The first case of Covid-19 infection in Singapore was announced on 23 Jan 2020. We are now into the 4^th week of the outbreak in Singapore.

The situation in China appears mixed. The number of new infections each day seemed to have peaked. But apparently those happier numbers were due to under-diagnosis. Yesterday the numbers hit the roof with another 15000 new infections and 254 deaths in China in one day. There are now almost 64,000 cases and 1400 deaths in China. The number cases in Hubei province, including Wuhan, continues to outnumber those in the rest of China by about 4:1. This implies that there is still rapid transmission of cases both within and without Hubei. You know the battle is far from won in China when they have just removed the bosses of Hubei Province and Wuhan City (their party secretaries).

We Haven’t Seen The Fat Lady Yet

The current state of affairs in China is such that we really do not know if the worst is over. But there are some folks out there who repeatedly lobby for a softer stance in the fight against Covid-19. They say this is no more harmful than the common flu, which kills a lot more people every year than any coronavirus outbreak.

This hobbit would like to be a bit more cautious. For one, while we know it’s less deadly than SARS or MERS, we just do not know how less deadly it is. Statistics so far suggests so. Outside of Hubei province, the Case Fatality (CF) Rate is below 0.5%. While for Hubei it’s about 3%.

Why is the CF Rate for Hubei (and it’s provincial capital of Wuhan) so much higher? Many theories have been proffered. For one, being the place of origin of where Covid-19 started, the outbreak went undetected for 2 to 3 cycles longer than other cities, which had heightened awareness and sensitivity to the novel disease. By the time the disease reached other Chinese cities, it had already taken root in Wuhan and its surrounding cities. So the number of infections there are much larger.

But this does not alone explain the higher CF Rate. It could be that hospitals there are overwhelmed and the hospital themselves have become great incubators and reservoirs of the virus. They are so because therein lies a great number of sick people with many comorbidities and their chances of dying are much higher than the average person in the street. This is not much different from SARS where hospitals and hospital staff and patients had a much higher chance of being afflicted with the disease.

This is this hobbit’s theory of why the CF Rate in Hubei is much higher than other parts of China. And therefore, it is vital that we do not let our hospitals get hit by Covid-19. But it is only a theory. The truth is, we really don’t know for sure why Hubei is doing so badly in terms of the CF Rate.

The other two important factors are that we do not have drugs that can definitively treat the disease (like Tamiflu for influenza) and a vaccine.

And so, until we know for sure why Hubei is different from the rest, or that we have a drug for definitive treatment or a vaccine, it is best we don’t throw in the towel by treating Covid-19 like the influenza virus.

And besides, it is early days yet. SARS infected 238 persons in Singapore and killed 33. We have about 67 cases and no fatalities for Covid-19. It is too early to give up the fight.

Another factor to be considered is that China is now returning to work after the Chinese New Year extended holidays. Will that lead to another round of infections as hundreds of millions of people go on the road again from their hometowns to their place of work? Only time will tell. It is true that we have effectively closed off China as a new source of infections since everyone that comes to Singapore from China must be given leave of absence for 14 days. But one can still get infected in other countries before coming to Singapore – an imported case, but not from China, so to speak.

So as the saying goes, “It ain’t over till the fat lady sings”. No one is quite sure if they have seen the fat lady yet…..let alone see her sing.

And so, that means we, the ground troops, must slog and plod on in our clinics and hospitals.

Logistic Fog of War

After three weeks, things are really getting a little edgy on the ground in the private sector, to put it mildly. If you are the grunt troops fighting in the trenches, after three weeks, you are going to be in pretty low morale if you have had only 5 warm meals and 3 changes of underwear and socks and you are down to your last 2 magazines of rounds. You are sick of eating combat rations, you have bad body odour and you are starting to get foot rot.

We have learnt from SARS that when we fight a communicable disease outbreak, we are really fighting on at least three fronts: medical, logistic and psychological.

For the front line troops in the private clinics and hospitals, we are failing quite badly on the logistic front, I am afraid. That is, until the Health Minister announced he was giving 1M masks to the private sector doctors 2 days ago. This hobbit reckons these 1M masks will last the private sector for about 3 to 4 weeks.

Simply put, private sector doctors have no visibility, let alone clarity or assurance, of the government’s resupply plans for them. How much of the National Stockpile of PPEs is meant for the private sector? Nobody knows and all of us in the private sector are fighting Covid-19 while blinded by this fog of war on the logistic side.

Let’s Do The Maths

Let’s take a recap. Up till now, assuming you have been on the ball as a GP securing your masks, here is what you would have gotten from “official channels”:

• From SMA (they obtain their stocks from government): 3 boxes of N95 and 1 box of surgical masks.
• From Zuellig Pharma (The government authorised dealer): 1 box of N95 and 2 boxes of surgical if you are a GP, 1 box of N95 and 1 box of surgical if you are a specialist

Which means the MAXIMUM amount of masks you could have gotten so far are 4 boxes (80 pcs) of N95 and 3 boxes (150pcs) of surgical masks after three weeks in the trenches.

Zuelling is selling another round of masks now, also along the same lines as the previous round. Assuming you are lucky and get what you want, you would have accumulated a total of 5 boxes of N95 (100pcs) and 5 surgical masks of N95s (250pcs) if you are a GP. And if you are a specialist, it’s a maximum of 100pcs of N95 and 150pcs of surgical masks after 20+days at the front lines.

Most folks out there do not achieve this maximum allocation of masks. And we haven’t even started talking about isolation gowns.

Strangely speaking, or maybe my memory is failing me in my old age, I can’t seem to recall we were so short of PPEs during SARS, other than for N95s. Certainly, we weren’t so short of surgical masks then.

A typical GP clinic will have 3 to 4 working persons, including the doctor. Assuming each mask lasts 6 hours, you will use up 2 masks a person or about 6 to 8 surgical masks a day. You are also required to put a mask on a person with fever or respiratory symptoms as per MOH requirements. That would easily take up 10 to 15 surgical masks. In other words, a small solo GP clinic working 3 shifts easily consumes 20 to 25 surgical masks in a day if not more. Now that we are in Dorscon Orange, a solo GP practice would use up to 4 N95s a day in addition to the surgical mask utilisation (One N95 for GP and one for triage nurse per shift, assuming 2 to 3 shifts a day, so 2×2 = 4 N95s a day. If you go for extended (stingy) use, then maybe 2N95s a day).

Assuming the GP works 6 days a week, the clinic will consume 120 to 150 surgical masks a week and another 12 to 24 N95s a week

But as the records show, in the last 3 weeks, we could only have received 80 pcs of N95s and 150 pcs of surgical masks with hopefully another 20 N95s and 100 pcs of surgical masks on the way from Zuellig. This is simply not enough to keep the GP and his clinic going.

It is understandable that we teach the public to limit the use of PPEs and to concentrate on efforts to improve hand and personal hygiene as well as to limit large group interaction. But it is another thing altogether when we try to squeeze the PPE supply to the private healthcare establishments and their staff, when they have to face people who are sick, i.e. a high risk segment of the population.

We Need An Integrated Approach to Making PPE-Related Policies

There is a fine line between conserving PPEs and keeping morale up, i.e. winning the psychological war. Ultimately when everyone does not know when the next batch of masks will come, morale will suffer. Just like troop morale will drop when they don’t know if they will be resupplied with food, water, clothing and ammunition. Everyone is thinking of getting or have been getting their masks from private suppliers. And prices are going up. A box of surgical masks (50pcs) have gone up from $3.50 to $4 before the outbreak to around $25! That is, if you can find them in the first place.

The truth is that PPE consumption rate is influenced by a few factors:

1. The epidemiological features of the disease
2. Dorscon status
3. Case definitions of the disease
4. PPE usage policy

We can’t do much about the natural epidemiological features of Covid-19. It is what it is. But case definitions are largely man-made. If your case definitions are too broad and too many persons fall under the suspect category, then the use of PPEs will shoot up. Likewise for Dorscon status. PPE usage policy also heavily influences usage, although admittedly this is also in turn determined by the epidemiological features of the disease. But whatever the case, the resupply operations must support what the case definitions and mask usage policies demand.

