The social transformation of Singapore medicine through 55 years of the SMJ

INTRODUCTION

The portrait of an era which witnessed the emergence of Singapore from Third to First World is often framed by a narrative of dramatic progress, from a colonial outpost in the backwater to a metropolis with a skyline of towering buildings stabbing the sky. In a quiet and measured way, this transformation is also chronicled in the Singapore Medical Journal (SMJ), which has charted medical advances in tandem with Singapore’s socioeconomic development in the past 55 years. The published papers defined these changes and have become milestones that acquired a sepia tone with the march of time.

SMJ THROUGH THE PAST 55 YEARS

In the early 1960s, with the insalubrious state of public health, SMJ papers were focused mainly on tetanus, cholera, leprosy, tuberculosis, gonorrhoea, syphilis, diphtheria, malaria and worm infestation. Professor Tow SH published his seminal work on choriocarcinoma in 1965,(1) and Dr Gwee Ah Leng headed the medical team during the koro epidemic of 1969.(2) In the 1970s, there were publications on social problems like opium addiction,(3) heroin abuse,(4) smoking(5) and alcoholism.(6) Military doctors wrote on the health of national servicemen.(7)

However, in the 1980s, the published work on illness patterns was decidedly different. There were studies on AIDS,(8) anorexia nervosa(9) and work stress.(10) The Hotel New World disaster was reported by Dr Lim Meng Kin and the medical rescue team.(11) In the 1990s, communicable diseases no longer dominated the contents of the SMJ; research papers were on the ageing population,(12) escalating health costs,(13) cancer,(14) obesity(15) and doctor’s stress.(16) A report on the mental health of the nation was published in 1998,(17) while Dr How J wrote on decompression sickness and the Mass Rapid Transit (MRT), a landmark national development in Singapore.(18)

The new millennium heralded changes in the health and social landscapes of Singapore. SMJ papers included molecular genetics,(19) Internet medicine,(20) positron emission tomography scan,(21) liver transplantation,(22) gambling addiction,(23) health economics,(24) palliative medicine,(25) sports medicine,(26) cosmetic surgery(27) and robot-assisted surgery.(28) The SARS epidemic, a tragic event in Singapore’s history, was documented by doctors on the front line.(29,30)

In 2005, medical education was the focus during the centennial of the National University of Singapore Medical School. A few years earlier in 1998, Professor Tan Chorh Chuan, who was then the dean, published a paper on rethinking medical education.(31) Leading nursing educationists wrote on the new Alice Lee Centre for Nursing Studies(32) and Dr Cheong Pak Yean expatiated on the future of family medicine training.(33)

During the 2015 Jubilee year, two papers reflected important societal issues in Singapore – the Mental Capacity Act for the care of the cognitively impaired elderly(34) and polypharmacy in the treatment of elderly patients, especially in nursing homes.(35) The short-lived upheaval in Little India was reported by emergency doctors caring for victims of the riot.(36)

THE ETHICAL MIND: SMA LECTURES

The SMJ publishes the annual Singapore Medical Association (SMA) Lecture, which often highlights prevailing and pressing socio-medical matters. With rising healthcare costs, some doctors have questioned whether healthcare is a commodity to be bought and sold in the marketplace. Corporate terms like ‘customers’ and ‘clients’ are now used in hospitals to replace ‘patients’. In the 1996 SMA Lecture, Dr Charles Toh cautioned that “economic growth driven by a free market does not necessarily translate into better healthcare for all.”(37) Dr Yong Nen Khiong, in the 1993 Lecture, opined: “Good doctoring keeps cost down.”(38)

Focusing on the ethical mind, Professor SS Ratnam challenged the medical fraternity in the 1977 Lecture: “I think the time has come when we critically review our own position in relation to society and its needs and to re-dedicate ourselves to our first and only cause as doctors in making our only role that of helping the sick.”(39) In the 1999 Lecture, Dr Chew Chin Hin reminded the doctors “not to be ministered unto, but to minister”.(40) A few years earlier, in the 1971 Lecture, Dr Yahya Cohen exhorted the SMA to “instil among its adherents a sense of values so necessary to dignified survival – of values such as pride but not arrogance, of discipline but not servility, of respect but not fear, of loyalty but not subservience, and in so doing to imbue the coming generations with a deportment that is both discriminating and courageous”.(41) With the restructuring of hospitals and new governance, there was an uneasiness about the role of administrators. Professor Woo Keng Thye, who spoke on doctor leadership at the 2007 Lecture, stressed the need to “walk the ground”, invoking the principles of Sun Tzu’s Art of War.(42)

One of the most inspiring speeches published in the SMJ was the SMA Lecture of 1997 by Dr Wong Heck Sing on role models in medicine.(43) He enumerated the attributes of a good mentor: clinical competence; broad perspective of life; well-versed with the art and science of medicine; ability to teach; and making the patient’s welfare a priority. His Hall of Famers included Arthur Ransome, Yahya Cohen, Thamboo John Danaraj, Gwee Ah Leng, Lim Kee Jin, Seah Cheng Siang, Wong Hock Boon and K Shanmugaratnam.

FROM THE ARCHIVES

In the last 55 years, the SMJ has recorded the social history of public health and medical advances in Singapore. As you scan through the catalogue of papers culled from the archives (Table I), you will be amazed that some of the diseases that were prevalent in the 1960s are now rarely encountered. There is also a sense of nostalgia reading the papers, especially if you personally know the doctors, some of whom have passed on; these pioneer doctors were able to conduct research with meagre or no grants and write papers, albeit encumbered by heavy daily clinical duties.

Table I

Selected SMJ papers from the archives.

CONCLUSION

The SMJ has chronicled the rise of Singapore medicine and the socioeconomic development of this city state. With the ferocity of the pace of life, some publications may have been missed or read and forgotten. There was a gentle reminder by Dr Raj Mohan Nambiar in the 2004 SMA Lecture, when he warned of escalating medical litigation and the surge in insurance premiums.(44) In the 2005 Lecture, Dr Chee Yam Cheng quoted that the insurance premium for cosmetic practice had risen phenomenally from $5,250 in 2000 to $22,875 in 2005, and general practice from $700 to $1,740.(45) The emphasis or re-emphasis must be primum non nocere or ‘first, do no harm’.

As Singapore medicine evolves and expands, the SMJ will continue to reflect this transformation. In the next decade, the publications are unlikely to be on cholera, malnutrition, worm infestation or opium addiction. There may be more publications on health costs, integrated regional health system, translational research and dementia prevention.

A notable change in the authorship of the SMJ papers is the increasing number of women authors. In the sixties, there were less than 10%, as compared to nearly 40% in the last decade; even the authorship of this paper is a fine balance of genders. With the global feminisation of medicine, it is perhaps timely for the SMA – possibly one of the last few bastions of male dominance in Singapore – to consider, in the not-to-distant future, a woman as the SMJ Editor.

The Past Editor Series is a collection of invited articles written by former SMJ Editors and their co-authors, who are respected medical practitioners in their respective field of expertise.