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Theodore Roosevelt famously once said that the more you know about the past, the better prepared you are for the future. This rings true ever more so in our healthcare landscape, where important lessons can be gleaned from the journeys of our pioneers and mentors. SMA News’ Dr Toh Han Chong seeks an insight into Singapore’s medical history by speaking with Prof Chew Chin Hin, one of SMA's Founder Members.
Dr Toh Han Chong (THC): Prof Chew, thank you very much for doing this SMA News interview in the Tan Tock Seng Hospital (TTSH) Heritage Museum. This place must bring back so many memories for you.
Prof Chew Chin Hin (CCH): During the Second World War, my parents and I stayed in 3-5 Jalan Tan Tock Seng; the house was there until about three years ago when it was brought down. It then became the Housemen’s Quarters, and later the consultants’ offices, just next to Dover Park Hospice.
THC: Oh really? That’s where your house was?
CCH: No, that’s where my parents’ house was. Mine was in 15 Akyab Road, where my family lived in for 31 years!
THC: Now you don’t live around here?
CCH: Not too far – just a five-minute drive away.
Back to the beginning
THC: As this issue is dedicated to celebrating SMA’s 60th anniversary, we hope to include your views as a senior leader in health policy, clinical medicine and education.
Years back, you saw how the Malaya Branch of the British Medical Association (BMA) eventually became the SMA. Do share with us some reflections of those times and what you thought the role and contributions of the Association was.
CCH: As a background, I think you have to revisit the pre-war years, the war years (1941 to 1945) and the immediate post-war years. The British did many good things; although some parts of colonisation were not so great, their contributions to the judiciary, rule of law and civil service, were some of their greatest. They did quite a lot for medical education as well. In 1905, the British set up the medical school. In fact, did you know that there was a medical association at that time?
THC: Was it the BMA?
CCH: Even before that, there was the Straits Medical Association in the 1890s and their first president was the Scottish doctor Sir David Galloway. The Scots also played a great part in medical education in Singapore. Sir David had some influence establishing the College of Medicine in 1905, albeit with initial misgivings, but it was mainly the local medical people who edged it forward. Even then, the medical service was very good compared to the surrounding countries and colonies. Our local doctors did a great job. In Dr Wong Heck Sing’s 1997 SMA Lecture, he mentioned two of these role models who had their heart and soul in teaching, including some British (eg, Prof Sir Gordon Ransome and Prof Eric Mekie). Even before Prof Ransome, there was Sir Brunel Hawes, who was also a great medical teacher and he was knighted for this. They were excellent colonial role models.
However, our local doctors were not happy during the pre-war years because of the two-tier system. When the British doctors joined the civil service at our hospitals, their starting position was “Medical Officer” and above, while our local doctors were “Assistant Medical Officers”. So although the General Medical Council recognised our local doctors as equivalent to the British almost from the beginning, there was a two-tier system. From the 1920s, the quality of these local doctors was equally good but they were held down. They were not allowed to proceed to the UK on scholarships for higher qualifications. Even if they went, they could only take a diploma and not the memberships or fellowships of the Royal Colleges. However, paediatrician Dr Gopal Haridas, who was sent to take the Diploma in Child Health, quietly took the London membership on his own and passed on his first attempt! (laughs)
THC: Those were the days – the other side of colonialism!
CCH: Those were the pre-war days. Then the war came – horrendous years. Almost all the British medical staff were interned. All the hospitals reserved for “locals” – Yio Chu Kang Hospital, TTSH and Kandang Kerbau Hospital (KKH) – were manned entirely by local staff! For three-and-a-half years, during the Japanese Occupation, local staff managed the hospitals superbly and they were the real and true role models. Dr Benjamin Sheares was in KKH with Dr BR Sreenivasan, and my father, Dr Benjamin Chew, was in TTSH with Dr Clarence Smith and Dr WA Balhatchet. They managed the hospitals with scarce resources and hardly any drugs, but with excellent nursing and camaraderie. Everyone was like family during those difficult years. They treated the local population as well as they could despite considerable numbers of tuberculosis patients and those with infectious diseases and other illnesses.