To the uninformed, it would appear that the 4 policies are governed by different groups of people working independently of each other. The resupply practices of 20 pcs of N95 and 100 pcs of surgical masks a week is not keeping up with the demands of the case definitions or the Dorscon status. It looks like the resupply guy is still in Dorscon Yellow while his colleagues in the other departments or ministries have moved on to Orange.

Talk about frustration.

What this Hobbit would like to see is that the authorities commit to a certain rate of resupply for GP and private sector community specialist clinics. E.g. 1 box of 20 N95s every two weeks, 3 boxes or 150pcs of surgical masks a week and 10 isolation gowns a week and maybe 2 bottles of sanitizers/hand rub. Then all of us doctors can concentrate on picking up new Covid-19 cases and treating other patients instead of constantly worrying about where their PPEs will come from. We will pay for the PPEs too, we don’t need freebies. And of course, community clinics with more than one doctor should appropriately receive more PPEs than the solo GP.

Public Health Preparedness Clinic (PHPC)

That brings us to what is listed as a MOH National Scheme called the Public Health Preparedness Clinic (PHPC). This Scheme “consolidates the primary care clinic response to public health emergencies such as influenza pandemic, haze and anthrax outbreak into a single scheme for better management”. (www.primarycarepages.sg/practice-management/moh-national-schemes/public-health-preparedness-clinic-(phpc)

For volunteering to be on this wonderful Scheme, MOH is supposed to provide you with “up to 12 weeks’ supply of PPE for staff at no cost”. This sounds great right now because I know some GPs who will pawn their grandmothers for 12 weeks of free PPEs.

But, according to a circular issued on 11 Feb 2020 by MOH, this Scheme hadn’t been activated yet. Therefore, no one has received any PPE free of charge under this Scheme either. Today it has been finally activated. Maybe it’s about tough love on Valentine’s Day.

Frankly, this hobbit cannot understand why the Covid-19 wasn’t considered a public health emergency until today. The Scheme was increasingly looking like a joke until a powerful necromancer decided to breathe some life into this cadaver of a national scheme today.

Come Down Hard On False Declarations

Doctors and other healthcare workers need to be protected with PPEs. But they also need to be protected against reckless and selfish people who put others, especially healthcare workers (HCWs) and healthcare establishments, at risk. Several people have already been punished for breaking quarantine. But this hobbit thinks there are far more people who give false declarations about the travel and contact history. I think practically all doctors out there know other doctors who have had seen irresponsible people after they had made false declarations, even if they had not met one themselves.

The authorities should protect the public and HCWs by taking these false declarers to task, and charge them under certain provisions of the Infectious Diseases Act. This would send a clear signal that false declarations will not be tolerated, and not just those that illegally break quarantine orders.

The New Battlefront: Private Hospitals

This Hobbit opined in Part 1 that Generals fail when they fight the last war. Generals often assume the new enemy is like the last enemy and they will win against this new kid on the block by bashing him/it the same way as they bashed the previous kid on the block. And they are often proven wrong when they do so.

The recent spate of cases whereby patients and staff have been exposed to confirmed cases underline this point. During SARS, the private hospitals were spared and the restructured hospitals bore the brunt of outbreak. This time is different. The first two hospitals to have unprotected staff exposed to confirmed patients were private hospitals. The first healthcare worker who contracted Covid- 19 was a private sector anaesthetist who was rumoured to have seen patients in more than one private hospital.

It is clear that the private hospitals are at as much risk as restructured hospitals for Covid-19. Some of these hospitals are running very short on PPEs. But this hobbit was told they are expected to source for them on their own. The Singaporean equivalent of the biblical Joseph guarding our National Stockpile should quickly beef up the dwindling stocks in the private hospitals. MOH should also ensure that private hospitals have the same standards of disease control as restructured ones, especially in terms of PPE usage, triage and limitation of doctor movement.

When stocks are running low, private hospitals and clinics have no choice but to make compromises on PPE usage, leading to suboptimal infection control. And we are only as strong as the weakest link, as the saying goes.

Research

Singapore has the most cases of Covid-19 after China. (Other than the cruise liner docked off Japan). It is interesting that Chinese, HK, USA, Germany have all published research papers in reputed research journals and Singapore hasn’t. That’s a shame, given our reputation as a medical hub with top-notch researchers and clinician scientists. What’s happening?

And so…..

Again, as this hobbit has said in Part 1, there will be many twists and turns to this blockbuster saga sequel to SARS. And we are now beginning to see some of these twists and turns.

As Winston Churchill said long ago while fighting another war, “Now this is not the end. It is not even the beginning of the end. But it is perhaps, the end of the beginning”.

The situation in China is getting grimmer by the day. Yesterday, some 2900+ new cases of 2019-nCoV infections were reported. With the total number of infected exceeding 17000, this ugly new virus has blew away SARS in this aspect. A record number of people (57) died yesterday, pushing the total number of deaths due to the disease to 361. More lives have been lost in China to 2019-nCoV than SARS. These are breath-taking numbers

Hence, hearing then Health Minister speak in Parliament today was reassuring. The Ministry is certainly working their butts off to try and prevent local transmission of the 2019-nCoV. It is also working out scenarios on how to manage the situation should the virus be found to be transmitting locally.

This novel 2019-nCoV is one mean SOB, you have to admit. It’s as mean if not meaner that SARS in at least 3 ways.

For one, it has been now established that a patient is infectious even during the incubation period. This was published in as a correspondence to the NEJM by German doctors a few days ago.

Secondly, about 80% of patients exhibit easily detectable symptoms or signs such as fever or cough. That means even with temperature screening, 1 in 5 patients may escape detection. This was published in The Lancet a few days ago too.

Thirdly, Chinese health officials suggest that a person may get re-infected with the virus. In other words, one is not off the hook as immunity may be fleeting. If that is the case, it would also suggest it may very difficult to develop an effective vaccine that confers lasting immunity.

Singapore has been gearing up to meet the threat of 2019-nCoV. It certainly warmed the heart of this hobbit to see our NSF boys packing surgical masks for distribution to every household in Singapore.

Since we are on the issue of masks. This hobbit would like to say a few words about our mask policy. The official message is, unless you are dealing with potential high risk patients, such as potential suspect patients, one doesn’t have to wear a mask.

But on the ground and when policies are actually rolled out, there is wide variation in interpretation. This can be observed on the 1 Feb 2020 print copy of The Straits Times. On one page was an article describing how during the ruling party PAP’s Meet-The-People Sessions (MPS), temperature screening is now being carried out. The same article also said that MPs and party activists should not be wearing masks (in line with the prevailing instructions of government then).

Several pages later, under reporting coverage for the recently held Chingay Festival, there was a large photograph showing masked-up temperature screeners checking on Chingay Festival attendees. I think the Chingay Festival is an event sanctioned by the government.

Personally for me, I think the logical thing to do in a gathering of normal-risk people, is NOT to conduct temperature screening and NOT to wear a mask, if we truly believe there is no local transmission of the disease. We should conduct temperature screening when there is a gathering of higher-risk persons, such as patients seeking care (and accompanying persons) in hospitals or clinics. In which case, temperature screeners should wear a surgical mask because they need to be protected in case a suspect case of 2019-nCoV turns up. Therefore, to forbid a screener from wearing a mask suggests that there is practically no chance of the screener meeting a suspect case, in which case, then why screen at all? Does this make sense? In other words, do not screen for fever at all. But if you do decide to conduct temperature screening, please let the screener wear a mask.

Another interesting feature is the definition of a suspect case. The current MOH definition of a suspect case of the 2019-nCoV infection (unchanged since 25 January) is:

a) A person with clinical signs and symptoms suggestive of pneumonia or severe respiratory infection with breathlessness AND travel to mainland China within 14 days before onset of illness; OR

b) A person with an acute respiratory illness of any degree of severity who, within 14 days before onset of illness had:

• Been to Wuhan city or Hubei Province, China; OR
• Been to a hospital in mainland China; OR
• Had close contact with a case of 2019 novel coronavirus infection.

On 1 Feb 2020, Singapore moved to bar all recent travellers to China from entering Singapore (other than Singapore residents). This would suggest that the authorities have deemed that the risk of contracting 2019-nCoV is so high for the whole of China that it makes no sense to distinguish a person who has been to Hubei province from another person who has been to another part of Mainland China in terms of risk posed to Singapore.

