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Public Health Spaces

A Public Health Stranger in the Land of Medical Care

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Posted by Stewart Auyash at 7:27PM   |  21 comments
Equator Picture

Since the beginning of January, I have been living in Singapore. It is almost exactly halfway around the globe from my home in Ithaca. The plane from Newark that brought me here traveled due north to the North Pole, then due south to Singapore.   It is a mere 85 miles north of the equator. Ithaca, it is not.

If you twirl a globe or look at a world map you will notice that the equator traverses mostly water. Going west from Singapore, it crosses Maldives then Somalia, Kenya, Uganda, Congo, Sao Tome and Principe, and Gabon in sub-Saharan Africa .  It cuts across the Amazon in northern Brazil, Colombia, and Ecuador in South America. From there, it’s a long ocean passage west to Kiribati and Indonesia, with Singapore nearby.

This geographic location made me think about the health issues of people who live near the equator, where the weather is hot and sticky in some places, hot and dry in others, but always hot. Images of the equator conjure worries of insects with malaria and dengue fever,  jungles with snakes and spiders, or deserts with scorpion and drought.  The amount of sunlight and darkness hardly changes at all during the year at the equator.

Of the countries listed above through which the equator passes directly, most are poor with poor health data. For example, the life expectancy of Somalis is about 35 years, about 145 children out of 1000 die before the age of 5, and  they spend an average of $18 per person each year on health expenditures (of course it is hard to spend when one does not have). Ecuador, along with Brazil, have the most healthy overall populations on the Equator.  Ecuadorans live to about 73 years old, 24 children out of 1000 children die before the age of 5, and they spend about $297 per person each year on health expenditures.  The other  countries are somewhere in between according to the data from the WHO (http://www.who.int).

Singapore is quite a contrast. The average life expectancy is about 81 and only about 3 children out of 1000 die before the age of 5. These are among the best statistics in the world, significantly higher than the US even though Singapore spends only $1228 per person each year on health expenditures compared to about $6700 for the USA.

To explain this contrast could take awhile, but I will try to summarize here in two words: public health. Of course, it is more complicated than that. Singapore is a relatively new country forming in 1965 after a failed merger with Malaysia. (For an interest recent perspective on the current state of the country, try reading this piece from National Geographic:  http://ngm.nationalgeographic.com/2010/01/singapore/jacobson-text) 

Singapore is also a country that carefully controls its borders,  has low rates of unemployment and crime, high rates of home and apartment ownership in safe neighborhoods, integrates government ownership with private ownership of industry, and provides quality education. Most of which are strong determinants of health. The water is safe to drink and the island is malaria free (though dengue fever is a concern). To some, this has come at some cost such as the bulldozing of small (and less healthy) villages, severe criminal penalties for illegal drug use and trafficking, very high taxes on alcohol, and a government Health Promotions Board that enforces bans on smoking and spitting. It’s rare to walk more than a block without seeing some evidence of a health marketing campaign.  Yet from a public health perspective, the results are remarkable. 

Now that I am a resident, stay tuned for more comments about life and health in this part of the world.


21 Comments

hi there, i am a singaporean and i happened to come across your blog. It is indeed surprising that countries along the equator have pretty bad health care but not singapore.

i feel the reason is mainly due to the small size of the country which makes controlling diseases and maintaining high level of health care standards easier.



I agree that size makes a difference. Singapore has other geographic advantages: It is an island that can control its borders easily and it sits at the tip of the Straits of Melacca where many oil and cargo ships pass through and stop.

Thanks for your comment.

It is always, always interesting to have an alternative perspective on Singapore. Having stayed here all my life (almost divulged my age there, the horror!), I can scarcely imagine a world where I actually would not feel safe strolling out at 2:30am in the morning to get some roti prata - fried dough - much less imagine a world without the health safety signs, warnings to litterbugs; indeed, thermometer-wielding masked men in times of medical duress.

That said, a very important takeaway from the insightful National Geographic article is that everything is planned. And the only trade off here is that between pragmatism and.. I don't even know the antonym for it. Spoken like a true blue Singaporean.

Seriously though, it is undeniable that bureaucracy has reached unequaled heights here, and proliferate continuously unfettered. This means that all those tiresome administration is streamlined, but also that the big guy knows what you eat say buy write drive.