The post-war years
CCH: After the war, when the British medical team returned, several local doctors got together and wrote a petition to the Secretary of State for Colonies in London about how they had managed this place well and appealed that it was imperative that this discriminate two-tier system be abolished. My father was the scribe, and the doctors involved included Dr BR Sreenivasan, Dr Benjamin Sheares, Dr LS da Silva, and one or two more. A reply letter came shortly after to say yes to removing the two-tier system, and that a new system would be established soon after the post-war British government had settled down. It took over two years before it was finally implemented. By then, many of them had resigned – Dr BR Sreenivasan, my father and others left for private practice.
The progress of sending local specialists for specialist training was very slow; there were not more than 40 who had higher qualifications. They then sent a few more of us to the UK to take the membership and fellowships.
In the 1900s, one of the greatest physicians was Sir William Osler, a professor of medicine in both the US and at Oxford University. In fact, in the beginning of the century, all our students here used his textbook of medicine. I gave Prof Chee Yam Cheng his book titled “Aequanimitas”. Many of Osler’s devotional sayings were really true and relevant. During World War I, he lost his son tragically while he was teaching in Oxford. That really broke him. But still he continued; he died in 1919, but his textbook continued to carry the legacy of his great reputation. Besides his remarkable clinical prowess, he was also an organisation man. He was the leader who advised his medical brethren to be involved in professional associations and colleges, as it would promote not only fellowship and discourse, and even overcome what he termed “self-centredness”. Based on Osler’s teachings, you had to be true to the profession and possess humility. That’s how we were all taught – values such as how medicine should never be a trade or business, but a calling.
The formation of SMA
CCH: I graduated in 1955, did my first housemanship in Hong Kong, and with Prof Ransome at Singapore General Hospital (SGH), then returned to TTSH as a medical officer in 1957. And who should I meet? Dr Clarence Smith. He was with my father during the Japanese Occupation, and also the one whom my father gave the first course of penicillin here. He almost died from a serious lung infection, but he did recover after that. He was the medical superintendent at TTSH when I joined. I stayed for another six months or so, doing respiratory medicine, before going back to Prof Ransome’s unit in Medical Unit I.
At that time, we had the Malaya Branch of the BMA. In Singapore, this included Malaya and Singapore. I was a member of both the BMA and the Alumni Association (AA). The People’s Action Party came in as self-government in 1959. That’s also when SMA was formed, taking over from the Malaya Branch of the BMA and some of the functions of the AA. Before this, the AA did a lot; all the clinical meetings in those days were organised by the local doctors. The clinic-pathological conferences and their annual meetings were documented in Proceedings of AA, which became the Singapore Medical Journal when SMA was formed. As their professional functions were transferred to SMA, the AA became almost like a social old boys’ club. They obtained the building at 4ACollege Road and did well to house all the medical organisations including SMA.
The first meeting of SMA was held in September 1959. That was exactly the month when my wife and I, and Dr Oon Chong Lin, booked our flight to the UK for our fellowships. The three of us took the Comet 4; two of the earlier Comets had crashed into the Mediterranean Sea because of metal fatigue. Thankfully, we were safe on that flight but it took us about three days to reach London as we had to make about six stops. I was not there for the first SMA meeting but I was told, in writing if I’m not mistaken, that I would be a Founder Member of the SMA. In fact, we wanted it to be a Malaya Medical Association but this was not allowed, possibly due to political reasons as Malaya was an independent country while Singapore was still under the British. So we had to have SMA, but we share the same motto as the Malaysian Medical Association: “Jasa Utama” (Service before Self). All these medical organisations were formed during the country’s political developments. The Academy of Medicine, Singapore (AMS) was formed two years earlier in 1957 with 34 founder members as a specialist body.