As such, this hobbit thinks that the case definition of a suspect case should likewise not make any distinction between Wuhan, Hubei or a hospital in mainland China. I hope someone updates the case definition soon.

A third interesting feature in the latest list of notifiable diseases under Section 6 of the infectious Diseases Act, 2019-nCoV is NOT on the list as of today if you google it. But if you login through SingPass into the CD LENS system, it is there. Can someone please fix this discrepancy? Very confusing to simpleton hobbits.

Finally, back to Epicentre China. This week and over the next few days, Wuhan will be commissioning an additional 2600 beds to treat 2019-nCoV patients in its two coronavirus hospitals: Huoshenshan (fire god mountain) and Leishenshan (thunder god mountain) hospitals. Beijing has also brought out of mothball a SARS hospital with 1000 beds (Xiaotangshan hospital). This probably reflects what the Chinese leadership is thinking now about where the 2019-nCoV epidemic is heading. This is what we call a “lead indicator”, as opposed to lag indicators that tell us about things that have already happened. Health authorities build hospitals and commission beds in anticipation that they will mostly be filled. With such a huge number of beds put into circulation at such blinding speed, it suggests that the worst is yet to come and the outbreak has not been brought under control yet. The daily surging number of new infections and deaths also underscore this point.

This hobbit will be looking out if more such coronavirus hospitals will be built in China soon. If more are built, then it suggests that the epidemic is still growing quickly. If no new hospitals are built, then it may be that growth of the epidemic is slowing down or that the epidemic is being slowly brought under control. Or maybe the authorities have concluded isolating and treating these patients in new hospitals may be futile in controlling the epidemic and other measures need to be taken.

In the Napoleonic era, Prussian diplomat von Metternich said “When French sneezes, the whole of Europe catches a cold”. This was modified in the later half of the last century to “When America sneezes, the whole world catches a cold”, to underline America’s preeminent place in world affairs. Given the current state of the 2019-nCoV epidemic, it may not be out of place to say that “When China catches pneumonia, the whole of Asia is breathless”

We are in this for the long haul, folks.

Make no mistake, the 2019-nCOV virus is not a remake of SARS. It is a blockbuster sequel. Like Empire Strikes Back. And like all well-made sequels, there should be many surprising twists and turns to the plot. I call this a sequel because both SARS and 2019-nCOV belong to the coronavirus family of viruses.

For other old coots like me, we have fought and survived SARS. I wouldn’t call it a victory, but we survived. That’s enough for me because I know people who literally and physically did not survive SARS. The 2019-nCOV is the big test for the current young generation of healthcare workers.

Like most major and surprising developments, there is good news and then there is bad news.

First the good news. From a case-fatality (CF) rate perspective, the 2019-nCOV is less lethal than SARS. The CF rate for SARS was about 10% (10% of those infected died) while the CF rate for 2019-nCOV is hovering around 3%. The other good news is that the international healthcare community has developed very quickly diagnostic tests that can give you a result in about 24 hours, versus SARS when diagnostic tests took about 2 to 3 days to give a result and these tests were only developed late into the outbreak. But even so, we should remain guarded on this point because we are not sure when the tests can pick up the disease because we do not know for sure when the disease turns detectable. The third piece of good news is that this new disease is spread by droplets (and not airborne) like SARS and a good mask and universal precautions should be enough to break the transmission.

So much for the good news. Now for the bad news, of which there are many.

The 2019-nCOV outbreak (I wish someone in WHO or China will give this bug a more catchy name, like R2D2 or BB8 for example) is designed to perfection in several ways. First, it is perfect in timing. It blew up about a week before Chinese New Year in China, the busiest week of the year when hundreds of millions of Chinese are travelling back to their villages or for holidays, both within China or beyond China’s borders. The size of the travelling population in the week preceding Chinese New Year has been likened to the entire populations of France, Britain, Germany, Italy and Spain going on the road at the same time. Or the whole of USA moving. In other words, timing-wise, it is timed to perfection for maximum dissemination/propagation of the virus. And it is not done yet. These people now in their hometowns have to return back to their workplace – so a few hundred million people have to go on the road again soon in the next one or two weeks.

In comparison, SARS occurred post-Chinese New Year in 2003, in mid-spring, when Chinese New Year travelling had already been done and dusted.

Outbreak-wise, the 2019-nCOV is location-perfect. It has chosen Wuhan, the city right in the middle of the world’s most populous country with the most comprehensive network of high-speed trains, otherwise known as the High-Speed Rail (HSR). Wuhan is a bit like the Toa Payoh of Singapore in terms of location- smack in the middle. From Toa Payoh, you can easily travel to Jurong, Yishun, the CBD or Changi by a network of expressways. Similarly, from Wuhan, you can travel to the populous Sichuan province and Chongqing in the west, Beijing in the north, Shanghai in the east or Guangzhou and the Greater Bay area in the south within 4 to 6 hours by HSR.

Wuhan and its surrounding areas are so central that since ancient times, it has been a battlefield for different armies contesting for supremacy of China. This is especially evident in the Three Kingdoms period (at the end of the Han Dynasty in the third century) where the Three Kingdoms of Wei, Wu, and Shu fought around Wuhan and the nearby cities, such as Jingzhou. Wuhan is at the junction or confluent point of these three kingdoms, which underlies the centricity of it’s location. The biggest battle of the Three Kingdom period took place in Chibi or Red Cliff on a tributary of the Yangtze. It’s so famous that director John Woo made a two-part movie about it (Battle of Red Cliff) with a star-studded cast in 2008. Chibi is a stone’s throw from Wuhan and one of the first cities to be locked down together with Wuhan.

You cannot choose a better location than Wuhan in Hubei province to plant a disease outbreak in China. As they say, location, location, location. And Dr Evil couldn’t have chosen a better location even if he wanted to.

Next is the speed of transmission. In the past, a migrant worker may take up to four or five days to return to his kampong from centrally-placed Wuhan – You take a few slow trains, take a bus, hitch a ride and walk etc. Now with the HSR, you are home probably on the same day, within 24 hours, for 90% of China’s migrant working population. China’s HSR and road network is as good as any developed country in the world. That means the spread of 2019-nCOV is several times faster than the 2003 SARS, thanks to great travel infrastructure in 2019. In other words, in terms of coverage, 2019-nCOV beats SARS hands down.

Outside of China, the spread is also of many orders of magnitude faster and bigger than SARS, thanks to the huge number of Chinese travellers going overseas for holidays over the festive period. In 2003, SARS only came to Singapore because the virus travelled to Hong Kong and several Singaporeans caught the infection when they travelled to Hong Kong and stayed at the Metropole Hotel and brought the virus back to Singapore. That took time and quite a few people. Now in 2019, you can see that most countries have the infection introduced to them by people travelling from Wuhan directly to these countries. The number of travellers coming from Wuhan number in the tens of thousands in any given month to major cities in Asia. The number of Chinese travelling abroad in 2003 was a fraction of what we have in 2019. In 2003, we had to “import” SARS from HK, which in turn was imported from Guangdong, China. Now Wuhan has directly “exported” 2019-nCOV to Singapore and several other countries.

SARS lasted quite a few months in 2003. In the end there were about 8000 cases and 800 deaths. Contrast this to 2019-nCOV. Official investigations into this new disease started after the Chinese National Health Commission was alerted to the outbreak on 30 Dec 2019. It took only 4 weeks since then for this new disease to infect about 4000 people, half the total number of SARS patients. It is no surprise that the official (let alone the unofficial) statistics reflect the speed of the spread. This hobbit predicts that many more people will be infected with 2019-nCOV than SARS. Hopefully with a lower CF rate, and better facilities, therapeutic options now than in 2003, not too many people will perish. But I am not betting the farm on this hope…..