I for one, am used to cheap medical attention at the polyclinics, affordable (quoting, not my opinion) education, equal (or at least decently disguised unfairness) employment opportunities, good rads clean malls more malls even more malls, parks conjured like magic, overhead bridges, and yes. MediShield and MediSave, the institutionalised compulsory personal savings specifically for medical uses.

Pardon my lack of wordly knowledge, but how is citizenship different in your country, on a daily, medical, educational, social, sans-signboards-stating-fines basis?

As a Singaporean, I find that we often take Singapore's good public health for granted. We complain (it's a national hobby) about everything, including the long queues at the polyclinics (public clinics that offer subsidised consultations and medicine), or how we have to get to these polyclinics really early to miss the crowds, and also the long waits we have to endure at hospitals.

Compared to other many countries, at least we have clean, sanitised healthcare facilities. It's no wonder then that people from around the region, especially the Indonesians, often come to Singapore for their medical procedures.

I was speaking to a German friend recently, and she was telling me how she had to take many injections just so she could step in to India. I can't remember the number now, but I believe it was definitely more than 5. Correct me if I'm wrong, but I don't think travellers required to take so many (or any at all) jabs to Singapore. The general health levels in Singapore makes me glad that I live in Singapore.

Singapore's healthcare system is one of the reasons why I'm glad to be born here.

Given that our only natural resource is people, it is in the government's best interest to keep us healthy and therefore productive.

I live and have been raised in Singapore and agree that Singapore's public health standard is particularly high. Even with all of Singapore's strict rules and authoritative ways, the government does indeed look after her own citizens. There are programs such as medisave and medicare that help citizens afford public health care and hospitalisation. Furthermore there is a Central Provident Fund that helps Singaporeans who have worked in Singapore have money to fall back on for retirement or when purchasing property. These systems work in a way such that the government takes money out of an employee's pay as well as an employer having to contribute a certain amount and places it into an account that can only be taken out at a certain age (amidst retirement) or when certain requirements call for it. Thus, it makes sure that Singaporeans have some money to fall back on and not be left penniless.

I agree with Zhang Mei's point that since Singapore is a relatively small country, it does help that it allows for a tighter control over her citizens. However, I feel that with the way Singapore is run, it makes sure that citizens are brought up with a standard cleanliness of personal hygiene, not just in terms of school education, but also through vast mediums of government campaigns to educate the mass public.

I live and have been raised in Singapore and agree that Singapore's public health standard is particularly high. Even with all of Singapore's strict rules and authoritative ways, the government does indeed look after her own citizens. There are programs such as medisave and medicare that help citizens afford public health care and hospitalisation. Furthermore there is a Central Provident Fund that helps Singaporeans who have worked in Singapore have money to fall back on for retirement or when purchasing property. These systems work in a way such that the government takes money out of an employee's pay as well as an employer having to contribute a certain amount and places it into an account that can only be taken out at a certain age (amidst retirement) or when certain requirements call for it. Thus, it makes sure that Singaporeans have some money to fall back on and not be left penniless.

I agree with Zhang Mei's point that since Singapore is a relatively small country, it does help that it allows for a tighter control over her citizens. However, I feel that with the way Singapore is run, it makes sure that citizens are brought up with a standard cleanliness of personal hygiene, not just in terms of school education, but also through vast mediums of government campaigns to educate the mass public.

Yes, if there is something I appreciate the most about Singapore it's our health care system.

I can fall sick (not that I want to but if it happens) without worry about having to track 10km into the town for a doctor as 24-hr clinics are available. Such accessibility is often taken for granted by pampered locals.

Apart from the size of this island, kudos to the government for having the great sense and foresight in setting up a Medisave account in the 80s for each citizen. They probably realised that not everyone can be relied on to take care of themselves prudently and financially.

It's good to save up for a rainy day, because in the tropics, monsoons happen.

I am a senior graduate student (if you get my drift) at Western Michigan, I am reviewing data on alcoholic abuse in the North American Indian population, I have been to Singapore and number of times, as well as many other equatorial counties. My experience is that the further you go away from the equator the higher the probability for alcohol abuse. I think the a primary factor, maybe the historic culture, driven by longer nights in the winter.

Never the less, poverty does not equal poorer health. The United States spends more than any other country in the world (50% of all medical cost globally are spent in the US) yet we are ranked 30th for overall health based on a combined index that considers life expectancy, general diseases, like heart, lung, obesity, diabetes, etc.