Developing the medical landscape
THC: In the 1960s, how did you see the medical association and the role of your friends and you shaping healthcare policies in Singapore?
CCH: In a nutshell, it’s like holding and keeping the doctors’ and patients’ interests at heart. Sometimes, the thinking of the doctors was not in line with that of the Ministry of Health (MOH). So we became a kind of an “unofficial opposition” in the MOH. (laughs) However, on the whole, we were quite cordial in working with the Ministry. After all, it’s like a check and balance. It was all good when we were in agreement with Government policies, but when we had to point out certain things we disagreed on with the Ministry, of course it was not so pleasant. For example, when the intake of medical students was reduced from 180 to 120, it was quite a sudden drop and affected the supply of doctors. The situation created much unhappiness, but of course we understood later that manpower planning is not an easy job. The then Ministry had thought that there was going to be a surplus of doctors, but we found our hospitals short of junior doctors. Another issue was National Service (NS). When NS was implemented, the male doctors had to enlist. Many were unhappy. If doctors had thought deeper, they would see that it should be for the nation. Dr Kwa Soon Bee and 14 of us actually volunteered to help the Singapore Armed Forces soon after independence. At that time, we felt that we had to support NS. We were left truly on our own as a nation and did not know whether we could survive as a small nation – as a “red dot”. There was much uncertainty in the region.
THC: Any interesting memories or reflections from the 1960s and 1970s?
CCH: In the 1960s, it was about building and developing the medical services in Singapore. Many of us were returning with postgraduate qualifications. For chest physicians like myself, we had to go to Edinburgh, where Prof John Crofton was the pre-eminent chest physician, and then Cardiff with Prof Frederick Heaf to obtain a diploma in tuberculosis and chest disease. Thus, my first training was in Edinburgh followed by some months in Wales for the diploma. After just over a year there, we decided to take a “slow” boat back in January 1961 from Marseille.
THC: You must have enjoyed it so much!
CCH: We arrived back home in February 1961 and settled in 15 Akyab Road in TTSH grounds not too long after. Those were the days when positions, even for senior registrars, were established posts. You had to compete not only for academic positions but also in the civil service. There was only one senior consultant post (Superscale Grade E) for a major discipline, thus one senior physician for medicine, one senior surgeon for surgery, one senior O&G and one senior chest physician. Those were the days. Established posts were limited even for consultant and senior registrar positions. The level of competition was high and we were all interviewed by the Public Service Commission.
At TTSH, we had three medical units – Medical Unit I, II and III. The then medical superintendent Dr Andrew Chew approached me and said “Chin Hin, you head the forth unit.” As I was a consultant by then, I began building this fourth medical unit with a good team.
Teaching and medical education had always been an interest even before I left Medical Unit I for the UK. Soon after I came back, Prof Ransome and Dr Seah Cheng Siang at Toa Payoh Hospital said, “Come and join us in our ward rounds and in teaching.” So I was like an additional staff to Medical Unit I and taught there. And because the number of tuberculosis cases was gradually decreasing, I proposed the gradual transformation of TTSH to a general hospital. So that’s how the chest units were gradually being converted. I got my old chief, Prof Ransome, to come over once a week to discuss interesting and complex medical cases. He was happy to return to TTSH as he was turning 60 – the retirement age for university professors. That’s how the hospital resumed its original mission as a teaching hospital. With the gradual development, we brought in an experienced surgeon (Mr Ken Morris) from Melbourne, strangely enough, not in general surgery but in cardiothoracic surgery to help Dr NC Tan. We later had the Department of Neurosurgery (with neurology). They were the early surgical departments at TTSH.
