Meng-Kin Lim

Risk perception and impact of severe acute respiratory syndrome (SARS) on work and personal lives of healthcare workers in Singapore : What can we learn?

Introduction:Healthcare workers (HCWs) were at the frontline during the battle against Severe Acute Respiratory Syndrome (SARS). Understanding their fears and anxieties may hold lessons for handling future outbreaks, including acts of bioterrorism. Method:We measured risk perception and impact on personal and work life of 15,025 HCWs from 9 major healthcare institutions during the SARS epidemic in Singapore using a self-administered questionnaire and Impact of Events Scale and analyzed the results with bivariate and multivariate statistics. Results:From 10,511 valid questionnaires (70% response), we found that although the majority (76%) perceived a great personal risk of falling ill with SARS, they (69.5%) also accepted the risk as part of their job. Clinical staff (doctors and nurses), staff in daily contact with SARS patients, and staff from SARS-affected institutions expressed significantly higher levels of anxiety. More than half reported increased work stress (56%) and work load (53%). Many experienced social stigmatization (49%) and ostracism by family members (31%), but most (77%) felt appreciated by society. Most felt that the personal protective measures implemented were effective (96%) and that the institutional policies and protocols were clear (93%) and timely (90%). Conclusion:During epidemics, healthcare institutions have a duty to protect HCWs and help them cope with their personal fears and the very stressful work situation. Singapores experience shows that simple protective measures based on sound epidemiological principles, when implemented in a timely manner, go a long way to reassure HCWs.

Six Countries, Six Health Reform Models? Health Care Reform in Chile, Israel, Singapore, Switzerland, Taiwan and The Netherlands

Abstract This research contribution presents a diagnosis of the health reform experience of six small and mid-sized industrial democracies: Chile, Israel, Singapore, Switzerland, Taiwan and The Netherlands during the last decades of the twentieth century. It addresses the following questions: why have these six countries, facing similar pressures to reform their health care systems, with similar options for government action, chosen very different pathways to restructure their health care? What did they do? And what happened after the implementation of those reforms? The article describes the current arrangements for funding, contracting and payment, ownership and administration (or “governance”) of health care at the beginning of the twenty-first century, the origins of the health care reforms, the discussion and choice of policy options, processes of implementation and “after reform adjustments”. The article looks at factors that help explain the variety in reform paths, such as national politics, dominant cultural orientations and the positions of major stakeholders.

SARS: health care work can be hazardous to health.