Cultural behavior is far more of a determinant, Singaporeans are a good example, they maintain a good work life balance, have a vibrant economy, have a highly educated work forces and strong family values. These are all direct contributors to a healthly culture and population. Good luck with your research.

Actually, i never realize this. I better bookmark it. Thanks!

http://athleanx.com

I find it extremely interesting that equatorial countries seem to be in poor health, with the exception of Singapore. There are many possible causes for this: the heat, the insects, the drought, or even just the fact that they are more densely populated and not as developed as other countries in the world. It could also be a total coincidence. However, it is clear that Singapore is the exception to the rule. Not only is the health of Singapore superior to other countries along the equator, it is superior to most countries in the world. Singapore has the #6 best healthcare in the world and spends only $1228 per person, a strong contrast to #37 – the United States – who spends nearly six times as much. It is possible that the relative size and geographic attributes of Singapore, among other things, have a positive effect on health there. In comparison, I think that as a developed country, the United States tends to focus too much on finding a cure for diseases rather than preventing them. Other than vaccinations, we do not put a large emphasis on public health and prevention, which makes me think that perhaps that is where Singapore is getting it right. As Professor Auyash said, “It’s rare to walk more than a block without seeing some evidence of a health marketing campaign.” It is evident that the Singaporean government looks out for the health of its people, something that has been extremely lacking in America for a long time. In relation to the Wilkinson and Picket book, it is likely that people in Singapore are also healthier because they don’t have to worry as much about what would happen to them if they did get sick. In America, it is the opposite: you have to constantly be worried and save money just in case something happens – it is enough to actually make you sick!

As Singapore stands out as the health champion along the equator it is interesting to see how they compare with the United States. As you mentioned in a previous post, Singapore was ranked 6th for best health care system while the United States fell much lower at 37th. I was surprised to see how each country spends their money with Singapore spending $1,228 per person annually and the United States significantly higher at $6,200. Singapore proves that good health does not necessarily cost more. Given the evident signs of public health that you were constantly surrounded by, Larry Gordon and David Hemenway would see Singapore as the perfect model for societies that successfully invest in preventative public health measures that improve the overall country health.

Singapore is near other countries with much lower life expectancies, yet has an average life expectancy of 81.How can this be? If Singapore is also near the equator and faces scorching temperatures as well, whereas other nearby countries have life expectancies rates of 35 years?

To bring it back home to the US before I go on- it reigns a little bit too familiar. We are nowhere near the equator yet inequality and socioeconomic status gaps exist in varying forms depending on the corner you turn. US citizens generally don’t face scorching temperatures, or rare changes in the amount of sunlight and darkness and we’re not very likely to contract malaria.

However, we do face high unemployment rates, poverty, increasing costs of health care, an increasing number of people who lack health insurance and homelessness. So, how does a country such as Singapore reign over us when Singapore spends only $1128 per person each year on health expenditures compared to about $6,700 for the USA?

The answer lies within where Stewart stated that Singapore has safe neighborhoods, quality education and low rates of unemployment. If every area of the United States or country elsewhere had safe neighborhoods, quality education and low rates of unemployment there would be less of a divide concerning equality amongst its citizens. High employment rates lead to lower stress levels. Lower stress levels lead to a lower likelihood of being obese and developing chronic diseases such as heart disease. Theoretically those reasons right there would automatically decrease funds spent on health care. Safe neighborhoods increase the likelihood of one walking outside, allowing their kids to play outside and less physical anxiety concerning safety. Singapore is also malaria free, which was obviously not always the case. Public health, education and awareness played an enormous roll in eradicating Malaria. Thus I am not surprised at Singapore’s healthy statistics, but impressed, they seemed to have it figured out.

Singapore is a reminder to the US that you don’t need to spend outrageous amounts of money on health expenditures. The United States does have an excellent public health system I mean, look at our water filtration system, amazing. However, not all neighborhoods are safe, lifestyle diseases are causing the amount we spend on health care to increase, we have high stress levels and our inequality levels from person to person are ridiculous. Possibly the answer to improving our health system stems from taking a look at individuals as a whole vs. writing a prescription to lower cholesterol.

The National Geographic article really put Singapore’s transformation into perspective. The comparison mentioned between Switzerland and Singapore made more sense that I had ever thought of, given that both have very successful health care systems. It is incredible to see how Singapore has progressed since being a colonized territory. Many countries that also lie along the equator, like many African and South American countries, were also previously colonized by European powers yet have struggled to become nearly as successful as Singapore.