The neurosurgery and neurology departments were headed by Dr Tham Cheok Fai, assisted by Dr Loong Si Chin, and the cardiothoracic surgery was headed by Dr NC Tan. Later, we formally established anaesthesia department, and I said we also needed an A&E department. Following that, we started an orthopaedic unit. The first head was Dr Chan Heng Thye, an orthopaedic surgeon and a former TTSH student. He started the A&E and orthopaedics surgery departments, and for general surgery we had Dr Wong Nan Eong from Toa Payoh Hospital. By the mid-1970s, TTSH was a full and comprehensive general hospital including radiology, rehabilitation medicine and paediatrics. In the Medical Units, we started elementary clinics in 1964. I’m not sure if they have elementary clinics nowadays. We taught basic clinical bedside medicine and meticulous history-taking. The first batch included Krishnamoorthy, Lindy Lin, Quek Swee Peng, Lenny Tan, Chan Heng Thye and Cheng Heng Kok. I think the batch also included Tan Cheng Bock. Heng Thye later headed the A&E department with orthopaedics, and Heng Kok in paediatrics.
THC: Let’s fast forward for one second – were you instrumental in helping to develop the Lee Kong Chain School of Medicine?
CCH: No. That’s very recent. Still, I was happy as it was always my hope that TTSH regains its status as a premier teaching hospital, because before the war, it was the main teaching hospital.
THC: Yes, even in my time. I did the majority of my medical officer training at TTSH. It has always been an excellent teaching hospital with such dedicated and wonderful peers and mentors.
CCH: Before the war, Prof Ransome’s house was here (points to map). It’s gone now. It was my office when I was Medical Director. Prof Eric Mekie’s bungalow was down the road, where the Tuberculosis Control Unit now occupies.
In Prof Lee Yong Kiat’s papers, he even mentioned that TTSH was better staffed than SGH (laughs), I think referring to pre-war years. Down the road, behind the Dover Park Hospice, was the medical students’ hostel where Dr Mahathir stayed as a medical student. It is now the Lee Kong Chian School of Medicine headquarters – a historical heritage building. That was then called the Straits Settlements Hostel.
The first medical student casualty from Japanese shelling died here at TTSH the day before the British surrendered on 15 February 1942. They brought his body back to be buried at Sepoy Lines. Alongside him, another ten medical students were shelled and killed – a most tragic and cruel episode. The war years were horrendous. I saw the first bombs come down over Chinatown. Our SGH mortuary was filled to over-capacity – all the other bodies were laid on the grass outside. We were living not far away. That was a horrible scene. Our local community was very unhappy on how the British allowed this to happen.
THC: What do you mean “allowed this to happen”?
CCH: Singapore was supposed to be impregnable! I think the British High Command shifted their sights and focus. Of course they underestimated the Japanese Imperial Army. The war was going on in Europe – most of their resources were there, and all their airpower with Spitfires and Hurricanes were there. We were left with clumsy Buffalo fighter planes which were not the same; they paled in comparison to the Japanese Zero aircrafts (and kamikaze pilots).
THC: But then they had the Prince of Wales and the Repulse Battleships.
CCH: They thought that the two “invincible” ships could overcome the Japanese. However, there was no air support and within a few hours, the ships were sunk – virtually “sitting ducks”!
THC: Surprising, because then Prime Minister Winston Churchill said that Singapore was strategically very important.
CCH: He said that Singapore was impregnable! They left us to the Japanese. (sighs)
THC: Following medical leadership at TTSH, you became deputy director of medical services. Looking at Singapore as a healthcare system, through the 1960s, 1970s and beyond, can you comment on how Singapore’s healthcare was evolving?
CCH: It was an unusual privilege to serve MOH throughout the 1980s, overseeing our hospitals and the restructuring process. But before this, we owe a huge debt to British medicine in the early years. That’s an invaluable and priceless contribution. Even till this day, excellent clinical and bedside medicine remains the bedrock of our medical training and professional calling. However, one of the things we realised when we went to the UK for our postgraduate examinations was that there was a shortage of doctors here compared to British hospitals, in terms of the doctor-to-patient ratio. If we were fortunate, about two or three would come back within a year. For example, Dr Andrew Chew obtained his London membership within six months and flew back to start work. He could have stayed there but he didn’t want to. He came back. I spent just over a year abroad. But many went for two to three years, especially for radiology and surgical disciplines, which took longer – a loss to our workforce and also economy.
