Global health: challenges and opportunities for Singapore.

Over the past decade, global health has evolved from a buzzword to a discipline, attracting interest from governments, academic institutions and funding organisations. Global health centres, institutes and initiatives in Western countries have increased in both size and number, aided primarily by institutional backing and supportive funding mechanisms. As the rise to prominence of global health on the public health agenda also coincides with shifts in global balances of power, Asia, as well as Singapore, has an expanded role to play in supporting global health teaching and research, both in the region and throughout the world. Foundations, universities, government agencies, statutory boards and the private sector all have an important role to play in moving the global health agenda forward in Singapore. Rigorous global health training and increased funding for global health research are now timely and essential in order for global health, as a discipline, to develop within Singapore and have an impact within the region.

Combined effect of socioeconomic status, viral hepatitis, and lifestyles on hepatocelluar carcinoma risk in Korea.

BACKGROUND: The independent and combined effects of socioeconomic status (SES), viral hepatitis, and other lifestyle factors on hepatocellular carcinoma (HCC) risk have not been investigated among Koreans. METHODS: From the National Cancer Center Hospital, 207 HCC cases and 828 age- and gender-matched controls aged 30 years or older were recruited. Socio-demographic and behavioural risk factors were ascertained through personal interview, and infection with hepatitis B and C viruses was determined by their serologic markers. Multivariate logistic regression and synergy index methods were applied for statistical analysis. RESULTS: HB surface antigen (HbsAg) and anti-HCV-positive rates were 149.3 and 185.1 times higher in cases than controls, respectively. Lifetime alcohol consumption (odds ratio: 2.96, 95% CI: 1.29-6.79), cigarette smoking (OR: 3.53, 95% CI: 1.31-9.52), and family income (OR: 17.07, 95% CI: 4.27-68.25) were independently associated with the risk of HCC in subjects with or without viral hepatitis. Synergistic interaction on HCC risk was observed between low income and HBsAg positivity (SI: 3.12, 95% CI: 1.51-6.47) and between low income and heavy alcohol intake (SI: 2.93, 95% CI: 1.24-6.89). CONCLUSION: The inverse association with SES suggests SES as an independent and synergistic predictor of HCC. Heavy alcohol intake also showed a combined effect with low SES on HCC risk.

Does child gender determine household decision for health care in rural Thatta, Pakistan?

BACKGROUND: In South Asia, gender disparity in child mortality is highest in Pakistan. We examined the influence of child gender on household decision regarding health care. METHODS: Prevalence ratios were calculated for 3740 children aged 1-59 months from 92 randomly selected villages of rural Pakistan using a cluster-adjusted log-binomial model. Level 1 variables included child and household characteristics and level 2 included village characteristics. RESULTS: There were 25 more girl deaths than boys per 1000 live births (95% CI: 13.9, 48.6) among post-neonates and 38 more among children aged 12-59 months (95% CI: 10.5, 65.5). However, in adjusted analysis, gender was not a significant predictor of illness reporting, visit to health facilities, choice of provider, hospitalization and health expenditure. Significant predictors of health care were child's age, illness characteristics, number of children in the family, household socio-economic status and absence of girls' school in the village. CONCLUSIONS: Differential care seeking for boys and girls is not seen in Thatta despite clear differences in mortality ratios. This calls for more creative research to identify pathways for gender differential in child mortality. Factors identified as influencing child health care and amenable to modification include poverty alleviation and girls' education.

Transforming Singapore health care: public-private partnership.

Prudent health care policies that encourage public-private participation in health care financing and provisioning have conferred on Singapore the advantage of flexible response as it faces the potentially conflicting challenges of becoming a regional medical hub attracting foreign patients and ensuring domestic access to affordable health care. Both the external and internal health care markets are two sides of the same coin, the competition to be decided on price and quality. For effective regulation, a tripartite model, involving not just the government and providers but empowered consumers, is needed. Government should distance itself from the provider role while providers should compete - and cooperate - to create higher-value health care systems than what others can offer. Health care policies should be better informed by health policy research.

Complementary and alternative medicine use in multiracial Singapore.

