PUBLIC HFALTH CONFERENCE AND STUDI TOUR

Sponsored by the

:,t WORLD HEAIa'H ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC I in Collaboration with

THE GOVEIUftIENl'S OF SINGAPORE AND THE FEDERATION OF MAlAYA

SINGAPORE 21-25 August 1960

FEDERATION OF MAlAYA 25 August - 2 September 1960

FINAL REfORT

World Health Organization Western Pacific Regional. Of'fice Manila, .Philippines September 1960 CONTENrS

PART I

1. GENERAL DESCRIPl'ION OF THE CONFERENCE AND STUDY TOlR • •• 1

1.1 (lroigin ••••••.•••••••.••••••••••• "" " ••••••••• "" • 1 1.2 Preliminary Planning and OVerall Responsibility •• 1

2. .... " .. " ." ... " ... " " " " ... " .. " .. " ... " " ." ..... 1 ORGANIZATION AND ADMINISTRATION •••••••••••••••••••••••• 2

3.1 Location of the Conference and Study Tour ." ." ... 2 3.2 Facilities and Services Provided by the Host Governments 2 .... " " " " " " " " " " " " " " " " " " " " " " " " " " " 3.3 Language 2 " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " . THE CONFERENCE AND STtIDy TOUR .PROGlWtlE AND PROCEDURE •• 2

t Opening CeremOll¥ 2 4.1 " " " " " " " " " " " " . " " " " " " " " " " " " " " " " " " 4.2 Background Information •.•••••••••••••••••••.•••• 2 -- 4.3 Working .PJ:-ocedtlre " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " 2

PART n

3 ." ." " " " " " " " " " " " " " " " " " " " " " " " "" " " " " " " " " " " "

PART nI

1 LIST OF "PARTICIPANTS ." " " " " " " " " " " " " " " " " " " " " " " " " " 55

n ITINERARY " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " " "" 58 In LIST OF INSTITUTIONS AND PROJECTS VISITED ••••••• 65 •\

-i- CONTENTS

ANNEXES (cont Id.) It IV ADDBESS OF MJNISTER OF HEALTH, STATE OF smGAFORE, AT OPENmG CEREMONY •••••••••••••••••• 68

v ADDRESS OF DR. L. FLORIO, IEADER OF THE GROUP •••

VI RERlRT BY DR. C. MARCUS, DlRECTOR OF NE:DICAL SERVICES, SmGAFORE, ON MEDICAL AND HEALTH DEVEI£)1?!(ENT IN SINGAPORE •••••• ,,""""""""""""""""" 70

vn ADDRESS OF MINISTER OF HEALTH AND SOOIAL WELFARE, FEDERATION OF MlIAYA,AT OFENmG CEREMONY •••••••• 77

VIII OPENmG ADDRESS OF DR. TEN YOON FONG, CO-LEADER •• 79

]X ADDRESS OF HIS HIGHNESS THE SULTAN OF KEDAH 81 ." " " . X REMARKS BY DR. K. KANAGARATNAM, co-r.EADER, AT CIDSmG SESSIQ{ " " " " " " " " " " "" " " "" " " " " " " " " " "" "" 83

XI SUMMARY OF S5EX:H OF 'l1iE MINISTER OF REAL'm AND SOCrAL WELFARE, FEDERATION OF MA.IAYA., AT THE ClDS ING CEREMONY " " " " " " " " " " " " " " " " " " " " " " " " " " " 84 XII REPORT BY THE T.FAPER OF THE GROUP, DR. L. FLORIO. 85

-ii- aRT I

1. GENERAL DESCRIPrION OF THE CONFERE~E AND STtIDY Tom

1.1 Origin

The WHO Regional Committee for the Western Facific at its ninth session and the Twelfth World Health Assemb~ approved the organization of a pub1ic­ health conference and stUC\Y tour in 1960. The description ot this project was:

11 • • • • • • • • • • •• to inTite senior health administrators frau ~mber States represented on the Regional COmmittee, and from their territories, to participate in a public-health conference and study tour in 1960, covering two countries and lasting about fourteen clqs. Such a conference and study tour should encourage local health workers to evaluate their progress and stimulate interest in health among local officials and the general population".l

1.2 Preliminary .P.l.anning and CNerall Responsibility

Operational responsibility tor the conference and study tour was Tested in the Regional Public-Health Administrator (Dr. C. Y. Shu) at the WHO Regional Office tor the Western Pacific. A preparatory committee was established at the Regional Office consisting of two Public-Health Admiidstrators, the Education and Training Adviser, two Administration and Finance Officers, the Administrative Services Officer, and the tranalator. This cammittee worked closely with Dr. W. W. Yung, Area Representative, Singapore.

2. PARTICIPANTS

lhvitations were sent to all countries and territories in the Western Pacific Region and seventeen participants were nominated. The Host Governments each nominated two participants. (For full list see Annex I).

At a meeting held in Manila 011 Friday, 19 August, the group elected Dr. IJ.oyd Florio (thited states of America), as the leader of the group and Dr. C. Marcus (Singapore). and Dr. Ten Yoon Fong (Federation ot ~a) as co-leaders. Later, in the Federation of Malaya, Dr. K. KanagaratD8Jll (Singapore) acted as a co-leader in place of Dr. Marcus. The leader designated Dr. Dickie (Sarawale), Dr. Kranendonk {Netberlands New Guinea}, Dr. re-cuu Truong (Viet Ham) and Dr. Nolasco (HlUippines) as rapporteurs. Dr. van de Linde (Hong Kong) was later designated as the tifth rapporteur.

~ •

1 Off. Rec. Wld Hlth Org. 89, 2lf7 - 2 -

3. ORGANIZATION AND ADlffiUSTRATION

3.1 Location of the Conference and Study Tour The conference and stuqy tour took place in Singapore and the Federation of Mal8¥a. (See Annex II for detailed itinerar,y)

3.2 Facilities and Services Provided by the Host Governments The Governments of the State of Singapore and of the Federation of Malaya graciously agreed to be the hosts. They provided conference space, clerical assistance, transportation within cities and arranged for the visits made by the group to institutions and projects. A list of the centres visited appears in Annex III.

3.3 Language English and French were used during the conference and stud,y tour.

4. THE COOFERENCE AND STUDY TOtE. HtOGRAMME AND PROCEDURE

4.1 Opening Ceremony The conference and study tour was opened in Singapore on J'.bnd8¥, ;. 22 August, by the Minister for Health, Inche Ahmad bin IbrahimJ in Kuala Lumpur Federation of Mal8¥a on Frid8¥, 26 August by the Minister of Health and Social Welfare, the Honourable Ong Yoke Lin; and in JUra, Federation of Mal.8¥a on Monday, 29 August by His Highness, the Sultan of Kedah. It was closed in Kuala IAunpur, Federation of Malaya on Friday, 2 Sept.ember by the Minister of Health and Social. Welfare, the Honourable Ong Yoke Lin. 4.2 Background Information The institutions and projects visited, including the lJHO Epidemiological Intelligence Station in Singapore and the WHO-assisted projeots in both Singapore and the Federation of Mal8¥a, all provided background information 10 advance. These were translated or extracted into French. In addition, other literature was distributed during the visit.

4.3 WOrking Procedure

The group upon arrival at an institution or project was received by the officer-in-charge and his assistants who conducted the participants on a tour of the establishment. At the end of the visit or at the end of the d8¥, additional information was supplied and views exchanged during the discussions. The rapporteurs were responsible for the record. ." - 3 - PART n

MPFORTEURS' REPORTS

1. 22 August 1960, Singapore

1.1 Opening Meeting

The opening meeting of the Public Health Conference and stud,y Tour organized by the Ministry of Health, Singapore, was held in the Conference Hall in the Institute of Pathology at 9 a.m.

The Minister for Health, Inche Ahmad bin Ibrahim honoured the meeting by delivering the arficial opening address. In his speech the Minister 1I81comed the participants fran fifteen countries and territories in the Western Pacific Region and said that it was a privilege to act as host to them. He said that a heavy programme of visits to medical institutions, and discussions had been arranged, and he hoped that the oorticiiJ.W1.. s w.)uld bA given an idea of the medical and health developnentsin Singapore. lie gave a brief account of the health problems in the State - tuberculosis, ete. and the preventive measures being planned to canbat them. Curative services and the training programme were also specially mentioned. He paid tribute to the help received fran the World Health Organization, especially in the field of nurse training and the postgraduate training of' doctors for the Diploma in Public Health. He stressed the fact that his GDrernment intended to press ahead with the training of local doctors and tile improvement of the standards of medical education. But until sufficient J.ocal doctors become available, his Government intended to recruit doctors from Japan, Israel and Commonwealth Countries, to allow the medical services to develop, and to allow local doctors to get post-graduate training abroad. (See Annex [fY for full text)

The Director of Medical Services, Dr. C. Marcus, then presented a report on the developnent of the medical and health services since their inception. He outlined the history of the developnent of Western medicine since tb! nineteenth century. The growth of' the Ministry of Heal th, the integration of the City Council Medical Service, and the DepartDe nt of Chemistry into the Ministry, were also explained. Dr. Marcus gave the meeting interesting statisti~al facts about the existing facilities - curative and preventive and about the training facilities available in Singapore for doctors, nurses, midwives and other auxiliary medical staff. He touched on the hospital facilities available for general medical and surgical work, for maternal and child welfare work, for obstetrics and gynaecOlogy and for specialised diseases such as tuberculosis.

