A Public Health Stranger in the Land of Medical Care
Wednesday, February 3, 2010
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: )
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.
Sunday, September 20, 2009
I don’t need to know if you are sick. Or do I? How about if you have a contagious illness? Perhaps H1N1?
Fortunately, the latest pandemic has not been as fatal as we had feared. While tragedy has struck some families, the death rate is about the same as or less than seasonal flu. Most of those who have perished had prior illnesses or conditions that left them susceptible to opportunistic infections like H1N1.
In the Ithaca community, tragedy struck a Cornell senior who became the third college student to die from H1N1 in the US. We do not know if any prior conditions contributed to his death. Yet, headlines in the Cornell Daily Sun this week read:
Hospital Says It Has Not Discussed Whether Any Underlying Condition Contributed to H1N1 Death
The laws are clear: patient privacy is secure and protected. Only the patient or the family has the right to grant access to health information. Even when the climate of fear permeates the community, our culture and laws value and protect the individual right to privacy. For that we should be thankful. For now.
What about the next epidemic? When the extent of the disease is more widespread, the fatality rates are higher, and underlying conditions are an obvious risk factor? What can we learn from the current epidemic? Shall we do anything different? Dare say, shall we suspend the laws and culture of privacy, for example? They do that in many other parts of the world in order to protect the public's health.
Do I need to know if you are sick? Or did you have an underlying condition, or not? Is the greater responsibility to protect the community or the individual right to privacy?
Stay tuned. The next epidemic is…..
Meanwhile, here is my highly recommended reading for this subject: The Last Town on Earth by Thomas Mullen; a novel about the morality issues of isolation, quarantine, and fear surrounding the deadly 1918 flu pandemic.