice justice as my friend’s patient was detained by being a victim and they let the perpetrator go despite his diary claiming he planned to kill one person for every year he spent in Broadmoor!

Young then proceeded to find employment as a shopkeeper at Bovingdon, Hertfordshire, where his co-workers were one by one struck by a mysterious illness nicknamed “the Bovingdon Bug”. One died but Young’s arrogance brought his downfall. He challenged the doctor dealing with the “Bug” in a public meeting as to why Thallium poisoning was not considered!

At one time, Thallium was used as a rat poison as even the rats could not detect it by taste. Now it has been banned in most countries but still poses a health risk.

As recently as 2007, two women, a mother and a daughter, who were both born in Russia but became American citizens, had Thallium poisoning on visiting Russia. They survived. The mother is a medical doctor.

It turned out that my friend’s patient was being poisoned by her partner. Prussian Blue was prescribed as the remedy and she survived, sort of, with residual neurological damage due to delay in diagnosis and appropriate treatment.

Paranoid psychosis indeed!

Just remember: it may not be all in the mind.

Review on Amazon

Readers' views.

The Cockroach Catcher on Amazon Kindle UK, Amazon Kindle US

3082012 244pm

Mysterious Psychosis: One Patient One Disease

Teratoma: An Extract,

It May Not Be All In The Mind

Brexit & Coffee: Fakes and Failures!

With clear evidence that politicians ignore professional advice and that looming Brexit is going to harm patients when there is uncertainty about the availability of certain life-maintaining medications from Insulin down. I am reprinting what I have written about how ignoring professionals cost the French dearly over the construction of the Panama Canal.

Panama has been associated with some fabricated plots. There were the John Le Carre book The Tailor of Panama that was turned into a film, the location shoot of the Quantum of Solace (in Panama, doubling as a country in South America), and the Canoeist faking death, just to mention a few.

Then there was the coffee scandal.

In 1996 in California, a certain  Michel Norton, owner of Kona Kai Coffee was sentenced to 30 months in prison. Apparently for an extended period of time (some reckoned a decade may not be an over estimate), cheaper and “lower grade” Panamanian and Costa Rican coffee were used to pass off as “Pure Kona Coffee”.

Cheaper, certainly, as you would not otherwise be doing it. But, INFERIOR? I think many would certainly dispute that. I do not think you can really use an inferior product to pass off as something superior and fool people for long.

So the Ambassador of Panama in Washington D.C. wrote to the New York Times:

To the Editor:
I read with amusement about the indictment of a coffee supplier on selling fraudulently marked beans to retailers (news article, Nov. 13).
Without making light of the charges, I am pleased that the coffee buyer for Peet's Coffee and Tea is uncertain that he can tell the difference between the ''cheaper'' Panamanian beans allegedly substituted for the more expensive Kona.
Panama's coffee is among the world's best. In fact, members of my staff have seen Panamanian beans for sale at high-end coffeehouses for little less than Kona. Perhaps we can arrange a taste test of Kona and Panamanian coffee for the sellers mentioned in the article. I am sure that no one will be more pleased with the results than my native coffee growers. 

Panama Coffee is now world famous.

Poor Theresa May, she is not so lucky with Brexit but perhaps she is rich enough not to worry too much about her insulin!

Politician & The Panama Canal

It is a common practice for politicians to ignore professional advice. As The Cockroach Catcher, his wife and friends cruise across this greatest of all human endeavour, he likes to re-post one of the Panama Posts.Sometimes they might get away with it; sometimes it led to failure, gross failure as in the case of the French attempt at building the Panama Canal.Can we really learn anything from such a colossal failure?

C.G. Jung

We learn little or nothing from our successes. 

They mainly confirm our mistakes, while our failures,

 on the other hand, 

are priceless experiences in that 

they not only open up the way to a deeper truth, 

but force us to change our views and methods. 

Panama Canal © 2008 Am Ang Zhang

Most people probably know about the French failure to build the Panama Canal. Many thought that this was due to yellow fever and malaria which were diseases thought to be due to some toxic fume from exposed soil.

Extracted from the Official Website: Panama Canal Authority /French Construction

In 1879, Ferdinand Marie de Lesseps, with the success he had with the construction of the Suez Canal in Egypt just ten years earlier, proposed a sea level canal through Panama. He was no engineer but a career politician and he rejected outright what the chief engineer for the French Department of Bridges and Highways, Baron Godin de Lépinay proposed, a lock canal.

The engineer was no match for a career politician:

“There was no question that a sea level canal was the correct type of canal to build and no question at all that Panama was the best and only place to build it. Any problems – and, of course, there would be some - would resolve themselves, as they had at Suez.”

“The resolution passed with 74 in favour and 8 opposed. The ‘no’ votes included de Lépinay and Alexandre Gustave Eiffel. Thirty-eight Committee members were absent and 16, including Ammen and Menocal, abstained. The predominantly French ‘yea’ votes did not include any of the five delegates from the French Society of Engineers. Of the 74 voting in favor, only 19 were engineers and of those, only one, Pedro Sosa of Panama, had ever been in Central America.”

The French failed in a spectacular fashion.

Cost to the French: $287 Million (1893 dollars) or $6.8 Billion (2007 dollars)

Many reasons can be stated for the French failure, but it seems clear that the principal reason was de Lesseps’ stubbornness in insisting on and sticking to the sea level plan.  But others were at fault also for not opposing him, arguing with him and encouraging him to change his mind.  His own charisma turned out to be his enemy.  People believed in him beyond reason.

Could any of us learn anything from this experience?

Hermione: "You pay a great deal too dear for what's given freely". -

(Act I, Scene I). The Winter’s Tale.

David Cameron & The NHS: Abandon! Abandon! Abandon!
Links

President Jimmy Carter: Time

Interesting Data
Smithsonian Institute
Web Cam

Panama:

Panama Canal: Diseases & Failures.

Loquat, Winter Melon & Sapote

Coffee in Panama – Faking Is Not All Bad