These are the hard truths. But there is more. The prospects may be grimmer than the above because of our imperfect understanding of the disease on two fronts:

• We do not know if the infected person is infectious during the incubation period or not
• Simple signs like fever may not be a reliable sign for the disease

These two points dramatically changes the game for us battling this new disease. SARS patients were not infectious during the incubation period and when they were infectious, they had fever. That gave us time and ease of detection. Outbreak fighters were given up to one incubation period (a minimum of ~7 days) to locate close contacts of SARS patients so that they could be quarantined and in doing so, break the chain of transmission. Now, if claims that a patient is infectious even during the incubation period is true, that one-week window of safety may no longer be there. There may be no time to find and round up close contacts. The Chinese believe this is so while local (Singapore) experts think this point is still debatable. We don’t have conclusive evidence on this one way or the other.

The next point is that fever may not be a reliable sign, although according to a study published in The Lancet on 24 Jan 2020 for a cohort of 41 patients, 40 out of 41 or 98% of patients developed a fever, though it was not stated if they developed the fever early or late into the course of the disease. Other reports cite that up to 30% of patients do not develop fever. The jury is still out for fever as a reliable sign. From a study design point of view, the power of a study based on a cohort size of 41 is debatable. We need bigger studies.

In Singapore, there is no evidence of community spread. Strictly speaking, there is no cause for panic. Or even N95 masks. So surgical masks should suffice for front line staff unless you are dealing with a suspect case, pending serological confirmation, in which case you need to get a N95. But if you are dealing with a suspect case, you are probably working in a restructured hospital, armed to the teeth with PPEs (Personal Protective Equipment) and as a SARS veteran yourself or a younger doctor supervised by a SARS veteran, you should be OK.

The problematic issues for now remain on two fronts

• Where do we get surgical masks (and other PPEs) in the private sector?
• How to risk stratify and what responses should we make to different risk levels

For folks in the private sector, surgical masks are getting increasingly if not impossible to get. Strangely, you can still get your box of N95s from SMA. But no one can promise you your supply of surgical masks beyond the odd box of 50 masks here or there. That is hardly reassuring to the GPs in the frontlines. This hobbit would like to think or hope that someone is sitting on a war-chest of surgical masks (and gowns) like Joseph hoarding grain in biblical times, now ready to unlock the supply that will be enough to feed Egypt in a famine lasting seven years. Or at least enough masks for seven weeks lah……

As for risk stratification, policy makers have made it clear that travel to China is a major risk factor.

Returning (from China) students and healthcare/eldercare workers are required to be quarantined. The selection of these groups reflects the thinking that these are people with the potential for spreading the disease to many people quickly, should they be infected.

A much more worrisome point is that it has now been reported that 2000 persons who are now in Singapore have been to Hubei recently. How many of these are already carrying the infection? What are the chances that community or local transmission will arise from these 2000 persons?

The next question we must ask is that how do we enforce a proper quarantine for these groups? Should they be monitored closely like in the past during SARS? Does home quarantine suffice, since fever may not be a reliable sign and they may be infectious during incubation and hence may spread the disease to family members? Should we think about hotel quarantine instead? (Since there are going to be quite a few empty hotel rooms soon, I guess)

There are many questions. But as with any novel disease outbreak, the answers are few. We need to buckle down, keep our morale up, and observe strict discipline in our infection control practices. These are obvious.

What is less obvious, and quite worrisome, is that we must avoid the mistake that many generals make – generals often fail or get defeated when they fight the last war.

These is a new enemy. A new war. We have to think new too.

Locums are an important segment of the profession, particularly for those of us who work as GPs/Family Practitioners.

This hobbit used to do a lot of locums in his younger days. Mainly because he had mouths to feed and loans to pay. Old coots like me will reminiscence about the bad old days when we were paid as low as $40 an hour, saw 12 to 15 patients per hour etc.

Times have changed. From the chat groups I am in, I hear disturbing stuff about some locums. They may not represent the majority and it is unfair to tar all locums with the same brush. Apparently, there are locums that:

1. Refuse to see more than 4 to 5 patients an hour
2. Refuse to take blood (or perform any procedure) or give injections
3. Refuse to see female patients
4. Refuse to see children
5. Refuse to review lab and radiological reports (even if ordered by the locum)
6. Refuse to turn up the next day (although already booked for say, the entire week) unless you pay him more per hour because the clinic was busier than what the locum thought.

The last point is particularly galling because it is purely a point about lack of honour and professionalism bordering on blackmail. I wonder if our mammoth SMC ECEG covers such unbecoming behaviour.

There are one or two infamous locums in my time that are still circulating perilously in the market now as full-time locums which many GPs are afraid to engage. But most of these stories involve young doctors. They may be full-time or part-time locums.

But this is not another article by an old coot complaining about the state of young doctors and locums. Other than point 6 above, the other five points beg the question – what is the root cause? Is it just bad attitude? Maybe not.

My guess is that maybe it is also due to competency, experience, and risk-averseness.

One cannot but wonder with today’s residency and workload caps, are young doctors trained to cope with high workloads? Also the breadth of experience that the system affords. For example, other than in polyclinics and A&E, many young doctors never see kids after they graduate. In NHG for example, there is no paediatrics or O&G department. With the three clusters now firmly in place and cross-cluster movement of doctors not happening much if at all, how does one get broad-based training?

After all, it doesn’t take much to be a locum. All you need to be is to be fully registered with SMC. But being fully registered doesn’t mean you are comfortable seeing kids or women. The locum may never have been part of a structured training program if he wasn’t a resident.

The other possible explanation is that due to efforts to improve quality and risk-averseness in our public institutions, many things are pushed upwards to more and more senior people and younger people are less and less trained or exposed. This is not new and has been taking place for decades to be sure. In the past, a second year registrar can perform a gastrectomy himself competently. Now, I am not so sure even a second year Associate Consultant can do a gastrectomy all by himself. It’s not entirely a bad thing and its inevitable as society progresses.

But there is a downside when things are carried out too far. I have been told that some locums refuse to take blood because they are “not confident”. And these are not old doctors suffering from failing eyesight or hand tremors. Maybe, it is because many of these “simple” procedures are now carried out by technicians such as phlebotomists and hence the lack of confidence.

Many locums refuse to perform “risky” procedures now (such as H&L injections, ear syringing) because they are not paid adequately if at all to assume the higher risk. They are after all paid by the hour. This is understandable. If I was still locuming, I would maybe do likewise. But taking blood or giving injections and vaccinations are really, really bread and butter.

The point that really needs to be made is that GPs only hire locums because they want their patients to have continuity of care when they aren’t around and that the locums pay for themselves. Yes, the hard truth is that locums have to earn their keep. With locum rates at anywhere from $100 to $120 per hour, a locum has to generate at least $200 to $250 of revenue per hour for the clinic so that it makes hiring the locum worthwhile.

But if a locum refuses to do many things, or caps his work-rate to 4 or 6 patients an hour then it is kind of difficult to justify hiring him. It is really down to the locum’s productivity in dollar and cents. So if a locum wants to stay in the business of locuming (And it is possible to make a very good living by being a full-time locum), he needs to get repeat business from clinics. To achieve this, he has to make more for the clinic than what he takes. It’s that simple.

All of us agree that the quality of locums are really patchy. Sometimes, you really get a locum from hell, and sometimes you get a wonderful one, and all your clinic assistants tell you the locum gets things done with minimal fuss and is even a joy to work with.

Thinking aloud, maybe it is possible to accredit or certify trained locums on a voluntary basis. Maybe a responsible professional body like the College of Family Physicians Singapore can run courses for people to attend and certify these locums of certain competencies and skills. This training is not about the latest in medical science etc but skills every locum needs – common office procedures, like taking blood, ear syringing, I&D, T&S etc as well as certifying stuff like fitness to drive etc.

One may argue that what the locums really need is to attend the Graduate Diploma in Family Medicine (GDFM) course. But frankly, many locums do not have the opportunity to attend a full diploma course. Maybe a Locum Certificate course is all that he can afford for the time being.

I think many GPs in the market who use locums will welcome such a Locum Certificate course. At the very least, the holder of this Certificate cannot say he does not want to give injections or doesn’t know how to take blood and he may even be able to command a small premium in terms of his hourly locum rate.