Severe acute respiratory syndrome (SARS) is possibly the first globally significant occupational disease to emerge in the twenty-first century. It first surfaced in Guangdong, China, in November 2002, made its appearance in Hong Kong in February 2003, and then subsequently spread by air travel to Vietnam, Singapore and Canada. SARS has now encircled the globe, affecting 30 countries. As of 13 May, the World Health Organization (WHO) [1] reported 7548 probable SARS cases and 573 deaths. The case fatality ratio varies from 0 to 50%, depending on the age of the patient, with an overall estimate of 14–15% [2]. These figures will undoubtedly change with time as more cases emerge. The aetiological agent is a novel coronavirus (SARS-CoV), with patterns of spread suggesting droplet or contact transmission [3,4]. Clinical features are those of atypical pneumonia, with the common presenting symptoms being fever and dry cough. SARS patients are classified as either ‘suspect’ or ‘probable’ cases [5]. A suspect case is a patient who presents with a history of high fever (>38°C) and a cough or breathing difficulty. In addition, there must be one or more of the following exposures within 10 days of the onset of symptoms: either a close contact with a person who is a suspect or probable case of SARS, or a history of travel to a SARS-affected area. A suspect case is upgraded to ‘probable’ with the appearance of radiological changes consistent with pneumonia or respiratory distress syndrome (RDS), or in the event of death, autopsy findings consistent with the pathology of RDS without an identifiable cause. At the time of writing, there is no validated, widely and consistently available laboratory test for infection with the SARS-CoV. However, from 1 May 2003, the WHO amended the definition of a probable case to include a suspect case of SARS who has positive laboratory tests for SARS-CoV, under conditions drawn up by the WHO. Empirical therapy for SARS has included corticosteroids, a broad spectrum antiviral agent and antibacterial cover [6]. Health care workers (HCWs) are a high-risk group for SARS-CoV infection. According to the WHO, they constitute the biggest, single group of probable SARS patients worldwide. As at 4 May, 41% of 203 SARS patients in Singapore and 22% of 1629 cases in Hong Kong [7] were HCWs. The majority of cases in Canada (74.4%) have been attributed to exposure in a hospital or health care setting [8]. As at April 25, more than 100 hospital workers at three Greater Toronto Area hospitals have become ill with SARS [9]. Unfortunately, a number of deaths have occurred among HCWs. An early casualty was Dr Carlo Urbani, the WHO expert working in Hanoi who was among the first to identify the clinical disease, and in whose honour it has been proposed that the causative agent bear his name. The index case (and first reported death) of the Hong Kong outbreak was an elderly Chinese physician who had treated SARS patients in Guangdong. Three doctors, two nurses and a health care attendant in Singapore have also succumbed to SARS. The vulnerability of HCWs can be explained by their close contact with patients. The innocuous, ‘flu-like’ clinical presentation of SARS does not help to raise the index of suspicion. In the early stages of the outbreak, there was also not the same degree of vigilance with regards to potentially high exposure situations such as aerosol-generating procedures. These included aerosolized medication treatments (i.e. nebulizers), the use of high-flow Venturi masks and non-invasive positive pressure ventilation for SARS patients, airway suctioning and endotracheal intubations. As a poignant illustration, in Singapore, a cluster of 41 probable and 21 suspected cases was traced to a single SARS patient who was initially undiagnosed for 10 days and treated for gastrointestinal bleeding, chronic kidney disease and diabetes [10]. The cluster included 26 hospital staff working as doctors, nurses, radiographers and housekeepers. An occupational health audit, which included a walk-through of the hospital ‘hot spots’ carried out by the authors, revealed a small number of deficiencies which could well be weak links in an otherwise strong preventive chain. That the cluster of cases included housekeepers is also significant—preventive measures need to target much broader groups of HCWs than just the doctors and nurses in direct contact with patients. Frontline HCWs like counter clerks, porters and ambulance drivers are also at risk, and must be educated and protected. The encouraging news is that with the institution of stringent infection control measures and personal protection, the situation appears to have improved somewhat. This was the case in a Singapore hospital [11], where the experience was reported as: ‘We did not see any further transmission from this index patient after we implemented strict infection control measures involving use of N95 masks, gown, gloves, and handwashing before and after patient contact’. Doctors in Hong Kong [12] are also ‘hopeful that further cases among our staff will be

Values and Health Care: The Confucian Dimension in Health Care Reform

Are values and social priorities universal, or do they vary across geography, culture, and time? This question is very relevant to Asias emerging economies that are increasingly looking at Western models for answers to their own outmoded health care systems that are in dire need of reform. But is it safe for them to do so without sufficient regard to their own social, political, and philosophical moorings? This article argues that historical and cultural legacies influence prevailing social values with regard to health care financing and resource allocation, and that the Confucian dimension provides a helpful entry point for a deeper understanding of ongoing health care reforms in East Asia--as exemplified by the unique case of Singapore.

Global response to pandemic flu: more research needed on a critical front

If and when sustained human-to-human transmission of H5N1 becomes a reality, the world will no longer be dealing with sporadic avian flu borne along migratory flight paths of birds, but aviation flu – winged at subsonic speed along commercial air conduits to every corner of planet Earth. Given that air transportation is the one feature that most differentiates present day transmission scenarios from those in 1918, our present inability to prevent spread of influenza by international air travel, as reckoned by the World Health Organization, constitutes a major weakness in the current global preparedness plan against pandemic flu. Despite the lessons of SARS, it is surprising that aviation-related health policy options have not been more rigorously evaluated, or scientific research aimed at strengthening public health measures on the air transportation front, more energetically pursued.

Black or white cat? Ideology meets reality in healthcare finance and provision

Despite the intense debates over state or private sector dominance in healthcare finance and provision, there are no clear winners. Failed models exist on either end of the ideological spectrum and no country in the world has one that is purely public or purely private. Neither does a perfect public–private mix exist; all solutions are, at best, partial. The important questions are whether or not the political choices made are affordable, sustainable and equitable. When ideology meets reality, it boils down to what trade-offs different societies at different stages of economic development are willing to make.

Two horsemen of the Apocalypse

Throughout the war‐ and disease‐ridden history of our world, more have died from pathogens than have perished by the sword. Both kinds of war – one seen and one unseen – threaten our very existence. Yet we seem to have learned nothing from our experience on both fronts. What chance is there that our species will survive into the next millennium, as microbes almost certainly will?