The campa:l.gn against tuberculosis which is being planned, with the help of Colombo Plan aid from Australian experts was outlined by the Director and the work done by the Singapore Anti-Tuberculosis Association (SATA) was also mentioned. Leprosy was also receiving attention, and the treatment of patients suffering from mental disorders, in Woodbridge Hospital, and in psychiatric out-patient clinics, was developing rapidly. - 4 -

The dental services were described, and the training of dental auxlliaries in the future, also outlined.

Finally, Dr. Marcus touched on the problems of the increasing population in Singapore and the economic and social results which a rapid population increase ineVitably leads to. The principles which the Ministry of Health intended to follow, were stated. (See Annex VIfor full text)

Dr. IJ.oyd Florio, leader of the participants,. in a brief reply explained that they had come, not to advise, but to learn and discuss problems of mutual interest to countries in the WHO Western Pacific Region. He said that, on listening to the speeches made by the Minister and the Director of Medical Services, it was evident that Singapore was already well developed, as regards its medical and health services. But there WJJ:8 still much to be done, and he was glad to hear from the speeches nade, that this was realised by the authorities.

He finished by thanking the Govemment and people of Singapore for theD- welcome and their hospitality.

1.2 Visit to Institute of Health

Following a break for a short inspection of e display in the Inst±tute of Pathology musewn on medical and health developnents, the participants then proceeded to the !natitute of Health where Dr. Kanagaratnam provided them with general information on the functioning of the Institute of Health. Actually, three wings were observed. ; (1) The wing housing the school health service (2) The wing for maternity and child welfare (3) The UUversity Department of Social Medicine and Public Health

1.2.1 School Health Service

This central organization scheme "School Health Serviceft takes care of about 35 000 school children. The physical lay-out was observed including:

A. General

(a) Treatment facilities (about 400 a day) where four consultant health officers on school health are engaged.

(b) Clinical laboratory facilities, handling about fifty specimens a cUv.

(c) Injection room.

(d) Dispensary room. - 5 - B. Also there was observed the documentation section With its central records of aU school chUdren in Singapore examined by this section.

C. School tuberculosis olinic, giving examination for school chUdren, teaohers and also contacts of known infected cases living in the neighbouring area.

D. Sohool dental service where it is aiDe d to provide periodio examination once a year.

E. Publio Health Inspectors' Training School. This school is situated in the same wing and oaters for up to twenty pupU health inspectors from Singapore and neighbouring countries who undergo a nine~nth course of traini ng following two years' field work and on completion of the examination they are awarded the Diploma of Royal Society of Health.

1.2.2 Maternal and Child Health Clinic

The doctor in oharge of the clinio, Dr. Maggie .Lim, conducted the partioipants through the various sections of the olinic and explained the sequence followed by patients, viz.

(a) A central waiting room (b) Records Section which issues cards to patients (c) Sister's room where patients are examined and directed to the appropriate sections of the clinic (d) Doctor's consulting room (e) Treatment room (f) Dispensary (g) Injection room (h) Demonstration room (i) Midwives' supervisors rooms

Dr • .Lim also outlined by way of a map, the position of the 22 full-time and 7 part-time district clinics and explained that the central and district clinics deal with the ante-natal care of' mothers, poat-natal care of mothers and the wlllrare of' infants and chUdren up to seven years after which the children are handed over to the school health service. She also informed the participants that deliveries generally take place in Kandang Kerbau Hospital, and mothers are usually detained for o~ twenty-four hours after which they return home and are attended by the dOmiciliary midwives.

1.2.3 Department of' Social Medicine and Public Health

The Professor of Social Medicine and Public Health, Dr. IJ.oyd DaVies, conducted the party through the University Depart­ ment showing, first the public-health museum. He also outlined the training scheme for undergraduates and showed the participants some research schemes which are being conducted by the department at present. - 6 -

The party was then introduced to Dr. (Mrs.) Danaraj who is responaible for the post-graduate course leading to the Diploma in Public Health, which is a WHo-e.ssisted scheme and has at present eigbt:. students undergoing the course of study. It was not ed that of the eight students, one came from Hong Kong, one from Netherlands New Guinea, one from Korea, three from the Federst ion of Mals.ya and two from Singapore, several of whom were WHO fellows. Finally, Miss Goodwin, who is WHO Nurse Educator assisting in the training of public­ health nurses, gave a brief resume of the course of training she is conducting and introduced her pupils. This project has also the assistance or UNICEF.

1.3 School of Nursing

Atter lunch a visit was paid to the School of Nursing which is run in conjunction with the Singapore General Hospital. The participants were conducted round b,y the Matron and the work in progress in the various lecture rooms and demonstration rooms, was explained by the various tutors. It was noted that of eight tutors of the staff, four are males. student nurses undergo a preliminary training course after which an examinst ion has to be passed before they can proceed to ward work. Some preliminary training school nurses were seen in the kitchen receiving training in the simple cooking of invalid diets. Following the preliminary training school course, the Matron explained that a general course on training lasting three years is given, and on completion of this course an eX.91!!1 nation is set leading to the state Registered Nurse qualification. Nurses are then required to do a further year I s training in midwifery leading to the State Certificate in Midwifery before being eligible for promotion or being permitted to undertake specialised training in tuberculosis nursing, public-health nursing, paediatric nursing, etc. The Singapore qualifications are recognised by the General NurSing Council of the United Kingdom and by Commonwealth Countries.

1.4 Department of Dentistry and Dental School

In the absence of Professor Tickle, the participants were welcomed b,y the Senior Government Dental Officer, Mr. George Paul. It was explained that patients of all ages are attended at this clinic and they are first seen by a Dental Offiner who examines them and directs them to the various sections. II A total of about 350 patients are seen daily. Of' these, many are for alleviation of pain and the extraction of teeth. Those requiring conserva­ tive treatment are generally directed to the School of Dentistry housed in a spacious and airy room containing forty-five dental chairs. Dental students in their final years attend to these patients under the supervision of a staff of five dental officers. Each is therefore responsible for supervision up to a maximum of ten students. A visit was then paid to the various specialised units of the Department including the prosthetic unit and the oral surgery unit. The research department, the museum, the librar.r and the pre-medical unit where students work on dUlTllllies were also seen. Information about the fluoridation scheme was given by a member of the senior teaching staff. Finally, the future of the dental school was discussed, and the participants were informed that it is planned to take in fifty new dental students per annWll. - 7 -

1.5 Institute of Fathology

The Institute of Fathology was next visited, where the participants were shown pathological specimens being prepared, and museum exhibits. It was explained that the Institute deals with all necropsies, with the exception of medico-legal cases. It also teaches medical undergraduates and its awn laboratory technicians, but is not concerned with the teaching of &IV' other technicians. A visit was next paid to the government pathological laboratory housed in the same building which deals with diagnostic pathological work, bacteriology, bio-chem1stry, etc. Finally, the participants held a discussion under the chairmanship of Dr. Ten Yoon Fang of the Federation of Malaya.

1.6 Discussion: Chairman - Dr. Ten Yoon Fong

Dr. Wahab : Question whether in view of the shortage of train­ ing facUities in Brunei, Singapore would take in girls from Brunei for training as midwives at Kandang Kerbau Hospital and whether \tiO would assist in such a scheme.

Dr. Marcus : Singapore accepts candiciatEII from various countries such as Malaya, North Borneo aOO Sarawale and could only allocate places depending on the number of vacancies avallable.

Dr. Shu ; This matter could be arranged between the two Governments and if Singapore found any difficulty, the GovernmEnt could approach WHO for assistance.

Dr. van de Linde , What do you mean by midwife - a trained nurse with a certificate in midwifery or a lower grade?

Dr. Marcus s Both grades are being trained in Singapore #

(1) Midwife's certificate for trained nurses which takes approximately one year;

(2) Midwife training for girls with no previous nurse training which takes appratimately two years.

Dr. Nolasco : What criteria do you use when defining rural areas in Singapore? In the .Philippines, rural areas were areas without good roads, electricity, piped water, etc.