This reminds me of an old story. Upon finishing his 5-year bond, a brilliant classmate of mine left town and went for his training in the United States as an internist. He is now professor and head of department in a big hospital there. He underwent training in one of the most famous hospitals there. One night while on call, a distressed nurse called him to inform him she could not insert the IV cannula and wanted to call the phlebotomist on-call (but who was not stationed in hospital). My friend said he will insert the IV cannula. At the bedside, the nurse had an ultrasound machine on standby (thinking that the doctor/resident will insert the IV cannula under ultrasound guidance)

He inserted it on the first try without any fuss, without ultrasound guidance, Singapore style. The nurse was extremely grateful. The next morning, his boss, in front of the entire ward team, clapped his back and congratulated him on his grand endeavour of inserting an IV cannula while on call.

I have a bad feeling Singapore medicine may be heading in this same direction.

After a well-needed break last month, this hobbit is back with some New Year Wishes for 2019. Yes, some of these wishes are not exactly new stuff but hey, it’s like new year resolutions to lose weight. If it doesn’t happen, then you wish or resolve again in the new year!

Wish #1

MOH will finally fix all the lacunae in healthcare regulation – those “grey” area that have hitherto been deemed to be not worthy of direct regulation by MOH: Managed Care, Third Party Administrators, Medical Concierges and even Referral Portals that claim to represent all doctors.

These folks working in the shadows have been making a lot of dough because of MOH’s inattention and inertia!

Wish #2

Now that we have fee benchmarks for doctors’ procedure fees in place, it’s time to expand the scope and look at hospital, facility and implants charges etc. If not, private healthcare costs will continue to rise at an unsustainable rate.

Wish #3

Someone should look at public healthcare financing. The recent incident where an SNEC patient was only reimbursed for $4.50 from MediShield Life (MSL) is plainly unacceptable. Apparently, it’s because in this case, the patient went for the same procedure for both his eyes but MSL only allowed the claim to be made for one eye.

If possible, operating on both eyes actually is more cost-efficient and saves money in the long run. But if the funding mechanism cannot support such practices and generate bad press, then surgeons have no choice but to operate on one eye at a time. So much for innovation and efficiency.

Wish #4

The big healthcare news of 2018 was the Singhealth Cyberattack. We should learn from this incident and take a hard look at how IHIS is structured and governed. There is nothing much worse than a “monopoly vendor” whereby customers have to buy essential services or products from only ONE vendor. That’s what IHIS is – the public healthcare clusters have to buy essential IT services from ONE vendor – IHIS. Think about it, if you had to buy rice or toilet paper from only ONE supermarket operator….

Wish #5

Also arising from the ashes of the SInghealth Cyberattack – new laws should be passed that spell out clearly and safeguards patients’ privacy, confidentiality and security rights. The current situation whereby a National Medical Record (NMR) is exempt from PDPA requirements and the MOH/MOHH/IHIS guys “ownself regulate ownself” is unsatisfactory. Even if there are no new laws enacted, the whole NMR programme should be placed under PDPA to instill public confidence. Only with public confidence restored will public buy-in be re-established and the NMR initiative be put back on track.

Wish #6

Leadership renewal should be managed sensitively and transparently, especially in public institutions with a sizeable pool of talent and experience. In choosing a leader, one must balance the need to have a person who is perfectly aligned and loyal to the masters, as well as having a record of excellence and service to the institution. If it is too tilted towards one way or the other, either the larger system suffers or the institution in question suffers. If this sounds rather cryptic, just look at one of these institutions, resignations are spreading faster than a poorly differentiated cancer. The pool of talent and experience there is evaporating faster than a puddle in a dessert. Even neutrals will quit quickly when they realise meritocracy is a distant second to alignment.

Wish #7

The Courts are setting the pace in medical negligence, with their landmark rulings in the last few years. The Modified Montgomery Test is one such example. The recent judgment on the liposuction death is another. This hobbit hopes the SMC can also say something on important medical legal matters before the Courts issue definitive judgments (by which ‘case law’ is made). If SMC speaks up and provide guidance beyond the Ethical Code and Ethical Guidelines as well as the Handbook of Medical Ethics, the Courts will certainly have to take into account what the SMC has said on a certain subject before judgments are made and new case laws are set in stone.

The advantage SMC has is that it can say a lot of things about a medical-legal subject at any time even when there is no existing SMC case ruling, with the objective of educating the medical profession. The Courts on the other hand, can only develop new case law when there is a case before them to judge.

Wish #8

Someone should really look at the number of people studying medicine, whether locally or overseas. We all can feel it in our bones that too many doctors are being trained. The legal profession and Ministry of Law have taken swift steps to address their glut. What about MOH and SMC?

The same principles must apply downstream to specialty training. The boom and bust in residency positions in recent times is really embarrassing.

Wish #9

ACGME-I Residency – Kill it or keep it? This is a tough call politically even if logic dictates otherwise. Even if no one wants to press the kill button, at the very least, we should really remove the double-yoke from our residents immediately – of having to fulfill ACGME-I requirements and passing the UK exams. Just let them choose one or the other. Stop testing them or examining them to death.

Wish #10

Family Medicine should be made a specialty and those with the FCFP qualification should be recognised as specialists by the Specialist Accreditation Board (SAB). Plain and simple

It had to come. Sooner or later. Like head lice or scabies when you live in the tropics and you don’t bathe for three months. “Making it harder for errant doctors to cheat” (The Straits Times, Opinion Page A28, 25 October) looks like another Salma Khalik hit job. It is also timed to be the journalistic equivalent of a Halloween trick or treat; designed to scare doctors and dentists by entreating the authorities to witch-hunt. She wants someone to clean up the houses of the medical and dental professions by writing this long opinion piece when all that is needed is for someone to pass Ms Salma a broom. This Hobbit happens to think she will look decidedly befitting with a broom. Preferably an anti-gravity one placed between the adductors.

Let’s first go back a little to 15 October 2018; in the article “Penalties are lower if doctors own up”, she wrote, “There is a big difference between tax avoidance and tax evasion. In avoidance, the person fully declares his income, but tries to pay lower taxes by using possible loopholes, such as setting up a company simply for tax breaks, or claiming personal expenses as legitimate business expense. The penalty for an “omission” is two times the taxable amount”

She moves seamlessly from tax evasion, tax avoidance to “omission”, giving the impression that the omission refers to avoidance. But actually, are they the same? Tax avoidance is NOT a crime or an offence. The person deemed to have committed tax avoidance by IRAS will be asked to pay up the difference between what he would have paid and what he actually paid and not “two times” the taxable amount.  The reasonable student of the English language on reading this, would probably infer that tax avoidance (like “omission”) is a crime and that it may be punished with a penalty of two times the taxable amount. No one really knows what is this omission she is talking about. Does omission equate to avoidance, or is she referring to evasion? Only she knows.

As for tax avoidance, the principle is simple – no one wants to pay more taxes if he can avoid doing so legally, just like you wouldn’t want to pay more for a pair of shoes if another shop offers the same pair at a lower price. IRAS is merely asking for information from some doctors and asking a few others to pay up for tax avoidance. If you agree to pay up, it stops there. There is no criminal record if you pay up. Has IRAS charged a doctor for a tax crime yet this year? Not that this hobbit knows of. And certainly, no doctor or dentist has been convicted of tax crimes this year yet.

In any case, with the obfuscating word “omission” in place, she launches her major offensive 10 days later with the aforesaid long opinion piece. Highly predictable; almost boring already.

Her strategy is to use the highly evocative and bewitching word “cheat”. She suggests many doctors and dentists are cheating, and gives a litany of examples: cheating Medisave money, cheating CHAS, cheating taxes, cheating insurance etc.

At last count, there are some 15,000 doctors and dentists in Singapore. Is there a cheating epidemic?  In the same article of 15 October, it was mentioned the last time a doctor was jailed for tax evasion was 2011 and he was subsequently suspended by SMC for four months. One case in 7 to 8 years doesn’t sound like an epidemic to me.

Then what is the whole point of her latest tirade against the medical and dental professions? Is she asking for

• Stricter or better laws or ethical codes?
• Better enforcement?
• More punishment?

She seems to be saying that doctors and dentists should be held to higher standards when they commit tax offences because they are “not ignorant” and doing so out of greed. The first principle of law is that the law shows no preference to any group of persons. All men are equal under the law. The same standards and burden of proof applies to everyone. A doctor should not be more easily convicted of tax offences just because he has a MBBS degree. Likewise, a doctor or dentist should not be punished more for tax crimes versus say a banker, journalist, accountant, lawyer, hawker or taxi driver.

