I argue for the necessity of a more holistic healthcare system to address contemporary health issues.
Healthcare in Singapore is seeing an improvement from technological advances such as the use of satellite imagery and geographical systems for urban planning and the tracking and prediction of infectious diseases from changes in the climate, of health information linking individuals to health services and social services for self-management and task shifting, and of big data and artificial intelligence for juxtaposing social, biological, and environmental data. Are we then on track to meet the healthcare challenges in the coming decades?
At a March 2018 panel on the ‘Future of Public Health’ at Yale-NUS College moderated by Dr. Jeanette Ickovics, both Dr. Sten Vermund, the dean of Yale School of Public Health and Dr. Teo Yik Ying, the dean of the Saw Swee Hock School of Public Health emphasized the need for integrating health systems across disciplines and stakeholders.
Dr. Ickovics remarked how while global life expectancy has doubled in past century due to advances in public health, there are new and existing health issues such as climate change, urbanization, migration, smog, sedentary lifestyles and food environments. These health challenges tend to be constructed not only from biological risk factors, but also from multiple social, environmental, and behavioural factors, which can no longer be addressed with traditional models of healthcare with a heavy emphasis on primary care and treatment. They instead require the expansion of our conception of healthcare into other domains of life such as the construction of the built environment in homes and workplaces, the norms and habits around eating and social interaction, or the production of energy and manufacturing of goods.
Take diabetes for example. Dr. Teo talked explicitly about how we cannot approach diabetes, a critical public health challenge in Singapore, as “a medical problem, but instead as a social issue.” Beyond the provision of blood glucose meters and insulin pumps, as well as having sufficient specialists and hospital infrastructure, the war on diabetes can and should be addressed as a transport, manpower, economic, and education challenge as well. For instance, the sedentary lifestyle that is one of the primary behavioural causes can be addressed by making the city less automobile-dependent through the creation of enhanced biking infrastructure.
Institutionally, this means that there needs to be collaboration between the Ministries of Health and Transport, or perhaps first for the Ministry of Health to be transformed to conceive of these more comprehensive policies and have the jurisdiction to make these recommendations to the Ministry of Transport. Dr. Teo commented that diabetes should thus be “an equal burden on the shoulders of the education minister as it is on the health minister.” And this is only an example of one intervention. To target behaviours in the workplace, the Ministry of Manpower might need to be invited to the table; for initiatives at building nutritional intelligence, the Ministry of Education; in changing the availability and demand for foods with high sugar content, the Ministry of Trade and Industry or Finance; and the list goes on.
Another issue that was brought up that seems to necessitate this sort of cross-ministry collaboration is anti-microbial resistance. Thinking about it as a traditional health problem is limiting and ineffective as many antibiotics are used in animal husbandry. This problem then straddles both the Ministry of Health and the Agri-Food and Veterinary Authority of Singapore under the Ministry of National Development. Concerning cost-effectiveness, interventions that are more desirable might not come from the medical sector as well, but from life science, engineering, and the built environment of agricultural space. Furthermore, thinking about this problem in this larger frame of health allows us to identify how the increased demand for food as the population grows can exacerbate this issue.
This logic extends to how we are gearing up to address the rise of other chronic conditions such as poor mental health and noncommunicable diseases (NCDs) like obesity. We can no longer focus our resources and energies on improving primary and hospital care, such as through the provision of blood glucose meters, insulin, and antidepressants, but turn instead towards prevention and the larger and more complex social and behavioural risk factors that lay the foundations on which these health issues are constructed atop.
One potential area for Singapore to focus its interventions may be in the domain of public housing, or HDBs. Over 80% of people live in public housing in Singapore and spend much of their time around their residential areas. It is imperative that we look at how both the physical and psychosocial landscape of public housing has been shaped and how these elements then shape the behaviours and habits of those who occupy them. Some of the risk factors that lead to these mounting challenges include social isolation and sedentary lifestyles, which can be addressed through interventions targeted at transforming public housing.
Singapore can become a global leader in health by initiating this transformation to a more holistic system of analysis and prevention, starting from the unique opportunity public housing presents in the form of HDBs.
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