Dr. Marcus s Those parts of Singapore which were previously under the jurisdiction of the City Council were called "City areas" and those outside of this area were called "rural areas". But most of Singapore are, in fact, urban areas in that they have good roads and usually eJ.ec1rid':;y and piped water. - 8 -

Dr. van de Linde : Is it the aim of the Government to have ultimately ~ Grade I midwives and abolish the training of Grade II midwives? Dr. Marcus = No. .. Dr. Kim , What about mothers who do not realise the benefits of modern medicine and do not come to the clinics and also whether it was the intention of Govern­ ment to integrate the various categories of school nurse, public-health nurse, tuberculosis nurse, dental nurse, etc. into one central organization?

Dr. Maggie Lil!l : In reply to the first question, our staff are instructed to advise all pregnant mothers whom they come across to visit the clinics. On the whole, only a small number of pregnant mothers do not come f~ medical care. The majority of them realise the importance of a birth certificate and the necessity of registering a new-born baby.

Dr. Marcus : With respect to the second part of the question, it is planned to regionalise the various health r services within a definite area and to have polyclinics as headquarters from which these services would operate.

Dr. Kim : Are blood tests done for syphilis on pregnant mothers?

Dr. Maggie Lim • Yes. In rural areas it is compulsory for all pregnant mothers to be given a blood test. In the city areas we are trying persuasion to get mothers to have this blood test but ld. thout too much success.

Dr. Kanagaratnam s This compulsory blood test was started five or six years ago and encountered considerable resistance. This has gradually disappeared and something like 12 000 cases were done in 1958 and the positive result was 0.7 in a 1000.

Dr. Nicholson : What are educational standards required for a Grade II midwife?

Dr. Maggie Lim : Standard vn or equivalent. - 9 -

Dr. Kranendonk : Question that though services were free. 300 of the 670 doctors in Singapore are private practitioners. Does the Government intend to bring them into a National Health Scheme?

Dr. Marcus s No.

Dr. Kanagaratnam s The question of a national insurance scheme was examined a few years ago by a canmittee and was fOlmd to be impracticable in Singapore for IDIIll¥ years to cQlDe.

Dr. Florio , In spite of your free services, why do people still go to private practitioners and whether private practitioners have a higher income than government doctors.

Dr. Marcus : The income of a government doctor and a private practitioner who is just starting out 1s almost the same but as the private practitioner gaiDs experience and renown,. his eamings outstrip that of the government doctor.

Dr. Florio : I should like Dr ~ Marcus to cClllllll8nt on the supPlY of medical and para-medical staff in relation to demand.

Dr. Marcus # The greatest shortage lies in fia d DB dical officers, i.e. doctors who see patients in clinics. As mentioned previouslY, we are seeing something like 9000 patients a d~ in our clinics and the average doctor in these clinics sees about 150-200 patients a ~. This type of medical coverage is obviouslY' inadequate. There has also been a drift of doctors to the Federation of Mal~a as Malaya is developing rapidly and there is a great demand for medical. care. There is a temporary shortage of nurses but we w1ll be turning out about 200 nurses a year and this eventually wi1l. fill the gap.

Dr. Kranendonk : Next year you will embark on a tuberculosis control programme. Does the Government envisage a venereal-disease or leprosy control programme?

Dr. Marcus : A. mass X-ray survey will commence in October this year. The venereal-disease problem is not very great in Singapore and I do nat think a mass survey jbr venereal-disease is necessary in Singapore • • On the question of a leprosy control programme, it is a question of having the specialist personnel. It will take some time before we can consider this. - 10 -

Dr. Nolasco Do persons who suffer from minor ailments get admitted into the General Hospital?

Dr. Marcus J No. Admission into the General Hospital is extremely strict and no person will be admitted immediately unless he is an emergenqy case.

Dr. Florio ; What is the average income of a person in Singapore?

Dr. Marcus , The average income for a man, his wife and two children would be about iJ.20/- per month.

Dr. L8-cuu Truong s Question about care of the indigent chronic sick.

Dr. Marcus r Government intends to open a chronic hospital of IBO beds during the year. There are also voluntary organizations run particularly by religious groups who cater for the aged and disabled. This problem here is not acute as, by tradition, the Chinese tend to look after their aged. We are also a nation of young people and the age group over sixty years is about 4%.

Dr. Nolaaco : Are government doctors allowed to do private practice?

Dr. Marcus No. l

The Chairman, Dr. Ten Yoon Fong, then summarised the proceedings and the session ended.

2. 23 August 1960, Singapore

2.1 Ubiversity of MalSla

At B.45 a.m. the group left the Biltmore Hotel and proceeded to the Ubiversity of Malaya. It is located in a nice hilly place of Singapore. ViBitswere paid to different departments of the lniversity establishment; chemistry, laboratory, pqysiology department, baeteriOlogy, parasitology, anatom,v departments and the medical libralY.

Tn the WHO Influenza and Poli~elitis Centre, Dr. Lim stated that a month ago about seventy cases of haemorrhagic fever were registered. Probably this outbreak was going on unnoticed until Dr. Lim was able to trace those seventy cases and with regard to this he is making an epidemiological survey. The symptoms are skin haemorrhage and slight fever but no haemorrhage fran the nose. The thiversity is continuing the activities of the projects of Poliom,yelitis and Influenza centres. He is studying the reports reoeived by the centre from the foreign countries. The countries receiving reports from -ll-

! the centre are Singapore~ Federation of Mal~a~ Hong KOng~ Viet Ham, North Borneo~ Indonesia~ Sarawak~ Brunei~ Cambodia and Laos.

The library was visited. From the ini'ormation furnished by the librar1an~ there are 47 000 books and journals and 800 periodicals. For the first two ye8J1S students of med1cine~ borrowing books from the libraryJ they allow only one week and from the third year up they allow two weeks. Professors and hospital staff are allowed to keep books for a longer period.

The department of anatOUU was then visited and according to the professor there is a shortage of cadavers. Two years ago they were able to have twenty but this year onJ.y seven and for every fourteen students they assign for dissection for limb and for the trunk: ten students.

The group proceeded to the office Of the Registrar and he informed them that the thiversity is offering various courses in medicine J pharmacy J law, dentistry and education. There is an enrolment of 1650 per year for the different colleges ill the thiversity. Among the medical students there are seventy graduatillg every year and of these, ~ goes to the Government and only l~ is going into private practice. Speaking about post-graduate courses, the, are offerillg courses ill Diplcma ill Public Health and ill Public Health Nursing. In a nutshell, the thiversity of Malaya is well established and the different departments are well equipped IIld the teaching staff can be rated as one of the best.

From the thiversity the group proceeded to the General HospitalJ firstJ in the out-patient department which is divided into two sections; one for emergenc.y cases and the other for general services. The first one attended to 300 patients per dq and the general services, 2500 a dq. There is a staft of sixteen ~siciaD8 and a good number of nurses. A visit was also paid to the blood trarulllsion section where it was understood that there was an average of forty blood donors a dq. Also visited was ~slotherapy, 8J111D&sium in the out-patient department with an average of 200 patients a day. From this the group proceeded to the hospital with a capacity of 1200 beds. It consists of a staff of sevent,-two doctors (30 interns), 700 nurses and a number of attendants, telephone operators, cooks, gardeners and so forth. The total number of personnel is 2000. or the 1200 beds, 100 beds are allocated for pay patients. The allowance for subsistence per patient is ~ for private patients and free patient is $1.20. The Govemment appropriates an amount of twelve million dollars. From this twelve million dollars, nine million dollars for the salary of the personnel and the rest are for subsistEnce, medicines and medical supplies. The bed occupanc.y is 92%.

There are a group of buildings in the compound which are divided into blocksJ as follows= Bow,yer Block - 6 buildings Stanley Block - 2 buildings Norris Block - 5 buildings • The group was infonned that these blocks were named atter personnel who died in the Second World War. -12 -

2.2 Discussion' Chairman - Dr. L. Florio

At the conclusion of the tour to the various departments of the General Hospital, a discussion was held.

Dr. Wahab J With regard to the medical records systems .. as Been at the General Hospital he wondered whether training facilities were possible for his medical persor.nel at Brunei.

Dr. Marcus : It is anticipated that a new administered records system will be developed for which WHO assistance will be requested.

Dr. Shu : A WH0-assisted training course in Hospital Records is being held at Penang.

Dr. Nolasco : What is the average time spent on the examination of patients by medical officers at the out-patient department?

Dr. Toh Chiung Hiang = Two minutes.

Dr. Shu s What is the average waiting period of patients of the out-patient department?

Dr. Toh Chiung Hiang J (he to two hours.

Dr. Florio : What is the average cost in medical care?

Dr. Marcus : $25/- for an in-patient care and $1./- tor all attendances at the out-patient depart­ ment.

Dr. Florio : Asked more infonnation on the separate kitchen facilities.

Dr. 1ti.rcus : The aeparate facUities are necessary due to requirements of multi-racial population of Singapore.

Comment: Ml.ss Lau - dietician - gave infcrmation.

