A national campaign
In 2016, the Ministry of Health (MOH), led by Minister for Health Mr Gan Kim Yong, declared a War on Diabetes. We had about 400,000 diabetics then; one in three diabetics did not know that they have the disease and for those who knew, one in three had poor control of their chronic disease.
This is no ordinary health campaign nor is it like any other health campaigns we have had in the past. When we declare war on a disease that affects a large number of people, every Singapore citizen should be committed to the war effort. To date, we have already committed more than 1 billion SGD a year to our war (against diabetes). This year, prediabetes has been included as one of the chronic conditions in our Chronic Disease Management Programme (CDMP) that is covered by the Community Health Assistance Scheme (CHAS) and Medisave.
We all recall many national campaigns, such as Save Water, the National Courtesy Campaign, the National Family Planning Campaign (Stop at Two), and Keep Singapore Clean, but none of them have been on such a large scale and hence its term "War on Diabetes". The Diabetes Prevention and Care Taskforce is made up of inter-ministerial committee members to coordinate our war efforts in the other aspects of our economy other than healthcare. Just as in any war, we need to mobilise the public, who are often the victims, to get them to achieve a healthy state so as to not be susceptible to the onslaught of hyperglycaemia. We need to gather the resources which would normally be employed elsewhere, to be allocated to focus on our war. I recall seeing frequent running commercials on the Pioneer Generation campaign, but the current television advertisements on diabetes look more like snippets from a Chinese kung fu movie. Perhaps the advertisement for diabetes-prevention is more erudite but I think I would have preferred to have kept it simple and easy to understand, so that it would improve retention with the requisite repetition of the campaign message to our citizens.
Nationwide efforts
This is not just a Government campaign though; we need to round up our Government agencies, private sector, healthcare personnel, patient advocacy groups, caregivers and case managers to fight this war. We need to make lifestyle changes and we need to persist till preventing diabetes is a way of life. For those who are already afflicted, we need to educate them to prevent their condition from further deterioration and to treat complications early. We also hope to see more media and propaganda messaging, as these are vital to motivate and educate our public, to empower them to be less dismissive and ignorant, and to reduce their susceptibility to the attack of diabetes.
There have been many other ideas from the community, such as the Running Society's mass run every weekend with the involvement of Residential Committees, and the Health Promotion Board's introduction of exercise programmes in parks and malls on weekends. Perhaps we could extend the ActiveSG funds to create a better environment for cycling and get students to do Community Involvement Programmes associated with these activities as well, instead of selling flags. Could we extend the Individual Physical Proficiency Test to all gender and ages, beyond reservist liability, with incentive of more subsidies if they achieve gold standard? Making bus stops further apart could be helpful, so people will choose to walk more; and more shelters to encourage walking under all weather conditions. The use of information technology and the Internet of Things to manage wearable devices should also be considered.
The war against diabetes also involves our allied health professionals, like physiotherapists, occupational therapists, podiatrists and medical social workers. As for the doctors, it is not just the responsibility of endocrinologists or diabetologists; every doctor is involved as diabetes is a multi-systemic organ disease. The complications are devastating and reach into every nook and cranny of our bodies. Diabetes can result in coma, stroke, blindness, heart disease, kidney disease, limb amputation and mental illness, as well as lead to inflated healthcare costs with spirals into poverty and bankruptcy.
Tools of war
The good news is that, of late, we have better armamentarium to fight this war – we have new drugs that not only control diabetes but also the complications of diabetes such as those that damage the heart and our vital organs. The bad news, however, is that our medical colleagues are still battling the usual problems in managing our patients, such as ignorance, poor awareness and poor insight leading to poor compliance.
Who should we set as a target group and when do we institute the recommended changes? We know that with the elderly group and their years of neglect, it is difficult as it may seem like a lost cause. We need to focus on our younger citizens. In fact, we should start with pregnant women and maybe even earlier at the preconception stage. After delivery, we should continue our efforts for both mother and child. The mothers will need to understand that gestational diabetes is an early warning signal for them to pursue preventive measures. For the children, we should start them early, guiding them by various means to achieve a healthy lifestyle. More health education efforts should be put in place in schools and for school-going children. There was even a suggestion to make it compulsory as part of Primary School Leaving Examination scores.
There are talks of legislation to curb the sugar intake and sugar tax. Punitive measures and negative reinforcements should not be a standalone. We should incentivise and give positive reinforcement to encourage correct behaviour. However, when our existing healthy food choices are considerably more costly to consume than junk food, we need to set it right so that the flow in behaviour will go along the correct gradients. Instead of gourmet holidays, we could change them to trail-walking and camping vacations. Instead of massive buffet feasts when we gather, we should have simple refreshments. Families should be getting together for activity-based events and perhaps the zoo and Sentosa could offer cheaper entrance fees on certain days to promote outdoor activities.
Another target to achieve is the prevention of complications. I believe more public education in the print media, social networks and public outreach can reduce the onset of complications. We know that many conditions, such as microalbuminuria and prediabetes, can be reversed early on through a healthy diet and lifestyle.
The War on Diabetes is a very good opportunity for us doctors to practise team-based holistic care. It is good to know that chronic disease management is not our burden to carry alone; we have multiple healthcare partners to bear the load and share their expertise to better manage our patients.
We hope to catch those with complications early so that there is a chance of reversal. We hope to catch those who are susceptible at an early stage to prevent them from contracting diabetes and to encourage a general healthy lifestyle among our citizens. We hope to move our patients away from the hospitals and back into their community. We aim to look beyond healthcare and instead into the health of our citizens.
After that, we still need to constantly ask ourselves these questions:
- Are we fighting a limited war or a total war? Have we mobilised enough of our nation?
- Who else has the public authority in this war? Certainly, it is not only our MOH?
- If this is intended to be a long-drawn war, what are the key sustainability objectives for the nation?
- Quality-adjusted life year;
- saving health dollars; or
- not to bankrupt the nation?
- Are the current communication and outreach methods enough? If they are enough, has the community been influenced? If so, how do we secure the commitment of the citizens, employers, National Trades Union Congress, food and beverage sectors, and more?
After all, we are not only for doctors but indeed, we are for our patients.