When former US president Richard Nixon took up office at the White House in 1969, he inherited a raging war in Vietnam amid large-scale political unrest and resistance to the war at home. He was faced with the option of continuing with former president Lyndon Johnson's policy of escalating the war, or finding some way to disengage and get American troops home. He established what became known as the Nixon Doctrine, which directed his administration to withdraw American troops over the next few years and replace them with Vietnamese soldiers.
While Nixon is now well known for triggering US withdrawal from the Vietnam War and ultimately closing this dark chapter in America's modern history, he is less well known for declaring two other "wars" during his term as president – the "War on Drugs" and the "War on Cancer".
The War on Drugs
The War on Drugs was launched by Nixon shortly after he took office and was partly a reaction to the rampant misuse of drugs both among US troops in Vietnam and on home territory. After all, this was at the height of the liberal "hippie" era where psychedelic drugs permeated popular culture and mass media, and fuelled the rock and roll lifestyle. Nixon famously declared: "America's public enemy number one in the United States is drug abuse. In order to fight and defeat this enemy, it is necessary to wage a new, all-out offensive."
This war on drugs brings to mind images of gun battles in inner cities between heavily armed police and roving drug gangs, or scenes from the 1994 movie Clear and Present Danger, where military forces were sent south of the US borders to wage a covert war against the Columbian drug cartels. In reality, the war on drugs was about the implementation of broad policies aimed at disrupting the production, distribution and consumption of illegal drugs: from the creation of the Drug Enforcement Administration that dealt with the supply side of the drug trade, to the federal-funded treatment programmes that helped to reduce demand.
Whether the war on drugs was successful in controlling drug abuse is still hotly debated and highly contentious. It carries with it not only a heavy economic cost (it is estimated that the US spends US$51 billion worth of taxpayers' money annually on the war on drugs), but also social costs such as the incarceration of hundreds of thousands of drug offenders – and yet the drug problem persists.
The War on Cancer
Nixon also declared a War on Cancer when he signed the National Cancer Act of 1971 into law on 23 December 1971. This was against the backdrop of abysmal survival rates for cancer at that time, coupled with the woeful lack of knowledge about the pathogenesis of cancer. If Americans were able to put a man on the moon in 1969, surely more could be done in terms of technological progress to find the "magic bullet" for cancer cure.
In his Pulitzer Prize winning book tracing the history of cancer, The Emperor of all Maladies, Dr Siddhartha Mukherjee wrote: "Cancer was missing not merely a medical cure but a political cure." A rallying call, such as declaring a war on cancer, would hopefully overcome the perceived lack of progress in cancer treatment, divert much needed funds into cancer research and provide hope to millions of Americans affected by the disease.
Critics of this strategy pointed out that it was premature to concentrate all that energy on cancer treatment and neglect other areas of research such as prevention. Mukherjee wrote: "The rhetoric of this war implied that its tools, its weapons, its army, its target and its strategy had been assembled. Science, the discovery of the unknown, was pushed to the peripheries of this battle. Massive, intensively funded clinical trials with combinations of cell-killing drugs would be heavily prioritised. The quest for universal causes and universal solutions – cancer viruses among them – would be highly funded.”
In their paper published in the England Journal of Medicine in May 1986, Bailar and Smith showed that age-adjusted cancer-related deaths had increased, primarily due to increase in smoking rates.1 They concluded that the war on cancer had been a failure and that more should be done for prevention rather than treatment, writing: "According to this measure, we are losing the war against cancer, notwithstanding progress against several uncommon forms of the disease, improvements in palliation, and extension of the productive years of life. A shift in research emphasis, from research on treatment to research on prevention, seems necessary if substantial progress against cancer is to be forthcoming."
Declaring War on Diabetes
Singapore made a bold move to battle a chronic disease when Minister for Health Mr Gan Kim Yong declared a "War on Diabetes" in his budget speech in parliament on 13 April 2016. This was a remarkable announcement because to my knowledge, no country has ever declared war on a chronic disease such as diabetes. Other than the above two examples on drugs and cancer, similar declarations have been made against tuberculosis (an infectious disease) and tobacco (a carcinogen).
Declaring war on diabetes brings to mind some immediate challenges. Firstly, the "enemy" is hard to detect. Symptoms of diabetes, such as polyuria and weight loss, can present late into the illness, and they are typically non¬specific. Early detection would depend on regular screening. Secondly, diabetes is an invisible disease with multifactorial causes and is thus hard for patients and the public to visualise and understand. Compared to pictures of a heroin-filled syringe, an ulcerating tumour, a lit cigarette or an infective microbe, diabetes is an abstract illness. Thirdly, you cannot "win" a war against diabetes because there is no cure, at least not in the foreseeable future. The number of cases of diabetes is expected to increase together with other chronic diseases, in tandem with the ageing population. As seen in the examples on the war on drugs and cancer, it is easy for detractors to criticise intervention programmes when perceived objectives are not met.
However, despite the many challenges, there are many good reasons to launch a public campaign of the war on diabetes.
Inciting urgency
Declaring a "war" lends the campaign a sense of urgency and emphasises its critical importance in public health. As Mr Gan reported in his 2016 budget speech, about 400,000 Singaporeans are diabetic and the lifetime risk of developing diabetes is 30%. Of those who have diabetes, one in three Singaporeans has not been diagnosed. And among those diagnosed, one in three has poor control of the condition. We hold the unfortunate distinction of having one of the world's highest rates of lower extremity amputations. These statistics are indeed worrying and serious enough to necessitate urgent attention.
Rallying the nation
A public declaration of "war" is a rallying call not just for the involvement of stakeholders like patients and healthcare providers, but for the whole nation. Every citizen has a part to play and can contribute to this national effort. Mr Gan said: "The key to winning the war on diabetes is for all Singaporeans to be engaged in the battle. The key partners in this war are the individuals, his/her family and the community. By working together, we hope to create an environment that makes healthy choices an easy option, but Singaporeans also need to play their part by eating healthily, exercising often, and going for the recommended screenings and follow-ups."
Engaging diverse stakeholders
The War on Diabetes cannot be fought by the Ministry of Health alone, which is why the Diabetes Prevention and Care Taskforce is co-chaired by the Minister for Health and the Acting Minister for Education, with representatives from Government agencies, the private sector, and patient advocacy and caregiver groups. The composition of this task force is a strong sign that the Government is serious in mobilising resources to tackle the burden of chronic disease in Singapore, such as inculcating good dietary and exercise habits in schools, providing healthy lifestyle programmes at workplaces, introducing more healthy foods catered by the food industry, introducing an expanded screening programme for early detection of diabetes for at-risk individuals, and introducing education and outreach programmes to fill knowledge gaps.
This will be a long battle ahead and the task force must be clear about the indicators that it tracks to monitor progress. It is important that the public is kept informed of the measures of success, such as an increase in the early detection of patients with diabetes, effectiveness of behavioural interventions, reduction in morbidity and mortality of patients with diabetes, and improvements in quality of life. To conclude, I quote Mr Gan: "The War on Diabetes will not be a quick battle, but a long war requiring sustained effort. Results of our efforts can only be seen in the long term, but we must persevere."