Dr. Nolasco : Wished to !mow what is the ratio of nurses to patients at the hospital.

Dr. Marcus : One nurse take s care of 2.5 beds which is on the twenty-four-hour basis. This applies to the General Hospital. - l3 -

Dr. Truong ; What is the ratio of paying and non-~ing patients at the General Hospital and how much the patients are required to share :in the cost of hospital expenditure?

Mr. A. T. lilyers # There are about 11 000 non-p8¥ing and 140 (SecretaryJ ~ing patients. First-class patients pay General Hospital) bed charge of ~25/- a day.and second-classJ f1j/- a day.

Dr. Kranendonk , Notes the increasing number of voluntary donors especially the Chinese for the blood transfusion service which amounts to about 40 000 donors a year.

Dr. Gibson-Hill s This is mainly the result of ten years of exliensive propaganda. lilanwhile, increasing pressure is given on the relatives of patients who receive blood transfusions to act as donors.

Dr. Shu Wished to be informed on the specialist­ consultant fees whether it apPlies to the government or the university consultants.

Dr. Marcus s Government consultants do not receive aqy fees whereas the university specialist-consultants receive ten per cent of the charges made b.Y the General Hospital.

Dr. Nolasco ; He liked to be informed on the occupancy relative to the capacity of the beds in the General Hospital.

Dr. Marcus = Out of the capacity of 1230 beds, occupancy is at an average of 1040.

In the afternoon the group visited the Trafalgar Home and the Woodbridge Hospital after half an hour drive b.Y bus from the centre of the city of Singapore.

2.3 Trafalgar Home

At Trafalgar Home which is reserved solely for the care of leprosy patients in Singapore, the gr 'lp was welcaned by the Medical Superintendent, Dr. P. Oorjitham. At the IDOment there are 744 in-pat1ents, of whom 260 are hospitalised in the main building, whereas the remainder live in quarters SurrolDlding the main building. It was noted that IDOst or the patients were males (566). There are 120 admissions yearly and about 70 discharges. All pat1ents are compulsorily segregated b.Y law at the Trafalgar Settlement, .. whereas discharged patients are followed up at the out-patient clinic • -14-

2.4 ~ridge Hospital The Woodbridge Hospital provides care for the mentally sick. Two thousand beds are available in well-bu1lt wards on an area of about 300 acres. The group was welccmed by the Medical Superintendent, Dr. Yap Meow Fooj .. Medical Otficer, Dr. J.T. Tassin; and the Matron, Miss McMunn. Dr. Yap first introduced to the group the general organisation of the Woodbridge Hospital. There are J psychiatrists, 2 psycholOgists, 22 psychiatric trained nurses, male as well as temales, and 68 nurses in training. He elaborated on the change to more modern treatment. Among others, he mentioned that nery etfort 1.8 being taken to have the building look more oheerful. A.t the oentral dining room about 700 patients are accCllllllOdated. It is aimed to have newJ.¥ adIIIitted patients to stq at the hospital for a period as short as possible, about one month. Attar-care is being provided at tour difterent centres in the town. The group made a tour through the hospital where there was an opportunity to see the central dining room, the tacilities for occupational theraw and the patients t warcls for male and female patiEnts. The group also had the opportun11'.7 to meet Mias R. H3Ewan who is responsible tor the WHO­ assisted psychiatrio nurse training. She explained to the group the training progr8JllDe. The COUl'se for general trained nurse i8 two years, howner, it is possible to receive the basic training of three years to obtain the diploma of Registered Mental Nurse.

2.5 Diacussion. ChaiDIan - Dr. IJ.oYd Florio

The Chairman said that as they had missed seeing the WHO-assisted projects this atternoon, it had been decided to invite Miss M=Larty to speak on them.

Miss McLarty stated that the project to i{hich she ar..d. three colleagues belonged included the psychiatric nurse training programme at Woodbridge Hospital, which had been visited that day and of which Mias McEwan was in charge. There were two other tutors assisting in nurse training at the General Hospital, and also in an assistant nurse training programme. The project incl1.lded developnent of pcst-basic training in gemral nursing, with special emphasis on clinical teaching as a means ot integrating thecry and practice. This latter was one ot the most vital aspects ot nursing education and also one ot the most difficult, and it was complicated by shortage of statf and extreme pressure ot acute work in the wards.

In the paediatric field, where Miss Lange was the WHO tutor assisted II by her national counterparts, clinioal. teaching in nursing care of chUdren in the basic general. training was developed tirst, and continued on a limited scale. There was also a post-basic paediatric course of two years duration, which was now entering its second year. There were eight students who were registered general nurses aM midwives. This course, in a special field of nursing which was an 1mportant one in Singapore with its extremeJ,y young popalation, vas developing well. The standard ot the course was such that. it was hoped to qua] i tr for recognition by the General Nursing Council of England and Wales. I I

- 15 ..

In basic training of general nurses, Miss w,yUe, assisted by her t counterparts was in charge of a programme to extend the training of the assistant nurse. Previously. this training was based entirely on Tan Tock Seng Hospital which deals onl¥ with tuberculosis. With the expansion of the services and the need f~ more assistant nurses with a wider training, the course had been revised.· Surgical experience was not available at the tuberculosis hospital, nor was it yet available at the new Thomson Road Hospital. Therefore, a clinical teaching prog.. 'amme had been established and was functiOning well in a surgical unit at the General Hospital, and pupil assistant nurses were drafted there for tour IIIOnths teaohing and experienoe in the latter part, of their training. A clinioal programme :in. general med1Clll.~ursing had also bee started this JIIOnth in a medioal ward at the Thomson Road Hospital which was the first district hospital in Singapore.

With regard to post-basio courses, there were several envisaged in the Singapore WHO progruaes, but at present there was only the paediatrio course in progress, in addition to the course for publio health nurses, based on the Institute of Health, which comes under a dUferent project. It was hoped that other courses could have been developed by now, and in 1958, assistanoe was given in planning and oonducting a course in ward administra­ tion for Sisters and experienced staff nurses. In that year, three courses of one month's duration were given and it was hoped to extend this to a thrse­ month oourse, but staff limitations had not made this possible. It was hoped to develop this as and when staff were available, but Miss McLarty was not very opt.:lJD1stio about this in the foreseeable future because expansion of the health services was IlAking such great d_ands on the present staff that it was difficult to release staff tor special courses.

The other part of the project was at adP1n1strative level, in which she herself' was involved. She was asked to assist at administrative level with the Principal Matron and matrons in charge of hospitals. Also, one of her functions was to advise on the revision of nursing legislation. There has been a NurSing Ordinanoe for oyer ten years but there was need for a good deal of revision. Work in Singapore was in progress on this but had not reached completion yet. There was great scope in Singapore for post-basic work, and there was also need for a review of the basic train:in.g to prepare nurses through a more comprehensive basic training tor their increasing responsibUities but this was limited by a shortage of tutors and shortage of senior staff. This latter was due to the rapid withdrawal of expatriate staff that had taken place over the last few years. This had thrown a treMndous burden on the present staff and Hiss }i)Larty said she spoke for her oolleagues also when saying that they had nothing but. admiration for the way the nursing staff were oarrying on in a t:iJlle of considerable difficulty.

Miss w,yUe was then asked to say a rew words about her part of the project and to answer arJ'I questions that the group might wish to ask • .. -16 -

Miss Wylie : r would like to say that in relation to the .., nurse training given to assistant nurses, it is orten asked whether we are lowering the standards of nursing care in Singapore. In 11V mind, the answer is "no". As long as the programme is well controlled and supervised, I cannot see how • it can lower the standards.

Dr. Dickie s What do you think should be the educational standard of assistant nurses, and secondly, what length of training should be given and whether there should be written and practical examina­ tions at the end of this period.

Miss Wylie ,~ As you are training a lower category of worker, the educational standards should not be as high ·as your trained nurse, and therefore more emphasis should be' given to the practical aspeet Jmd less to theory.

Miss M:3Larty ~ The length of training given here is 2 years and 4 months.

Dr. Nicholson ~Jbat are the comparable duties of assistant nurses and trained nurses?

Miss WyUe s As assistant nurses, they are to assist the trained Burses in her duties. They are not allowed to handle dangerous drugs, give injections, etc. ,In sODIe countries they do give injections, but this would. be the case in circumstances where assistant nurses either give injections, or patients do not receive them at all.

Dr. Nicholson J In Singapore you have sufficient girls for recruitment as nurses. Wh;y do you require assistant nurses? Is thi$ done on economic grounds?' II

Dr. Kanagaratnam .~ The 'assistant nurse training programme was started about nine years ago when there was a shortage of staff. It was first started in Tan Tock Seng Hospital (for tuberculosis) where it was felt that the work involved would be simple and les8 complicated. Tan Tock Seng Hospital has now become the centre for assistant nurse training. l't has been found that there is a place for the assistant nurse in our expansion programme and a substantial number of assistant nurses are employed. - 17 -

Dr. Nicholson • I feel that assistant nurses tend to lose interest in their work rather quickly as they feel that they are unable to go far in this branch of service.