As for ethical codes, the latest SMC Ethical Code and Ethical Guidelines (ECEG) as well as the accompanying Handbook of Medical Ethics (HME) are two of the lengthiest and most detailed publications of this sort in the world. And SMC is already empowered to strike-off a doctor. What else is there? Lengthen the SMC ECEG and HME some more? Empower the SMC to give 10 strokes of the rotan?

The doctor or dentist already suffers from “double jeopardy” of being punished by the professional board for bringing the profession into disrepute after he has been also punished by the other authorities. If a journalist is found cheating on taxes, he pays the fine, and he maybe goes to jail as well. He doesn’t have a Journalist Board or Council to suspend or strike him off the Journalist Register because there isn’t such a thing.

As for cheating CHAS, well, last I looked, I signed a CHAS contract with a public sector Polyclinic Group. It is what it is – a contract. If I am found to have filed claims wrongly, they can claw-back the monies as per contractual terms. There is no specific legislation for CHAS (unlike Medisave, which is covered under the CPF Act), so enforcement of a contract between contracting parties is quite different from enforcement of a law.

Then she complains about doctors who do not give adequate MC to foreign workers. Well, they should be punished. But do notice that she is completely uncritical of the other elephant in the room – the employers and supervisors. Is this just purely a doctor problem?

As for insurance, yes, she claims insurance patients with full first-dollar coverage may be over-serviced or over-charged and that compulsory co-payment will be introduced to address this. Well, evidence and experience around the world have shown that insurance claims are always higher when there is full first-dollar coverage. This is bad insurance design leading to bad doctor and patient behaviour. These outcomes have been replicated time and again all over the world. What does Ms Salma Khalik expect? Are Singapore and its doctors expected to be so different from the rest of the world?

Over-servicing is not just a doctor thing. Over-servicing can also originate from the patient. The patient, with full and first-dollar insurance coverage, often requests for more expensive services from the doctor. The doctor, being a patient-advocate, will happily oblige. For example, why should a doctor not use the best implant for his full-cover insurance patient and choose something inferior (but adequate)? After all, if my patient has paid for it through his insurance premiums, I will use the best. In fact, if I don’t use the best implant (which is often also the most expensive), the patient may be unhappy with me afterwards. He may tell me “Doc, what didn’t you use the best Brand Z pacemaker for me and instead used the cheaper, inferior Brand Y one when my insurance covers everything?”. Is that dishonesty on the part of the doctor? In fact, in the era of the Modified Montgomery test, I better use the best, lest I be accused of not considering a relevant consideration from the patient’s perspective that should lead me to offer the best pacemaker later on. You never know. Better safe than sorry.

Bad insurance product design probably drives patient and doctor behavior more than human greed, so to speak. Fear of the new medical legal climate also plays a part too.

As for her example about the probability of getting a procedure for unspecified gastritis, it really depends. There are more foreign patients in the private sector. They come here wanting to get a definitive diagnosis and treatment as quickly as possible and then go home, hence the bigger demand for “a procedure” (probably a gastroscope). Also, many patients seek treatment in the public sector first for gastritis, and when the problem recurs, they often wrongly lose faith in our public hospitals, and seek care in the private sector, where again the pressure on the doctor to come to a diagnosis quickly results in more scopes. Yes, money does matter and some doctors do more procedures to earn the dough. But one must realise that in the private sector, there are also other factors that favour doing a scope which are not pecuniary. When you are the first doctor dealing with the problem, the patient is more patient (pun intended). When you are the second, third or fourth doctor dealing with the same problem, the patient has often run out of patience and is already very emotionally distressed. In addition, private hospital bed charges are a lot more than public ones and observing a patient for a few more days in the private hospital may cost as much as doing a scope. And even after observing the patient for a few more days, you may still not get a definitive diagnosis.

Shouldn’t a senior health correspondence with decades of experience in healthcare reporting give much more balanced analyses than this shallow sweep of “cheating” doctors and dentists?

Actually, she seems like a sulking kid who refuses to admit a mistake. “Salmatologists” (This hobbit is one) will recall that she wrote another long opinion piece on 26 March 2018 (Sunday Times) where she made the claim, “Drilling down, the MOH concluded that much of the higher claims was the result of overcharging and overtreatment by doctors in the private sector”. (“Diagnosing the cause of rising costs”).

This was clearly refuted by MOH and guess what, The Straits Times itself! On 30 March, the newspaper clarified that “This is incorrect, the Ministry of Health did not draw such a conclusion”. It was a mistake by her, pure and simple.

And now, once again, she is again asserting essentially the same erroneous claim, only albeit in a more convoluted way, and wisely not attributing this to MOH but to the insurance industry instead, presumably to “one insurer” and the COO of AIA, Ms Melita Teo.

So what’s the message here – that like Ms Salma Khalik, the “one insurer” and AIA’s Ms Melita Teo disagrees with MOH – overcharging and over-servicing by private sector doctors are the main reasons for rising insurance claims?

There is a pattern to all this of course. Her usual and favourite trick is to drive a wedge between MOH and the medical profession; then she entreats the government to come down hard on the medical profession. This can be seen on at least three occasions:

• FIn 2005, she made the assertion that the then DMS will remove dispensing rights from medical clinics, which the then DMS refuted.
• Then in March this year, she made the claim that MOH is of the position that higher insurance claims was the result of overcharging and over-treatment by doctors in the private sector, a position that the Straits Times has since said MOH didn’t arrive at.
• Now, she is asking MOH and other authorities to go tough on cheating and unethical doctors and dentists. And she has also apparently roped in the insurance folks to beef up her claims (pun unintended).

You have to give it to her. As an object of antiquity, she has enormous energy. Apparently, she’s 63 years old (give or take a year or two), and this hobbit can only wonder how long more can she keep going like this. But seriously folks, other than Salmatologists, no one really reads these long opinion pieces anymore in the age of Instagram and Twitter.

In the meantime, will someone give her a broom? This hobbit is thinking of giving her a hat as a year-end gift. The two gifts will go nicely together. Hopefully they will come in handy when she finally retires.

Happy Halloween

Even as the dust on the SingHealth cyberattack has barely settled, another piece of bad news has surfaced on healthcare IT systems offered by Integrated Health Information Systems (IHIS). IHIS is the IT arm of MOHH that oversees IT development and implementation in the public healthcare sector, and increasingly influences the private sector as well. It involved the mis-labelling of drugs affecting 400 GP patients who saw GPs who are using the GP Connect software that IHIS offers. Two days later it was reported that the affected number of affected patients is more likely to be double that of the original number – 836 patients seen in 104 clinics.

An egregious example given was that a patient who was supposed to take 10ml of cough mixture would be asked to take 10 bottles in instead. For codeine addicts, that’s like hitting the casino jackpot.

When such an incident happens, we need to ask a couple of inconvenient questions. First- if the patient indeed was dispensed 10 bottles and worse, took the amount as stipulated, who will be responsible for the unfortunate consequences?

The short answer to this question is “YOU, the GP”. (are you surprised?) As a GP in the private sector using GP Connect, it is quite unlikely you had hired a pharmacist or staff nurse to perform dispensing. If you did, then the pharmacist or staff nurse, both registered with the state and licensed to perform dispensing duties independently, has to bear the brunt of the responsibility. If not, the dispensing staff are dispensing under your supervision and you will have to take professional responsibility even if the IT system had printed out the labels wrongly. This is because you are supposed to have checked and realised the labels did not reflect what you had prescribed earlier on. You may be punished by MOH, Health Science Authority and/or SMC for dispensing the drug in wrong dosages.

What about the IHIS and the IHIS folks? Presumably, the people in there who developed GP Connect are NOT state-registered doctors, pharmacists and nurses. So, the most you can do is perhaps sue them for civil damages and get some money back. The people won’t be suspended or struck-off by some authority regulating the IT profession (IT professionals are not state-licensed).