It's not too surprising that most countries close to the equator are mostly poor. There are so many issues that work against individuals in these countries, such as climate which might make lands less arable and cause environmental issues, they're underdeveloped, and densely populated. As seen in some of the topics brought up in both the Perlman and Roy book as well as the Wilkinson and Pickett book, countries who are underdeveloped and densely populated don't have the necessary resources to provide good health care.
Singapore on the other hand is densely populated, but their economy is more developed. They have more resources, although it might not be as much as the U.S., to put towards health care for their population.
It's surprising Singapore spends less on health care than the United States, but they are healthier. The U.S. and Singapore populations seem very diverse and both have inequality issues, yet the U.S is worse off. I believe the number one reason for this difference is the U.S has many technological advances in medicine and the main focus is to cure diseases, not to prevent them. The mentality of the U.S. is to worry about the present, don't care about tomorrow, we'll deal with the problem when it arises. Most of the curative procedures used in the U.S. are very costly. Singapore chose the more cost-effective route. They spend a good amount on prevention and reap the benefits later. The policies created by Singapore such as no spitting or strong bans on smoking make a difference. The U.S. is only beginning to create these types of policies, but they're hard to pass and aren't always enforced.
Most individual's in the U.S., and other countries as well, believe our/their system is the right one. Some dismiss other systems when every country could learn something from each other.

It is interesting that the United States spends such a large portion of money on health care, yet by doing so they land #37 on the list of best health care systems; clearly this is not a problem that the government can simply throw money at. Singapore surpasses the US on this list, landing at #6, and does so with much less money involved. So what is the United States doing wrong? Although this is a question with many possible answers, I think the everyday lifestyles of people in the U.S plays a major role in this. As mentioned above, “Singapore has low rates of unemployment and crime, high rates of home and apartment ownership in safe neighborhoods, integrates government ownership with private ownership of industry, and provides quality education.” For years the United States has looked to solve problems with monetary means towards the “big picture”, but not enough is done on the smaller level of healthcare. Also, as noted in the National Geographic article, Singapore has created a model for success “a unique mix of economic empowerment and tightly controlled personal liberties.” It is impressive to see how Singapore has grown and prospered, especially with respect to their health care systems, things that as an admittedly inadvertent ethnocentric American, I would not have expected. Although people in the U.S like to view their country as this “power house” it is interesting to see how far behind we really are a country for being so industrialized.

It is very interesting that countries along the equator seem to have poor health, but when given some thought it makes a lot of sense considering the environmental aspects like humidity and bugs as well as historical and economical factors (many of the countries along the equator have been through a long colonial history, which is detrimental on economics). Even more fascinating is the fact that Singapore stands out as an exception among these countries. Singapore, as earlier stated in this blog, has the #6th best health care in the world, while only spending $1228 per year per person. As a reader we might question, why is Singapore a stand out among other equatorial countries? And like you say in the blog: Public health. Singapore takes preventative measures in health care. You say that you witnessed a multitude of health claims, bans on smoking and spitting, high taxes on alcohol, and extreme penalties for illegal drug use—all enforcements that promote community health. I think that government control has a lot to do with Singapore’s good health. The government has been recently built up and has specific goals, health being one of them. In order for other countries to promote health in the same fashion, a systematic shift is necessary. Currently, the U.S. wouldn’t be able to pass a law banning smoking because too much opposition pertaining to the First Amendment would arise. I do think that other countries can adopt Singapore’s heavy focus on public health marketing. The more people are informed the better decisions they are prepared to make.