Mi.ss McLarty : This is an extremely important point and much thought has been given to it. It is felt thai; there should be avenues of advancement for the assistant nurse who is above average in quality ot wcr k and intelligence. It has been done in the past on a ver,y limited scale. It is 'realised that assistant nurses must have an incentive and avenues for promotion.

The Chairman then referred to the visit to the Medical Faculty or the Uh1versity of M8l~ and called for questions - there were no questions.

With regard to the visit to the Mental Diseases Hospital -

Dr. Shu •. In Woodbridge Hospital you have 2000 patients. Are the inmates, racially in proportion to that in an estimated population of 1.6 million of the • state? Dr. Yap : Quite approximately - yes. There is a slightly higher number of Indians than Malays though the Malays are a larger racial group than the IndianS, but this does not imJll¥ that there is a greater incidence of mental disease amOllg the Indians than Malays.

Dr. Florio : Are there an,y reasons for this such as cultural taboos and 80 forth?

Dr. Yap : Saneti.mes families with a mentally unbalanced member tend to hide them away in the hope of curing them. But it is difficult to be certain unless a house to house survey is made. I had made a survey from 1948 to 1955 and found that since 1952 the admission rate 18 definitely on the increase. I would say that this is eme to an increasing awareness of modern medicine rather than due to actual increase of the incidence of mental disease.

Dr. Nicholson • Do you treat flDlctionsl o&ses and what treatmEllt is given?

Dr. Yap • We prefer to treat them as outpatients. We have 4 outpatient clinics, 2 ot which are in the General Hospital. lI1en a neurotic case becomes ver,y acute, then we admit him to hospital. -18 ..

Dr. Truong : Do nurses with a post-basic training get any financial award?

Dr. Marcus : All nurses with a post-basic certificate aOO who specialise in this speciality are given a wage allowance of ~O/- p.m. and this certificate is also taken into consideration for promotion posts. .'

Regarding admissions to Woodbridge Hospital, I would like to clarify Dr. Yapls statement. It is the general pattern that the Indians apPly for admission in peroentage greater than the Chinese and Mal~s. Among the Chinese and Malays, there are traditional religious beliefs to see their local medical men first.

Dr. Florio : There are foci of leprosy found even in a city. Is this the case in Singapore where more cases originate in some part of the city or island which has no relation to population but mere~ areas which, for one reason or other, are responsible for a greater percentage of leprosy cases?

Dr. Ho J As far as we mow, it occurs in densely populated areas.

The session was brought to a close at 6,00 p.m.

3. 24 August 1960, Singapore

3.1 Visit to Kandang KSrbau Hospital

The I-group J'8:S shown around the Kandang Kerbau Hospital by the Medical Superintendent, Dr. S. N. Kapur. This hospital which has at present 370 beds for midwifery and 80 beds for gynaecology deals with an average or 92 deliveries per day, and in 1959, .3.3 609 births were recorded, i.e. over 5~ of all births in Singapore. A. new gynaecological wing has just been completed which has 1.30 beds and a suite of operating theatres. Visits were paid to the following sections of the hospital.

(a) Ante-natal section where d~ ante-natal clinics are held;

(b) Fbst-natal section;

(c) The gynaecological outpatient section which has a theatre for minor operations which are done daily;

(d) The domiciliary midwifery service. This is a training service and deals with about five domiciliary deliveries per day. Nurses taking their midwifery course spend half of their time in the hospital and the other half doing domiciliary deliveries. Pupil midwives doing the two-and-a-half"'.Year course spend the last five months of this course on domiciliary work. All eases for - 19 -

domiciliary delivery attend the ante-aatal clinics in the hospital. and following delivery in their houses by the dcmdciliary midwives are visited daily for seven to ten dqs by the midwives. The service is a free one. The group was shown the various delivery bags and puerperium bags used by the midwives and the contents explained by the Sister-in-ChargeJ

(e) Labour wards - There are two labour wards each containing forty-beds,.one on one floor where all abnormal deliveries take place, and the other on the floor above for normal deliveries;

(f) The post-aatal. ward where mothers remain for twenty-four hours after delivery before returning home. This ward has 133 beds and deals with an average of 80 to 100 admissions and discharges daily. The cost of running the hOSpital was estimated to be in the neighbourhood of t:J 500 000 per year.

3 .. 2 Pep Road Outpatient Clinic

A visit was paid to this new outpatient clinic which had been operating for about two years. It is of attractive and functional deSign and is the prototype for future out-door clinics. So far, three have been , built, including the Pegu Road Clinic out of a total of fifteen government clinios. In additim, there are eight City Council clinics whioh are in the process of being integrated into the general government outpatient facilities. An average of 600 patients per day are attended at this clinic of whom a hundred are for injections. The other 500 are for examination by the two .. full-time doctors and one part-time doctor on the ataff, and treatmsnta are given by two nurses. Attached to the main clinic building is a wing, housing a sister and a district nurse. The estimated cost of this unit is ~OO 000. staff consists of 3 doctors (one part-time), 2 nurses, 1 diapensar.y assistant, 1 dispenser, 2 clerks, 3 attendants and 3 amahs.

3.3 Thomson Road District HOSpital

This new district hospital which is situated in the centre of the island was originally built as a hospital for chronic patients and was opened in May 1959. It has now been decided to convert it into a district hospital to deal with the populaliion of the surro.mding areas which is estimated to be about 200 000. This is the first of three distrio~ hOSpitals which the Government plans to build to relieve the congestion in the General. Hospital. These three district hospitals will deal with the needs of the 600 000 population of the rural areas. At present, ClIIl4r three wards have been opened tor medical cases due to a shortage of doctors and nursing staff, but it is plaJ)DSd to open two more before the end ot 1960 and the rest before the end of 1961. In all, there will eventually be a total of 400 beds in the • hOSpital. The existing hospital buildings were estimated to have cost about i'+OOO per bed. The buildings are arranged in the shape of an n zn which allows the maximum cross ventUation~ and as the hospital is situated on a very attractive site on the top of a hill, exoellent cross ventilatim has been achieved. The ward blocks are six storeys high, but the ground floor ot one block is occupied by the administrative section which contains the Superintendent's otfice, general office, almoners' section and records - 20 - office, etc. The unit system of records was explained by the Superintendent who showed the group around. All patients treated in the hospital wUl be given a card which wUl be kept with the identity card, and the number of this card wUl be kept during the patient's whole life. An envelope contain­ ing all medical records of the patients will be stored in the records section • for future reference. other units visited were the physiotherapy and occupational therapy units, the library, kitchen, dispensary and wards. Each ward contains thirty-six beds arranged in ~s. Six bqs contain four beds each and six two beds. At the entrance are situated the doctor's roam, sist~r's room, ld.tchen, sterilising room,and the duty roam which has a clear view of the whole ward. At present, only three wards are in use containing about 100 beds. (be more unit on the top storey is being used as a training school for assistant nurses. It is planned to convert this ward into a prel1minar.Y training schoOl for assistsnt nurses, a practical lecture room and a lecture room for trainee assistant nurses. At present, the ratio of trained nurses to assistant nurses is 2'7, but it is hoped to increase the ratio of trained nurses as soon as they are available. QUarters are provided in the hospital canpolDld for only .30% of the staff and the remaining 70% will require to travel daily fran their homes •

.3.4 Sugapare Anti-Tuberculosis Association (SATA)

The Administrator of the Royal Singapore Chest Clinic, Dr. N. C. Sen Gupta, first outlined the history of the Singapore Anti-Tuberculosis Association since its formation in 1947 until the present building was occupied in 1952. The need for dOmiciliary treatment of patients suffering from tuberculosis was appreciated by the Association at an early date following a survey on the incidence of the disease in the Singapore populatiOD. The clinic which has no beds, is divided into two halves, a diagnostic centre concerned with case finding and a treatment centre, where patients are given treatment on an ambulatory basis. There is a rehabilitation centre; one of two such centres are run by the association. One section is in the South Winds settlement where farming is carried out. The fourth aspect of the association's work is preventive work, i.e. BCG vaccination, the publication of a bulletin and other anti-tuberculosis health education publications, and sn insurance scheme, especially for the staff of business firms. Visits were paid to the various sections of the clinic, including the diagnostic unit, treatment unit and rehabilitation centre. An attractive shop selling a large variety of goods of attractive design and excellent workmanship is attached to this centre.

