If you are an IC student or a college student at most any US college, consider this when you prepare to take your final exam:

You cannot enter the room until 10 minutes before the exam begins.

You will sit in assigned numbered seats.

You are in a room with 200-600 students from many different classes.

You must leave your backpacks outside of the exam room (in an unsecured open area).

You cannot leave the exam room for the first hour of the exam.

You must stay for the entire exam time (2-3 hours) or until the invigilators release you.

If you need to use the toilet during the exam, you will be escorted by an invigilator.

If you are a faculty member who is designated as the chief invigilator, you must read instructions from a prepared laminated sheet that is presented to you by the staff assistant assigned to the exam time.  As chief invigilator, you are to supervise the proctoring of the exam by other invigilators. In some final exam sessions, invigilators are not allowed to read, grade papers, or leave the room other than to escort students to the toilet (or use it themselves).  Of course, no food allowed.

Such were the rules that the students and I followed during an exam this week at the Nanyang Technological University in Singapore where I teach a class of 18 graduate students in Health Communication. I dutifully followed the instructions since I only skimmed the email that listed them all.

I was fortunate that the Chief Invigilator, whom I had never met before, turned out to be a friendly young faculty member who taught engineering. He misdiagnosed my accent and guessed that my geographical home was Australia.  But once he found out I was from New York, he beamed. He told me he was going to spend 4-6 days in New York City and asked me if there was enough to do there for that much time. I suggested 4-6 weeks at least.

So for the next 3 hours, myself and 9 other invigilators (all male) watched, walked, sat, and patiently waited (except one professor did sit down in an empty exam seat and slept for about an hour) for something to happen.  It did. Students needed to use the toilet, mostly women at first. Dutifully, the male invigilators followed the women out of the freezing ice-cold exam room out into the hot humid density of Singapore air to the ladies toilet. No, we did not go inside with them.  As far as I could tell, no cheating occurred. Thankfully.

The Singaporeans love air conditioning, or “aircon” as they say. They like it very very cold. It’s so cold that often when I leave my office, classroom, or taxis, my spectacles fog up and leave me temporarily blinded. This is a consistent concern for those of us who care about the environment and is also a reason that many of us carry sweaters or shawls around whenever we expect to spend time indoors. It was freezing in this exam room.

Back to the invigilation. At first, it was boring, really boring. So boring that I had to make things up to do. I decided to count the number of students in the room and to visually assess whether I thought they were overweight or not (this is the public health connection to this post for those of you who were waiting).  Of 178 students in the room, I counted a total of 10 (at most) who I thought were overweight.  I thought that was a remarkable (though not publishable) finding.  While overweight issues are considered a pandemic by the WHO, it was not so evident in this classroom.

Finally, we approached the end of the 3 hour exam. The Chief Invigilator gave a 15 minute warning and at exactly the prescribed time, students were told to put their writing utensils away, tie their exam books together with string (provided) and turn them into the invigilator. I brought my collection to the Chief Invigilator who verified and signed off that there were indeed were 18 exams. I was then asked to take an additional thicker piece like shoestring and tie all 18 exams together.  It was over and we took a class picture.

All these rules are intended to provide a fair playing field for the students.  I must admit that I could become accustomed to the reliability and consistency of this approach.  The rules are clear, followed in every exam, in every class. However, not all exams are created equal and not all courses might require an exam, but every class (except the lucky art courses) are required to have an exam of at least 30%.

I wonder if I can bring these procedures back to Ithaca.

I finally gave in and saw a health provider for my painful upper back. It felt like a bad stiff neck that normally would go away in a couple of days. Only it didn’t go away.

I made an appointment with an orthopedist. He had a tiny two room office in a fancy medical center complex. There was no examining table in the room only a bench. He spent about 3 minutes asking me questions and said I needed an x-ray, which I got immediately by going down the hall to an imaging clinic.  I waited for the results and they gave me the x-rays to take back to the doctor.

Back in his office, the doctor said that my problem was inflammation. He recommended an injection of shincort and a course of the medication celebrex. I  had never heard of shincort and asked him if it was like cortisone. He said it was a new and improved version. I am never eager to get invasive treatments, but I was in pain and desperate to heal (I signed up for a 168km bike ride at the end of the month) so I agreed to the shot as well as the celebrex.  He said I would see improvement in 3 days.

Before leaving his office, I paid the bill, which amounted to $350 US dollars. I do have insurance but I am not sure what they will pay given that this is Singapore. The bill included no diagnosis and no codes which are usually required by my insurer.

I was no better after 3 days so I decided to find a physical therapist. I’ve had mostly positive experiences with PTs in the US (some of whom are my colleagues at the College). They usually give me ultra sound, nerve stimulation, and exercises.  Here they are called physiotherapists. They are quite common but I could find none in the vicinity in which I live.  So I picked one based its website and on the ease at which I could get there (about 45 minutes on the bus/train).

In a few days I was a patient at a clinic where Sylvia examined me.  I told her the diagnosis the doctor provided but she didn’t fully agree. She asked me to lie face down on the examining table and started massaging and pressing my neck area. It was painful, but she said the massage would help and I told her to proceed.

After 10 minutes, she checked my next tightness and pain. It was less tight, but not good enough for Sylvia, so she pressed more. After 4 times of massaging and checking, she said that was all my neck could take in one session. She gave me a heating pad for 10 minutes and told me to return in a few days.  When I left the office, I could actually move my neck to the right without pain for the first time in a month.

Every day, my neck improved a bit more. I returned to Sylvia for another treatment and it improved further. I was a happy and recovering patient. By the way, each treatment cost about $56 and I don’t know what insurance will cover.  Most of all, I liked the hands on treatment – no machines- and I felt better.

I wanted to learn more about Singapore’s health system, but I didn’t think I would do it from a patient’s perspective.  In 2000,  Singapore’s health system was ranked 6^th best in the world by the World Health Organization while the US was 37^th. Check out (http://www.photius.com/rankings/healthranks.html) or for a rock’n’roll version:http://www.youtube.com/watch?v=yVgOl3cETb4

 I can move my neck but I hope I can ride my bike for 168km.

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.