It wasn’t until after reading this blog that I ever considered the possible health concerns facing many of the equatorial countries in regards to their constant climate. Living in the North East, central New York for that matter, for my entire life, I am used to summer turing into fall, fall becoming winter, winter turing into spring and all the while having a runny nose, itchy eyes and my allergies simply being uncontrollable at times. Having to be concerned with malaria, jungles with snakes and spiders, deserts with scorpions or even drought makes my allergy problems seem like a paper cut compared to what people living in Columbia, Kenya, Somalia, Ecuador or the Congo face. I was not surprised by Singapore's high health ratings due to stories I’ve heard about how clean the streets are from friends who have visited and health rating comparisons in other classes. However, I was very surprised to see some of the lowest health ratings of the countries be so heavily concentrated near the the equator.
I would have to agree with the other bloggers who equated size to being a large contributing factor as to how Singapore can keep such excellent health ratings. The smaller the country the easier it is for public health officials to prevent disease rather than constantly provide tertiary care. It also helps that they can control their borders. From an International Health approach, this eliminates the transaction and interaction of millions of people who carry diseases all over the world.
In the Spirit Level Level by Wilkinson and Pickett, they argue that inequality contributes to individuals poor health and bad habits. The book states greater equality makes societies stronger and healthier. The book goes on to say that within each country, people’s health and happiness are related to their incomes. Singapore has low rates of unemployment that could help keep the gap smaller. “Differences in the quality of medical care have less effect on people’s life expectancy than social differences in their risks of getting some life-threatening disease int he first place.”
Stewart stated how rare it is to walk down the street and not see a public health campaign. After being in New Zealand for five months, I can asset to seeing a much larger public health push than in America. Here in America, we may have a billboard here or there but in may other countries, New Zealand especially, it is not just the number of posters and advertisements around the country but the specific and graphic context that draws the reader in. Many of them really catch your attention and are quite blunt in their message or tug at your heart stings. On cable television in NZ, I would always see a commercial about a mother forgetting to replace the batteries in the smoke detectors and her daughter dying from it. There was another commercial that actually showed someone dying the passenger seat of their friends car who was drunk driving and drove off a cliff! Images like that would never be allowed in America but as disturbing as they were, they got the point across very clearly.

There are many factors that influence the health of a community and a country. This only seems reasonable, being as an individual’s health is comprised of a variety of factors, including physical, mental, emotional, and environmental, among others. According to Shewanee Howard, guest speaker for Professor Auyash’s International Health Issues class on September 27th, 2010, the factors affecting the health of an individual include poverty, race, ethnicity, gender, socioeconomic status, cultural and social capital, and history. Many, if not most of these factors, can be influenced by how equal a society is, whether related to income, social, or another aspect of equality. According to Richard Wilkinson and Kate Pickett in their book, The Spirit Level: Why Greater Equality Makes Societies Stronger, it matters not how poor a country is, but instead of great difference is between the richest and the poorest individuals of that nation. They claim that “the problems in rich countries are not caused by the society not being rich enough…but the scale of material differences between people within each society being too big. What matters is where we stand in relation to others in our own society” (Wilkinson & Pickett, pg. 25).
I find it interesting that Singapore has a history full of active attempts to create racially balanced housing systems and minority representation in political affairs. Eunice Chua addresses these actions in his article “Living Without Colorblindness: Comparing the US and Singapore’s Approach to Racial Equality” (http://works.bepress.com/cgi/viewcontent.cgi?article=1000&context=eunice_chua). The Constitution of the Republic of Singapore reflects these efforts:
152. (1) It shall be the responsibility of the Government constantly to care for the interests of the racial and religious minorities in Singapore.
(2) The Government shall exercise its functions in such a manner as to recognize the special position of the Malays, who are the indigenous people of Singapore, and accordingly it shall be the responsibility of the Government to protect, safeguard, support, foster and promote their political, educational, religious, economic, social and cultural interests and the Malay language.
Two areas in particular where Singapore has actively pursued these efforts are that of housing and of elections. According to Chua, the Government of Singapore encouraged a resettlement project under the direction of the Housing Development Board (“HDB”) to adhere to an ethnic quota system. In every “New Town” and block of HDB flats, an occupancy limit was assigned to each of the four major ethnic groups of Singapore in order to increase ethnic balance in the majority of the population. Also, in 1998, the Government of Singapore introduced the Group Representative Constituency (“GRC”) scheme, hoping to encourage multi-racial political representation. This most affects the electoral process; instead of candidates running individually for a seat in Parliament, they must run in teams where at least one individual is from a minority community. At least three-fifths of the total number of GRCs are designated to have at least one of the candidates belonging to a Malay community. While these efforts have been met with some opposition, I am contemplating their role in the health of Singaporeans and the country. If this information applies findings of Wilkinson and Pickett, this would also help to explain why Singapore is currently the sixth best health system in the world.

It is interesting to me that Singapore is doing this well, especially compared to its surrounding countries and how close it is to the Equator which means a constant heated climate. I guess the fact that the country plays a key role in international trade and finance has something to do with its quality programs. How much control does America have over Singapore's economy? Does Singapore produce what it consumes or is it an export-oriented country?

Ive always wondered about Singapore- I heard everything was real stringent there- like if you spit gum on the floor they would cut your tongue off is this all true?



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