The number of patients under treatment is 4000 at present with an inwke of 2000 new patients yearly. The cost of running the clinic is about one-and-a-half million dOllars a year, and funds are obtained partly from business firms, partly fran individual. patients who are able to pay part of their cost of treat~nt, and partly from fund-ra.tsing activities such as flag days, car seals and social functions. The Government also pqs the association for the treatment of patients receiving assistance. About 700 X-rqs are taken each da¥ by the static X-r~ units in the clinic and two mobile units which travel to various areas of the island carr,ying out case­ finding campaigns. From the figures obtained at a recent survey or this nature it was fOlDld that 4.5'1> of the population X-rqed had active tuberculosis and 12% showed some pulmonary abnonnality. The Administrator -21-

explained the system or coloured lines on the floors of the corridors, used t to direct the patients to the correct sections I and he also showd the group the mechanical system of case records used.

On the upper floor or the rehabUitation centre is the weltare section where the social workers deal with all welfare problems. It also contains • a lecture room for health education work.

Atter the visit to the Royal Singapore Chest Clinic, the group proceeded to the Tan Tock Seng Hospital tor tuberculosis. The hospital is located on a high hill and is divided into three groups. In the tirst group there are twelve buildings, in the second, tive, and in the third group, tour buildings. This hospital was given its name because ot the generous donation ot the land by Mr. Tan Tock Seng, where the hospital is now erected•

. The tuberculosis control unit is under the care ext: the Assistant Director ot Medical Service;s (TB). All the tuberculosis cases are registered in this unit and there is a law making it compulsory tor all physicians to notify the central unit and in tum on.q private practitioners are given a nominal pill' ot $2/- tor notification. The tuberculosis registry was organized in August 1958 and started operations in the same month. From that month up to December there were 2CJ79 registered cases. In 1959 there wre about 5666 registered.

BCG vaccination is done on children and thoslil entering tor the tirst time in the school, Out ext: the 33 000 births, 24 ClOO were vaccinated in the yelr 1955. Death due to tuberculosis is thirty-nine per thousand in 1959.

The budget tor the operation or this tuberculosis control progr8IIIIDS is • siX million dollars. Out of thiS, one mUlion dollars are tor the BeG and tuberculosis mobUe units. The statt consists ot 4 doctors, 26 nurses, 250 assistant nurses and 6 social workers. The cost ot subsistence is $1.80 per patient per day which is 60 cents higher than those tor tree patients in the Genral Hospital.

In the laboratory they were able to do tuberculosis culture 12 000 a year and out of this, $ are positive. or those negative they are checked three times within a period ot three months t interval.

There is another thing noticeable and this is it would seem that the Govemment is not co-ordinating its work with the Singapore Anti-Tuberculosis Association sutticientq and tor that reason there is some duplication of the work done. If this work were better co-ordiDated and integrated into the total programme of tuberculOSis control without the private tuberculosis socisty losing its identity, time would be.saved and tllle coverage would.be more. In the government institution there is no rehabilitation. It is noticed that in Singapore, restaurant servers and barbers are not required .. to have a health certificate showing that they are tree trom tuberculosis • , - 22 -

4. 25 August 1960, Singapore 11

4.1 WHO EPidemiOlogical.ffl!1!lligence Station

The first part of th1.8 day's programme was dedi cated to the WHO • Epidemiologieai Intelligence Station. The group was welcomed by its Director, Dr. W. W. Yung. In his introduction, Dr. Yung stated that this station was established in 1925 and was known as the Eastern Bureau of the Health Organiza- tion of the League of Nations. Since 1947 the Bureau had become a special office of the World Health Organization. The main function of the station was the administration of the International Sanitary Regulations. It was noted that, among others, SingapPre, Australia and Burma do not accept these International Sanitary Reg~tiQns. Dr. Yung informed the group on the requirement for governments to notify the occurrence of quarantinable diseases. The station collected info~tion on influenza and poliomyelitis. It was regrettable that not all c~~ies submitted all the information required. Therefore, the station alBo~d press reports (newspaper clippings) as an additional means for obtain,ing more complete infonnation. The weekly epidemiological infonnation ,was transmitted by the station on each Thursday by means of radio, telegraphic and postal services. The station also dealt with the settlement of complaints or disputes pertaining to the application of the International Sanitary Regulations. It was noted that the weekly epidemiological bulletins were sent to national health administrations, port and airport health authorities throughout South-East Asia and the Western Pacific and other co~tries served by the station. Although Mainland China, North Viet Nsm and North Korea did not notifY the station on quarantinable diseases, they nevertheless received from this station all available epidemiological infor.mation.

4.2 Middleton Hospital

This hospital provided for the care of infectious diseases. On arrival the group was welcomed by Dr. Ng See Yoke, City Health Officer,; Dr. W. Leong, Acting Medical Superintendent and by the Matron, Mrs. L. Wong. The group made a tCllr through the institution observing old and new wards, having a total bed capacity of 250. The average number of occupied beds was between 160 to 180, allowing reserves for emergency. The hospitalization of diphtheria, poliomyelitiS and typhoid was compulsory, although this may be optional in special circumstances. Diseases like measles and chickenpox were not compulsorily hospitalized. The group first observed the wards for poliomyelitis patients and the facUities for physiotherapy. The hospital took care of about 90 cases of poliomyelitiS each year. In the diphtheria wards with an annual admission of about 500 cases, it was observed that the patients were mostly in the toddler age group, i.e. below six years. The necessity for tracheotomy was rather high being about 12% of all cases hospitalized. Finally, the group visited the newest isolation ward which was built in 1956 and consisted of a block of cubicles. Here all cases of typhoid (100 per year) were accommodated. There was also one patient suffering from Japanese B Encephalitis. - 23 -

t Middle Road Hospital

The group next visited the Middle Road Hospital which provided care of venereal and skin diseases. Dr. Koh Kin Yong guided the group along the outpatient departllB nt to the attached fifty-eix-bed hospital. At the outpatient department there were daily some 400 male attendances (of which forty new cases) and 170 female attendances (of which twenty new cases). Out of a yearly total of about 17 000 cases there were 11 000 general skin diseases and 6000 venereal diseases (of which gonorrhoea .3000, non specific urethritis 1000, syphilis 800.. and other venereal diseases 1000). :rt. was noted that the incidence at gonorrhoea had remained largely constant during the last few years. The incidence a: syphilis, however, had decreaeed conSiderably. Every effort was being made to follow up the patients' fam:lly contacts. Search after the source of infection was however considered to be extremely difficult.

4.4 Maternal and Child Health Clinic at Pasir Panjang

Finally, the group had an opportunity to visit the maternal and child health clinic at zasir Panjang which was attached to the local community centre. This particular centre served a semi-rural population of about 20 000, predominantly Malqs:~ The group was welcamed by the Medical Officer in charge, Dr. (Mrs.) Anne Tq and Dr. Maggie Lim, doctor in charge of maternal and child health clinic in the Institute of Health. The facilities were shown and the activitie s described. The staff consisted of one medical officer, one sister (who also had responsibility for two other clinics) j three midwives (one in training), two health nurses and one almoner • • At the ante-natal and post-natal session there was on the average, a daily attendance of forty persons. It was noted that at these sessions intensive health education by II8&D8 of visual aids, flannel.graph, etc. was given before the individual examination and teaching. Before leaving, the group discussed the significance of family planning. Dr. Maggie Lim cOllll1ented that this was primarily a voluntary initiative, but the Government envisages a programme to~ the end at this year. Various methods of birth control were discussed while Dr. OAald coamented upon the scheme of f8lll1.ly planning in use in Japan.

4.5 Discussion

Following a preliminary question-and-4nswer session on the institutions visited during the morning, opening remarks about the Singapore section of the tour were given by the leader of the delegation, Dr. Florio. He cCllllD8nted on the very full programme which bad been arranged for the participants, and expressed regret that the participants had not had sufficient time to read all the documents which had been so carefully prepared by the organisers. :rt. was decided not to give a formal sUllllJl8.r,y and review as stated in the official programme but to declare the meeting open for the participants to discuss the broader aspects of the public health problems in their respective countries. -24-

Dr. Nolasco asked if barbers, waiters and other food handlers were required to have a certificate as to freedom from contagious diseases such as tuberculosis.

Dr. Kanagaratnam replied that there was no specific requirement for such a certificate, but there was provision in the laws for a person to be prohibited • from handling food if found to be suffering from an infectious disease.

Dr. Florio said that a compulsory examination tended to give a false sense of security, as the poSition might change overnight.

Dr. van de Linde said that in Hong Kong this was the view taken also, and it had been found b.Y experience that compulsory examinations were impracticable and bad been abandoned. This was the general view of the participants who spoke on this subject.

Dr~ Nicholson asked about the condition described in the virus research section called "haemorrhagic dengue".

Dr. Lim. said that a number ot cases of a disease were encountered at the end of July. Cases came about the end of a week of illness or longer. The disease presented as a febrile illness followed in a week or so by a rash, and later by petechial haemorrhages and a leucopenia. Research into this condition was going on. It was not yet known if it was due to a dengue virus or not, and Dr. Lim. gave more detailed technical details of the various lines of research being pursued.