OBJECTIVE: To determine the prevalence of complementary and alternative medicine (CAM) use in Singapore, the factors influencing CAM use, and the attitudes, beliefs and perceptions of the general population towards CAM. DESIGN: An interviewer-administered questionnaire survey in a housing estate with demographic and socioeconomic characteristics closely matching that of Singapore. RESULTS: 76% (95% C.I. 73.9-77.9%) used CAM over a 12-month period. Females were 2.1 times (95% C.I. 1.3-3.4) more likely than males to use CAM. Chinese (84%) were the most frequent users, followed by Malays (69%) and Indians (69%), with adjusted odds ratios of 0.4 (95% C.I. 0.2-0.7) for Malays and 0.4 (95% C.I. 0.2-0.8) for Indians. Traditional Chinese Medicine (88%) was the most widely used form of CAM, followed by Traditional Malay (Jamu) Medicine (8%) and Traditional Indian (Ayuverdic) Medicine (3%). Similar to western studies, CAM was more likely to be used for maintenance of health than for treatment of illness. Different from western studies, CAM use was not independently associated with household income, marital status, age and education. Seventy-four percent did not discuss their use of CAM with their western-trained doctors. CONCLUSIONS: The high prevalence of CAM use in multi-racial Singapore suggests the same may be true in other Asian countries. Western-trained doctors need to understand CAM better and communicate more with their patients regarding CAM use. The lack of a scientific evidence base for most forms of CAM notwithstanding, its ubiquitous use worldwide is something that governments and the medical profession cannot afford to ignore.

Validity and cost-effectiveness of diagnostic procedures in CS2 poisoning.

To determine relatively useful diagnostic procedures of carbon disulfide (CS2) poisoning in terms of validity and cost-effectiveness, several diagnostic tests are evaluated on 1,552 people by prevalence ratio (exposed/nonexposed), dose-response relationship, sensitivity and specificity, and the cost of the tests. Several symptoms with high kappa indices are found to be useful in various combinations, showing a consistent dose-response relationship and high exposed-nonexposed ratio. In clinicopathologic tests on functions of the kidney, liver and hematopoietic systems, eight items out of 22 have been shown to have significant dose-response relationship, mostly in liver function tests. A thorough dental examination failed to identify any useful indicator peculiar to the CS2 poisoning. Unlike Western people, the prevalence of coronary heart disease among Koreans was too low to be useful in the diagnosis of CS2 poisoning. Among four elective tests, i.e., Minnesota Multiphasic Personality Inventory (MMPI), Brain magnetic resonance imaging (MRI), nerve conduction velocity (NCV), and fluorescent angiography (FAG), the NCV appeared to be a more sensitive and specific test than the others are. Combinations of the tests improved the probability of diagnosing CS2 poisoning cases when any one test out of four was positive. Addition of other valid tests increased the probability of excluding non-cases. It was concluded that diagnosis of CS2 poisoning could be made validly and inexpensively if the diagnostic tests were carefully chosen step by step.

Doppler flow characteristics in the assessment of pulmonary artery pressure in ductus arteriosus.

The Doppler spectral pattern of flow through the ductus arteriosus was studied in 117 patients. In 37 who underwent catheterisation, Doppler records and aortic and pulmonary artery pressure were available (21 simultaneously with two catheters) for review while the others had surgical ligation of the duct on the basis of the results of non-invasive tests. Four flow patterns were obtained: (a) continuous flow, maximum velocity in late systole with gradual fall throughout diastole; (b) continuous flow, high systolic flow with rapid fall to a very low early diastolic velocity maintained throughout diastole; (c) continuous low velocity, maximum in late diastole; and (d) bidirectional flow. Flow pattern (a) was associated with normal or slightly raised pulmonary artery pressure; (b) with raised pulmonary artery pressure; and (c) and (d) with pulmonary artery pressure at systemic values. Comparison of the Doppler and measured pressure differences between the great arteries was reasonably good for peak values but poor for the trough readings. Doppler ultrasound clearly showed ductal flow; the flow pattern gave an indication of the pulmonary artery pressure, but pressure measurement by application of the Bernoulli equation to the flow velocities cannot yet be regarded as reliable.

Doppler assessment of the interventricular pressure drop in patients with ventricular septal defects.

Doppler ultrasound was used to assess the pressure drop between the ventricles in 109 infants and children (61 less than two years old) with a ventricular septal defect who underwent cardiac catheterisation. The pressure in both ventricles was measured at catheterisation in 103 patients either simultaneously through two catheters (41) or with a single catheter withdrawn across the septum or removed from one ventricle to the other (62). When pressure was measured simultaneously with two catheters (41 patients) the peak to peak and instantaneous gradients showed a maximum difference of 20 mm Hg with levels within 10 mm Hg of each other in 36. Comparison of the difference in the gradients with the average of the measurements demonstrated a tendency for Doppler to underestimate the difference when it was high (greater than 50 mm Hg) and overestimate it when it was low. A Doppler estimate of a low pressure difference between the ventricles indicates pulmonary arterial hypertension and a high one low pulmonary artery pressure, but in the intermediate group Doppler is as yet not sufficiently sensitive to allow selection of those patients who require further investigation and possible operation. Doppler ultrasound was found to be a sensitive method of detecting a very small ventricular septal defect. Thus although Doppler is a very useful means of assessing and following patients with a ventricular septal defect, further studies are required to determine its exact place in clinical practice.