Soon after I came back, we realised it was up to us to build our medical and health services. We had to also develop well-respected and well-recognised local postgraduate examinations and training.
We needed to train our own specialists with our growing expertise, instead of always going abroad for specialist examinations. Going overseas would mainly be to attend some courses and take some exams then, so why not have our own specialist board examinations here? For years, it remained an unresolved matter between our medical professional bodies and the establishment until Dr Toh Chin Chye made a speech in 1967 chastising the medical faculty for not making progress in postgraduate training and introducing local professional examinations. Prof K Shanmugaratnam was Master of the Academy at that time, I was “Bedel” and Censor in-Chief, and Prof Seah Cheng Siang was Assistant Master. Very soon after, Prof “Shanmu” called me and said, “Chin Hin, we have to respond to Toh Chin Chye.” I said, “Sure!” Next, Cheng Siang called me. I said “Let’s hold an emergency meeting.” Within a day, we sent a letter to Dr Toh – I think our letter is in our AMS archives – asking for a meeting. Very soon after, he replied, “Yes, let’s meet.”
So we met at City Hall at Dr Toh’s office – the Deputy Prime Minister’s (DPM) office. I don’t know whether it was the Surrender Chamber where the Japanese surrendered to Mountbatten, but it was a very impressive room. There were six of us with Dr Toh. During the meeting, he said, “Shanmu, you form and chair this committee to ensure we proceed.” Dr Koh Eng Kheng was SMA’s secretary, so Shanmu got SMA involved with Eng Kheng as secretary as well as AMS and the medical faculty, including Prof Wong Hock Boon. That’s how we started our MMed examinations in 1970. Shanmu was really excellent in getting this done in Singapore.
That was also how Dr Toh Chin Chye supported us and got the school and MMed qualifications established. The school was there but under the faculty. We proposed that the school has to be governed by an autonomous independent board, comprising four members of the Academy and four from the faculty, the vice-chancellor as chairman. The first chairman was Dr Toh Chin Chye himself; by this time he had become the vice-chancellor. Prof Wong Hock Boon was the first director and Prof Seah Cheng Siang the first deputy director. We were all on the board, together with one MOH representative – the Director of Medical Services, with the medical dean and AMS Master as an ex officio member. That was how the first board was established. We went on for about ten years before Hock Boon and Cheng Siang stepped down; I took over Cheng Siang’s place and Shan Ratnam took over Hock Boon’s place. We started with MMed (Internal Medicine), MMed (Surgery), which then included orthopaedics, MMed (O&G) and MMed (Paediatrics).
THC: Later on, the Royal Colleges agreed to partner MMed.
CCH: That was later, when they recognised that our standards were equal to their memberships and fellowships. We had insisted from the beginning that our standards and quality of candidates must be equivalent and, if possible, even better than the MRCP and FRCS. An important requirement was that we have one external examiner from Australasia and one from the UK. Sometimes, they nominated their colleges’ presidents. This continued for many years. Their reports of our examinations and standards were consistently good. Reciprocity came after about ten years. The first joint FRCS Edinburgh and MMed (Surgery) was held in 1986. For physicians, it was about ten years later. This was after the Edinburgh college president Dr Anthony Toff invited our AMS Master and his UK counterparts from London and Glasgow to a meeting for further collaboration in 1994. I represented then Master Prof TC Chao. Soon after in 1996, we had our first joint MMed (Internal Medicine and Paediatrics) with the MRCP UK Examination. This was before PACES – the new format for the final clinical examination.