Dr. Dickie, who was the only participant to have visited the government Medical Store and Drug Manufactory, was asked to give a brief review of his visit. He described the various sections of the store which he visited, and commented that his reason for visiting this institution was that in Sarawak, a new central medical store was to be built, and plans were being prepared on the lines of the Singapore Medical Store and Drug Manufactory. Also, with the kind assistance of the Government of Singapore, one of Sarawak's dispensary staff was undergoing a three-month course of training in tablet manufacturing. He stressed the savings which could be effected b.Y manufacturing one's own tablets. ampoules, etc. from bulk supplies of the ingredients, rather than importing the finished product. This point was also emphasised by Dr. Marcus who said that there was a net saving of a quarter of a million dollars or more gained through the operation of these laboratories.

Dr. Marcus discussed the lack of hospital beds and the expansion of domiciliary services, and asked for the views of the participants.

Dr. Florio commented that the United States of America or the United Kingdom standards of the number of beds required might be very m.:I.sl.eading.

Dr. van de Linde stated that the number of beds in Hong Kong was also inadequate and thought that a higher ratio of beds to population may be required, due to the poor housing conditions, over-crcwding, etc. - 25 -

• Dr. Nolasco thought that in Singapore not enough stress seemed to be placed on preventive services.

Dr. Shu asked wh;v there was practically no voluntary hospital institution in • Singapore • Dr. Harcus stated that there was one voluntary hOSpital, St. Andrew's Hospital for children, and second hospital was being built at Mount Elveira by a mission.

Dr. Dickie asked about the district nursing service which existed in certain areas. He had noted that at the Pegu Road out-door dispensary offices were provided there for a sister and district nurse, and asked for further informa­ tion about the service.

Dr. Marcus said that the district nurse service was a WHQ-assisted service with headquarters in the General Hospital. It was intended to extend the district nurses service to areas covering a limited population, and at one clinic at Buldt Panjang, the first experiment on these lines was being carried out. Dr. Kanagartnam stated that there had been a considerable expenditure on curative services since the war, but this was deliberate.

Dr. Kim asked 11' it was intended to bring curative and preventive services more into liaison at present•. and also ccmmented on the lack at health propaganda posters in the ou.,.tient clinic visited. • Dr. Marcus said that it was planned to incorporate the curative and preventive services in one building, and to extend the health propaganda work at the departJrent.

Dr. Kim asked about the hospitalisaticm of infeotious oases, and the danger of cross-infection. Dr. Ng replied thatbthere had been none so far in the Middleton Hospital.

Dr. Kim asked 11' it was necessary to segregate cases of Japanese "B" encephalitis and Dr. Kranendonk asked about compulsory segregation of poli~elitis O8ses.

Dr. Ng said that o~ the major infectious diseases were compulsorily segregated, but an attempt was always made to persuade polio cases to be admitted for the first three weeks of' their illness.

Dr. Chang asked about the school. health service. He thought that this service should be the joint responsibility at the Departments at Health ald .. Education. Teachers should have training in health education work • Dr. Kanagaratnam said that there was co-ordinatioo between the two departments, but administratively the service came under the control of' tha Department of Health. There was, however, a close l1.a1aon between the departments, especially on committees dealing with school buildings, etc. Teachers got training in health education in their teacher training course. - 26 -

Dr. Ozaki felt that there was a need for more diagnostic equipnent in the various institutions visited. • Dr. Truong said that great advances had already been made in the field of curative services, and he was most interested in the school health service. He especially commended the leprosy settlement and mental hospital. The Chairman endorsed this remark. •

Finally, the Chairman Dr. Florio, summed up by expressing appreciation of the careful planning and hard work which had gone to make the meeting so successful and smooth-running. MaQy people had obviously spent a long time planning the various visits, and the results were worth the eftorts made. Thanks were expressed to the followings

The Minister of Health The Director ot Medical Services Dr. K. Kanagar abam Heads ot all institutions visited Mr. T. F. 1ge Mrs. K. M. Knight The Minister ot Culture Dr. Monteiro and University Btaff Professor T. A.. lloyd Davies .. The Singapore Anti-Tuberculosis Association The Singapore Medical Association Dr. Yung, Director, Epidemiological Intelligence Station and Staft WHO Nurses Other members of staff - professional and non-professional

Dr. Marcus said it had been a great pleasure to act as host to the participants attending the conferenoe, and on behalf of the Minister of Health he wished to thank all the participants and to extend a welcome to ~ partieipant who might visit Singapore again.

Dr. Kanagaratnam said that if any ot the participants wished to follow up any question, he should write to the Director of Medical Services, who would deal with it.

The meeting ended after a tew announcements had been made by Dr. Shu. The group left Singapore by train at 10 p.m. for Kuala Lumpur and reached Kuala Lumpur the next morning. The group was met by the Officials of the Ministry of Health and Social Weltare and checked in at the station Hotel.

, .. 2? -

~. 26 August 1960, Kuala Lumpur t 5.1 Opening meeting

The opening meeting of the Public Health Conterence and Stud¥ Tour organized by the Ministry of Health and Social Welfare, Federation of Hal.qa, was held at 9.;30 a.m. in the lecture hall of the Institute fer Medical Research.

Dr. Hohamed Din bin Ahmad, Director of Medical Services" in introducing the Hlnister of Health and Social Welfare said that he wanted to welcome one and all of the partiCipants on arrival in the Federation of ~ya and in Kuala Lumpur especially after the,y had had a strenuous conference of the Regional COIIIDIittee in ManUa fallowed by a stud;y tour of Singapore. He said he saw many tamiliar faces whom he had met at previous conferences, and he thought that the,y would have a lot to talk over on the technical aide. He said the Honourable K1nister had veryldndly consented offic1ally to open the conference and stud;y tal r this morning and also to address the meeting. As lIl&D1'JfaJ.qans were aware, the Minister, Honourable ~g Yoke Lin, had demonstrated a very high quality of leadership in the field of health in the Federation of Mal~a and he had been acclaimed both by the public and professional staff.

Dr. Lloyd Florio thanked the Government and the people of the FsderatiClll 01' Malaya tor their hospitality extended to the participants and to the members of the WHO secretariat. • 5.2 Institute for Medical Research The participants spent a most interesting morning touring thia Institute and saw the following departments.

(a> Department of Bloch_sty (Mrs. Kem and Dr. (Lagy) Thomscm)

The ~rt1clpant. were told here of the studies in ch1ld nutrition and in the tood value and vitamin content of tresh water fish. This department also carried out routine services and research work tor other government departments.

(b) Department ot Entomoloq (Dr. Wharton) and PBrasitoloq (Dr. Byles)

These departments worked in close co-ordinatlon and the participants were told ot the work in connection with malaria and filariasis and saw interesting specimens connected with the work. • (c) Department of Bacterioloq (Dr. Bbagwan Singh) The work ot this department was divided into tour divisicms. (i) routine diagnostic work for five States of the Federation,; (11) the preparation of cholera, smallpox and TAB vaccines; - 28 -

(iii) advisory work; and (iv) research work. •

In addition, the participants were told of the training programme for medical officers and public health inspectors which was carried out in the various divisions. • (d) Department of Pathology (Dr. 'tIilliams)

The participants saw examples of the routine diagnostic work in this department and of the research work on the incidence of cancer in different racial groups.

(e) Virology section and research laboratory (Dr •.. Dara Tan)

The participants first saw the work done by this department in connection with leptospirosis including the examination of snakes for leptospirosis ant1-bodiee. Thet next saw the main virus laboratory in which diagnostic work 1188· carried out and also the preparation of anti-rabies vaccine •. Dr. Tan mentioned the poliallyelitis tissue culture unit which was to be established in the department and which would carry out mainly diagnostic work.

Th~ participants then inspected the work of the lhited states Ar1rr¥ Medical Services in premises provided by the Institute for overseas scientists. Dr. Elisberg described the investigation of virus diseases and explained that this was now pursued along two lines: (a) tbe investiga­ tion of outbreaks of diseases probably due to viruses and, (b) the investi~­ tion of specific clinical symptOllS. He mentioned in particular the invest~t1on of cases of sudden death among Gurkha soldiers.

5.3 Visit to Sungei Buloh leper Settlement

A short but very instructive visit was paid to the large Sungei Buloh Settlement for patients suffering from leprosy. This was situated on an extensivEt.and attractive site fourteen miles from Kuala Lumpur, and had 2473 patients. The participants were cODducted round the premises by the Superintendent, Dr. Bhojwani and the Matron. The settlement consisted of two sections, a hospital section, with accommodation for 4Q0-500 patients requiring hospital care, and a section consisting of chalets, where other patients lived. If requiring hospital treatment later, chalet patients were transferred back to the hospital.