This is what the financial and business world calls “skin in the game”. You, the doctor, have a lot more skin:- epidermis, dermis and hypodermis, in the game then the IT folks. This inequality or asymmetry in risk exposure leads to the inevitable cultivation of unhealthy behaviour. That’s not to say IT people are evil people, they are not. It’s just that if that is how the system is badly set-up, then suboptimal behaviour and outcomes are sure to follow. This phenomenon is pretty well described in famous economist Nassim Nicholas Taleb’s new book “Skin In The Game”. (He also wrote The Black Swan which sold 3M copies)

On 6 Sep 18, 2 days after the news first broke, it was revealed that this glitch was due to a “planned system update”. Frankly, this sounds terrible and this hobbit is not sure what is the messaging aim here. If a “planned” system update could mess up life like this, one should ask what if the update was unplanned? Would it have been far worse? Is it being “planned” a mitigating factor or an exacerbating factor? Are we supposed to commiserate with the patient, the GP, or get angrier with IHIS? Would the mess have been less if there wasn’t any update, whether planned or otherwise? I don’t know about you, but this hobbit is really confused.

Next on the radar screen are the anaesthetists in the private sector. Apparently, many of them have been targeted by the taxman. Let this hobbit be clear from the onset: he firmly believes the taxman is to more feared than the hitman. The hitman can’t do anything after you are dead. The taxman will get you, in this life or the after-life: he will hit your estate. They are even more powerful than forensic pathologists.

As we all know, most anaesthetists set up companies. Professional fees are paid to and recognised as revenue in these companies, and anaesthetists then get their income from these companies in the form of salaries, dividends and directors’ fees after expenses have been deducted.

Apparently, the taxman now thinks that because these companies who have no office, hire no staff other than the anaesthetists, they are nothing more than tax shelters providing tax avoidance for the owner-employee anaesthetists. The taxman now wants to claw back the difference in taxes the doctors have paid to the government had the doctor been taxed as an individual only when the doctor had paid taxes as a blend of different tax schemes (personal income tax for salary of up to 22%, 22% for director’s fees, 17% corporate tax rate for dividends).

This problem arose because the maximum tax rate for income tax now (22%) is significantly higher than for corporate tax (17%). Certain amounts of dividends are also given tax breaks and certain cost items can be “expensed off”, such as meals with colleagues or the purchase of your Ipad which you need for your work. Some people have received letters saying their claw-back will be up to 5 years. So now, an anaesthetist may now find himself owing the taxman hundreds of thousands of dollars.

It is therefore no surprise that many private sector anaesthetists are up in arms. I know many of them, and they have sought professional accounting and tax advice in the past to set up these companies to avoid paying more tax. They did so in good faith under professional advice. Why should they be penalised for something in the past, just because the taxman applies new rules of interpretation of (purportedly) Section 33 of the Income Tax Act? Who wants to pay more tax than what one is supposed to legally and in good faith?

In any case, tax avoidance may not also be the main reason why doctors set up companies. A private limited company, as the name suggests, is a way of limiting one’s exposure to damages arising from business activity. If you work for and under a company, your business liability is limited to the assets of the company, even though your professional liability is not. For example, the damages, say, your supplier, can get from you is limited to the company’s paid up capital and assets. Your supplier cannot touch the assets that you own personally which are not part of the company, such as your home or your personal-use car. As this hobbit sees it, this is the main advantage of setting up and working under the umbrella of a private limited company.

This liability limitation objective can be evinced by the fact that some companies set up by older anaesthetists have been in existence for decades. In the 80s and 90s, income tax was actually lower than corporate tax. These senior anaesthetists probably paid more money than they could have had they not sought a company structure to house their activities. Can they now claw-back the excess money from the taxman? In the name of fairness, surely there is is some merit in this argument?

Even if the taxman wants to take a new interpretation and get anaesthetists to pay more taxes, this new interpretation should not be applied retrospectively in claw-backs. It should at best be applied to current and future income. And the fact that because the anaesthetists don’t have an office and hire staff, they are then penalised to pay more taxes doesn’t make much sense. If 30 anaesthetists hired 5 receptionists and a tea lady and housed them in a 500 square-foot office in Yishun at $2 per square feet means paying much less taxes, then they may just do it. But what does that do to Singapore and the government’s drive for more productivity? Nothing. It may just mean more low productivity jobs that the Singapore economy doesn’t need.

Someone needs to see the Big Picture here. Obviously the taxman’s visual field and visual  acuity in the context of the Future Economy needs to be questioned here. If not, the road to lower taxes through lower productivity will surely be taken.

SingHealth Cyberattack 2018

The cyberattack into Singhealth dominated healthcare news not just in Singapore, but in the world as well. News of the attack was made public on 20 July 2018, exactly 5 months to the day when this Hobbit published “NEHR: A Patient’s Perspective from A Doctor’s Eyes”. In the section on “Security” in the aforesaid article, this Hobbit wrote:

“The last point I would like to deal with is that of security. Security can basically be defined as measures put in place to prevent breaches of confidentiality. How secure is the NEHR? I am confident that the planners and implementers have tried their reasonable best to ensure best practices in IT security have been put in place or are being put in place. After all, the NEHR, being backed by government, has enormous resources to do so.

Even then, no IT system, especially one that is internet-based and cloud-based, with literally unlimited number of entry points (every clinic or hospital computer that is linked to the internet is an entry point into the NEHR) is hack-proof. If it were not so, there would be no need for the government to delink civil servants’ work computers and intranet from the internet last year. It was reported this affected all 143,000 civil servants. That is a tacit admission that no security system is fool-proof or hack-proof. I suppose this shows cyberthreats cannot be wished away, but they can be effectively partitioned away.

This hobbit is sure the NEHR is as secure as can be, but not quite more secure from the civil servants’ work computers before they were delinked from the Internet. In fact, the fact that the NEHR exists must in itself be a very tempting trophy database for hackers from all over the world to try and test and breach.

In the event a breach happens and records and medical information are stolen, what is the liability of the NEHR or the government with regard to this breach, and what are the rights of the affected patients? Can he seek redress, compensation, damages etc.?”

Sometimes, this Hobbit wishes he isn’t so spot-on, although he was referring to the NEHR and not the current IHIS-Singhealth Electronic Medical Records (EMR) that had been hacked into. But if you replace “NEHR” with “IHIS-Singhealth EMR”, everything else pretty much applies. In fact, DPM Teo Chee Hean pretty much said so too when he said in hindsight, that internet surfing separation for public hospital separation should and could have been done earlier.

And it was just as well that this attack occurred before the NEHR was rolled out to the private sector. If that had already happened, then the cyber-attacker would have even more access points to hack via any computer in any of the 2000+ private clinics and laboratories all over Singapore.

This hobbit supposes that all the computer terminals in the three public healthcare clusters are well maintained with up-to-date antiviral software, server firewalls and robust security measures such as high security passwords etc. The public healthcare sector has dedicated IT teams and resources to ensure this. The same cannot be said for the private clinics. Do they have anti-viral software? Let alone up-to-date ones? And what about passwords? I won’t be surprised if many passwords are “qwerty”…

So, it was fortuitous that NEHR hasn’t been made mandatory yet in the private sector, if not the cyber-attackers would have found it even easier to launch a cyberattack, and probably an even more massive and debilitating one.

The authorities also said that the data that had been exfiltrated was “not sensitive”, and were “basic demographic data”. This was an attack on 1.5 million people, which is about 25 to 30% of the populace on this island. It is really an attack on Singapore, plain and simple. Singhealth was probably chosen because many, many influential people seek care in SGH, and the Outram Campus, which are part of SingHealth. If you want to dig out medical information on most of Singapore’s VVIPs and CIPs, the most ‘rewarding’ place to look would be SingHealth. It wouldn’t be NHG or NUHS. Anyone in healthcare long enough knows this.

I am not sure downplaying the impact of the cyberattack is the right strategy here. Sure, someone needs to strike a balance between unnecessarily pressing the panic button and euphemising a clear and present danger. I can decide what is “sensitive”, thank you. My birthday and my NRIC number are sensitive data alright.

In addition, the 160,000 medication records that had been exfiltrated was surely sensitive information. Any healthcare worker, be it a doctor, pharmacist or nurse can quite easily infer from the medication records with reasonable accuracy what disease(s) the patient is being treated for. And if you think about it, this is the most efficient way to know about a patient’s medical status. If you go and look at his investigation results, there will be many ‘uninteresting’ normal results. If you look at the record of procedures done, you may miss the pure medical diagnoses the patient has. But when you look at the medication records, almost everything there is sensitive and ‘useful’. This is a medically-intelligent cyber-attacker.