We were represented on the MRCP UK examination boards. I sat on the management board, Prof Chan Heng Leong on the Part Two Board, and I had Prof Tan Chorh Chuan to represent the Part One Board. As for Paediatrics, I had Prof Low Poh Sim to be involved. From 1986 to 2000, we were involved in developing PACES, the new clinical replacing the traditional long and short cases. In 2001, the first PACES was held here six weeks before UK and we had observers from Hong Kong. They also had the privilege on being on the UK boards. In 2001, paediatrics had their own examinations with Royal College of Paediatrics and Child Health, which took over the function from the UK Colleges of Physicians. Those were interesting days.
I stepped down when I got Prof Chee Yam Cheng to take over, the day after 9/11. That was a traumatic period. We had to visit the UK thrice yearly, to the three Colleges, so we took turns. I flew to Glasgow on 11 September 2001, that same day, in the morning. When I checked into the hotel, instead of taking me to reception, the hotel staff exclaimed, “Come, see what’s happening on the television!” The first Twin Tower had already gone down. Then the second tower fell. It was terrible to watch. Yam Cheng was in New York at that time. They closed Heathrow Airport and all US airports after that.
Thankfully, my daughter was there in the UK, residing near Oxford at the time. My wife and I were supposed to go to the US to attend another meeting, but we stayed with our daughter until Heathrow Airport reopened for international flights.
I retired as a civil servant in 1991 at the age of 60. After that, it was all “national service”. (laughs)
THC: How do you see SMA and medical bodies in Singapore contribute to shaping healthcare in Singapore?
CCH: As a doctor, you have to keep up with advances. I do a lot of reading especially with regard to my own field, to keep up with ethics such as on the care of the aged and finishing well. That’s my interest. What I can say is that over the last few decades, I believe we’ve done really well in relation to other countries, especially in comparison to, for example, the National Health Service (NHS) in the UK and other advanced countries.
THC: You think we are overall better than the NHS?
CCH: Yes, I think so! In fact, when the UK College examiners visit our hospitals, they’re really amazed. Some of the hospitals in the UK are still equipped with older technology and systems. The waiting list there is also much longer even for serious ailments. Therefore, I think all in all, our health services are really top class. But that’s not to say we are perfect – the best is yet to be.
Personally speaking
THC: What is your wish for Singapore healthcare for today and the future?
CCH: First of all, I think that healthcare must be accessible and affordable to everybody. Basic healthcare is not a problem – everybody gets it easily now. What’s more prohibitive is treatment for difficult and complex illnesses such as cancers, and the costs of drugs and investigations. My own brother is having target therapy for cancer. He’s doing quite well, but treatment is very expensive. This can be very prohibitive to many and these are worrying trends with more new expensive drugs being approved.
I must say that I’m very thankful, because as a civil service pensioner, I’m well cared for. As emeritus consultant, TTSH looks after me very well. As a wish list for all, I would like to see doctors who are not only caring, but also have compassion and integrity. However, integrity without knowledge is weak and useless. You must have knowledge. That’s why continuing medical education is very important. On the other hand, knowledge without integrity is dangerous and dreadful. And of course, my own physicians know well – they treat me holistically as a patient and not the diseases I have.
THC: Who are some of your role models?
CCH: I take off my hat to one of my Edinburgh mentors: Sir John Crofton. He was one of those who showed me the meaning of compassion and care; he was truly caring and committed to all his tuberculosis patients and we became lifelong friends. Others in the UK include Sir Ferguson Anderson, the father of geriatric medicine in Glasgow, and Sir Richard Doll, whom I came to know and admire. These are the giants I have looked up to as role models. In Singapore, as I have mentioned some names earlier, I have enormous regard for my brethren colleagues, young and old, even my former students who are so well respected in the profession today.
THC: Prof Chew, thank you very much for such an illuminating conversation and for bringing us on a journey through the history of Singapore medicine.