The externalities of this attack are significant. The attack does not only affect the 1.5m people or the 160,000 medication records. The Monetary Authority of Singapore (MAS) has already instructed all bank to take more steps to verify the identity beyond the basic demographic data that was exfiltrated. Unless you do not have a bank account or use only human teller services, we will all have to answer more questions to verify our identity, beyond name, NRIC, address and birthdate. In other words, practically everyone is affected adversely.
NEHR

Since we are on the subject of NEHR, let’s discuss security of the NEHR in the wake of the attack. The authorities have categorically stated that the move towards NEHR is inexorable. There is NO turning back. It is true that the move away from paper cannot be avoided. But it is also true the NEHR has many issues that need serious re-thinking and ironing out.

This Hobbit senses that there is an almost religious fervour amongst those in power to developing a monolithic glorious NEHR that will be the pride of Singapore and establish the country amongst the pantheon of IT gods as soon as possible. To be in the pantheon of IT gods is the geek’s ultimate fantasy. But we need to face up to reality beyond geek-ish obsessions. Perhaps it is wise to take a leaf from Steven Spielberg latest directorial effort, the hit movie “Ready Player One”. In this movie set in the future (2045AD), most people in the world are living in slums and finding happiness only in a virtual reality gaming world called OASIS. The founder James Halliday becomes the richest man on the planet, with a fortune of $1trillion. But at the end of his life, he realised that “reality is real”; not OASIS.

Indeed, reality is real. Reality involves looking at the NEHR with detached objectivity. But it is difficult. The people right in the thick of things can get easily enamoured with the whole idea. Even a tech giant like Facebook is not immune to such failings. In the wake of the Cambridge Analytica scandal, Facebook CEO Mark Zuckerberg said in an interview on 18 July 18 that “we were too focused on just the positives and not focused enough on some of the negatives”. When you make a Golden Calf and worship it, you seldom look at its negatives.

If you look at the NEHR publicity so far, it is all about the positives: continuity of care, ease of care, more efficiency, patient safety etc. It’s terrific spin. Nobody talks about the potential negativities. But one must wonder if the people driving this believe in their spin? As the saying goes – never believe in your own spin.

Former editor of The Straits Times, Han Fook Kwang had his finger on the pulse when he wrote, “(NEHR is) A no brainer for the medical fraternity? You would have thought so. But doctors are divided over it”. (Singapore needs to get smarter about digital world, 5 Aug 2018)

He also said’ “It is easy to be seduced by the appeal of placing everything in a common system under one control: It can be more efficient and is easier to manage. Very Singapore Inc, you might say”. The key word here is “seduced”. Mr Han goes on to explain the pros and cons of a centralised system versus a distributed one. He used to be an elite Administrative Officer with experience working in MOH so he obviously knows more than a bit about healthcare.

For sure, many doctors in the private sector, like this Hobbit, don’t buy the spin. Many have quietly voiced their reservations about the security dangers, loss of privacy rights and costs of maintaining the system etc. But the feedback has always been “We are going full-steam ahead”. Until this massive cyber-attack happened and Smart Nation projects was paused for a total of 14 days (20 July to 3 Aug). A cyberattack that affected 1.5 million people did not quite put a dent in the Charge of the NEHR Brigade beyond 14 days.

This hobbit hopes someone in authority is finally looking at the negatives seriously even as we continue to brandish the positives. For one, if internet surfing separation is going to be permanent, does it mean that there will be at least one computer terminal in each clinic dedicated to just NEHR and which is not connected to the Internet? Who pays for that and its upkeep as well? Even if that happens, what is there to prevent hackers from physically breaking into a GP clinic located in the HDB heartlands at night and launching a cyber-attack from there? Does it mean we have to physically secure each clinic to the same level as SGH?

Regulation of the Public Sector

On 4 Aug, NUS Law Dean Simon Chesterman wrote eruditely in The Straits Times that we should not waste the opportunities afforded by this Singhealth cyber-attack crisis and take a good look at revisiting the issue of privacy on top of addressing the obvious issue of security. He was obviously not enthusiastic of the fact that the entire Singapore public sector was exempted from the “relevant legislation” (i.e. the Personal Data Protection Act or PDPA in short) that governs data protection. (Singhealth breach may give privacy new life, 4 Aug 2018).

Many official sources have said that the NEHR is subject to even higher standards than what the PDPA requires so no one should be worried. But that is NOT the point. The point here is when the public sector fails the public and fails the standards that it is supposed to meet, what happens? The PDPA provides for clear penalties to be meted out and the rights of the private individual is clearly spelled out. What is the equivalent of that in the public sector? Can the patients now sue IHIS or Singhealth? Who regulates IHIS and Singhealth under which piece of legislation when a cyberattack is successful and patients’ privacy and confidentiality suffer?

A private hospital administrator said to this hobbit that if this cyberattack had happened in the private sector, the PDPA would have been enforced and in all likelihood, the party involved, say a private hospital, would have been punished under the clear provisions of the PDPA with hefty fines etc. But since the PDPA doesn’t apply to the public sector, it’s anyone’s guess.

The SMA-AMS-CFPS Survey on Patient Perspectives of NEHR

This point is in fact quite well echoed in the results of a survey which was commissioned recently by the Singapore Medical Association, College of Family Physicians and Academy of Medicine, Singapore which has been released to the members of SMA and AMS. Out of the 2100 people surveyed, no less than 81.7% were concerned that the NEHR was not subject to the requirements of the PDPA. A whopping 82.9% (1741 of 2100) were concerned that their medical information would be used for matters of public interest by the Ministry without their consent.

Other significant findings include:
• 581 of 2100 (27.7%) definitely wanted to have their records maintained in the NEHR
• 1175 of 2100 (56.0%) would like their records maintained in the NEHR but did not want any healthcare provider to access it without their explicit consent except in emergencies. (i.e. privacy concerns)

On the issue of security:
• 77.5% (1627 of 2100) of the respondents were confident that their data in the NEHR was secure,
• 70.8% (1487 of 2100) were confident that their data would not be misused by others.

This survey was done before the cyber-attack. Will 77.5% of people still be confident of the security of the NEHR now?

But there is good news for the authorities. Singaporeans understand the importance of having a NEHR. 92.2% of those surveyed were supportive to varying degrees of having an NEHR. But of course, the devil is in the details. And as this Hobbit has said some five months ago, the concerns and dangers are lurking somewhere in the alleys of privacy and security which need to be faced squarely and addressed adequately.

As you can see, many people who had been surveyed were already concerned with some of the potential negatives of the NEHR, even though they saw the need for electronic medical records. The findings are not surprising.

Time For A Rethink, Repositioning and Redirecting ?

This hobbit feels that the NEHR urgently needs a re-positioning. In the wake of the cyber-attack, it is not just enough to say the NEHR is good for continuity of care, efficiency, cost-effectiveness, patient safety etc. Yes, the NEHR works for the patient’s interest in these areas. But the NEHR must also work for the patient’s rights and interests in other equally important areas such as privacy, confidentiality and security. And it is not just spin. The public that is now “sensitised” to such issues will want to know what are the concrete policies and measures taken to do so.

The public will also want to know what are their rights to redress, compensation and damages if their privacy and confidentiality rights have been compromised. This is still unclear in the context of the Singhealth cyber-attack and even more nebulous with regard to the NEHR.

What has happened in the last few weeks with the cyberattack calls for deep reflection,  serious repositioning. It may even need some redirecting – a change in course if necessary. But this hobbit doesn’t think there will be much of these. Instead, the focus is still on achieving rapid deification through the NEHR.

Come to think of it, this hobbit feels the NEHR is turning out to be something between a sacred cow and a golden calf…..

Perhaps it is time to revisit Lord Alfred Tennyson’s famous poem, “Charge of the Light Brigade”, in particular, the 2nd stanza:

“Forward, the Light Brigade!”
Was there a man dismayed?
Not though the soldier knew
Someone had blundered.
Theirs not to make reply,
Theirs not to reason why,
Theirs but to do and die.
Into the valley of Death
Rode the six hundred.