The Superintendent explained that active treatment was carried out using D.D.S. injections normally (or tablets for out-patients) and eIBA 1906 had also been used with success especially for patients resistant to D.D.S. Infectious lepromatous cases and non-infectiOUS cases with complications • such as trophic ulcers were admitted to the settlement. Non-infectious tuberculoid cases were treated on an out-patient basis. Rehabilitation of deformed patients, prior to discharge from the settlement, played an i - 29 -

:lJaportant part in the work done at the settlement. Reconstructive surgery started in 1945, for the treatment of drop-foot, wrist-drop, facial paraqsis, • etc. Some impressive results of' this surgery were seen during the ward visit. Other rehabilitation work carried out was training in a trade - school established with the aid of the M!I.layan lA:Iprosy Relief Association, and • poultry, farming, etc. Land was acquired for re-settling patients • Visits were paid to the wards; the X-ray department,where coloured slides showing various lesions and deformities were shown; the pQysiotheraRY section, with a limb-fitting unit; the occupational therapy section; the research laboratory where new drugs were tried out. A BOG immunisation experimental survey has been carried out on a neighbouring island but results could not be given untU a further survey, had been carried out in five years' time. ImmWlological experiments were also being carried out.

Other places visited included the recreation hall with badminton courts, cinema and CouncU Offices, and a very attractive flower garden, constructed and tended by the patients. The school which catered for about 200 children, the police station, fire station, post office, etc. were seen from the bus, on passing.

5.4 Discussion I Chairman - Dr. K. Kanagaratnam

Institute for Medical Research

Dr. Chang I Are there any othe r laboratories producing vaccines in the Federation?

• Dr. Bhagwan Singh I No. IV laboratory produces TAB, cholera and smallpox vaccines.

Dr. Dickie s Has the Nutrition unit prepared diet sheets for hospital patients?

Dr. Din and Ml's. Merry : Yes. These had been published and reprints would, no doubt, be available. Diet sheets for residential institutions were also avaU­ able. Further Mrs. Merry stated that the results of ,the nutrition survey on salt water fish had been published but those on fresh water fish had not. Preliminary results could, however, be supplied in manuscript.

Dr. Wahab : Is Type I poliomyelitis the onl,y type isolated in the Federation?

Dr. Dora Tan I No typing of polio-virus had yet been done in this institute. Dr. Kanagaratnam added that Type I was predominant in Singapore but that • Type II also occurred • - 30 -

Dr. Nolasco , Is the enriching of rice compulsory by law? • Dr. Din and Mrs. Merry I No. Enriching is not practised in the Federation but the public eat more parboUed rice and no serious effects are thought to occur from the consumption of polished rice.

Dr. Kanagaratnam • Does routine service work interfere with research at the institute?

Mrs. Merry • Yes. At present it is having SaIB effect as is found elsewhere.

Dr. Truong s Does the Government cover the cost of examina­ tions carried out for private practitioners?

Dr. Din s No. These cases are charged unless the doctor certifies that the patient cannot pay.. All examinat10m for infectious diseases are free.

Sungei Buloh leper Settlement •

Dr. Nolasco ~ Is marriage between leprosy patients and others allowed? • Dr. Bhojwani : Intermarriage is allowed between patients and when discharged a cured patient is free to marry whom he likes. Babies bom to patients are separated immediately and none has ever developed clinical leprosy. Such babies are cared for either: (a) by adoption; (b) by the Social Welfare Qt't'ice untU the patients are discharged; or (c) by sending the child to relations. Dr. Bhojwani further stated tNt. 70/0 of admissions was voluntary, remainder being persuaded to cane in by the health authorities. The number ot' admissions was about 400 a year and nearly that number were discharged. About one patient absconded per month. Fatients proved non-infectious on examination were not admitted.

Dr. Wahab Is it reasonable to assume that hereditary transmission of leprosy does not occur?

Dr. Bhojwani This is assumed to be so but has not yet been conclusiv~ proved. - 31 -

Dr. Florio J Have any results of the BCG research been • obtained yet?

Dr. Walters : No. First reports will be available in 1963 •

• Dr. Florio = What drugs have been tested in the leprosy research laboratory?

Dr. walters : No new drugs but the sulphones (DlU'SONE) and ClBA. 1906 have been found effective. MA.CROOYCIDN is being tested. studies are being carried out on the relation between MlNTOllI and LEFRA tests but no conclusions have yet been reached.

Dr. Florio s What percentage of patients are employed in thl settlement?

Dr. Bhojwani and Dr. Din s About one quarter (600) are employed and receive allowances. The healt~ staff number about 100.

6. 27 AUgust 1960, KUala Lumpur

6.1 Seaport Estate • The group was welcomed by the General Manager, Hr. N. R. Tubbs. The group hospital served three estates and one factory. It had a capacity of thirty-three beds of which onl¥ an average of 10-15 were occupied. The staff consisted of one senior dresser (grade one) and one midwife. A medical officer visited the hospital once a week. The labour force of the estate numbered some 700 people both male and female. The number of dependent children and others was not known. All medical care was given free. Besides individual care, the whole population of the estate was seen twice a year. It was noted that in the past years not a single case of malaria infection had been found. Atter visiting the hospital the group went to see some of the housing facilities and a general store. The houses were well bullt. It was noted that the bathrocm was connected with the kitchen inside the house, whereas toUet was at scme distance behind. ToUets were of the squatting type provided with an automatic flush system.

6.2 Petaling Tin Htne

The General Manager, Mr. P. Burke IIld his assistant outlined to the group the organisation am the general set up of the tin mine. Tin was .. found as alluvio deposits in low lying river beds. Afterwards a visit was paid to one of the dredges which is one of the largest in the world. It had a digging capacity of about 20 tons of earth per minute. Using an ingenious washing process a final. product a eoncentrate of about 2~ of tin was obtained. The ultimate producing capacity was about 100 to 200 tons of tin a month • • As a by-product of the tin the mineral. ilmenite of which titanium was obtained. It vas stated that the medical and health care or the labourers was s1Jnilar to that of the rubber estate. - 32 -

6.3· Sunge! Wq New Village .. This was one of the maqy recently resettled villages in the Federation of Ma1qa. This particular village numbered sane 4000 inhabitants. Resettle­ ment was considered necessary during the emergency. The group was welcomed by the members of the village council and the chairman, Mr. Lee. The • supervision of the general cleanliness of the village was one of the duties of the council. Ten villagers were employed for the collection of garbage. The group visited the Chinese school as well as one of the dwellings.' It was noted that the general living conditions were satiBfact~. As far as medical care was concerned the village was visited by a travelling dispensary once a week. Emergency cases were sent to the General Hospital.

6.4 Petaling Jaya Housing Deve10pnent

P9taling Jaya, the urban housing developnent scheme was MBlSla1s first new town. Since 1953 resettlement programme for tl:s urban popula tion .r Kuala Lumpur had been developed. An eight million dollar fund was being used for the construction of roads and for water and light facilities. Loans were made available for the construction of individual homes. Besides dwellings the scheme also comprised some 450 acres for industrial developnent. Resettle­ ment scheme was outlined by the developnent officer, Mr. A. E.Abel. So far, 4500 houses had been built for 30 000 inhabitants. A tour was ade. A maternity hospital was seen and a visit paid to the modern. building of the .. publi.c works department. Finally, the group passed through the new campus of the lhiversity of Malaya in Kuala IAunpur •. 6.5 Rural Industrial Developnent Authority Training School (RIDA) • The Principal, Mrs. Azizah Jaafar explained to the group that thiB school was intended to assist in the social development of the rural people in Mals;ya. A three-month course was given to some fifty village girls of eighteen years of age and over. They are carefully selected fram all parts of the Federation of Malqa. The group was informed by the Principal that the school was run by the Government and the trainees were provided board and lodgings free of charge. There are six la~ teachers who. give training in child care, nutrition, communicable diseases and sanitation and handicrafts.

The group left Kuala Lumpur by plane at 4:50 p.l!l. and arrived in Penang at 6:00 p.m. The group was taken by bus to the E. & O. Hotel and checked in.

7. 28 August 1960, Penang

7.1 Tuberculosis Settlement At about 8:15 a.m. the Chief Medical and Health Qfficer,.Dr. S. .. Nadarajah and Mr. Yusoff accompanied by some members of the Malayan Film lhit arrived at the hotel by bus.

The group left the hotel by bus at about 8130 a.m. for Glugor Pier i and proceeded by motorboat to the island of PUlau Jerejak, which was nearly five miles away from Penang Island. - 33 -

I • The group was welcomed by Mr.. T. Karthigesu, the Lay Superintendent, and Dr.• Lim Hor Seng at the Tuberculosis Settlement" Camp I. Mr. Karthigesu gave .a brief history of the island. He said that nearly 150 years ago this was a quarantine station, the building of which still existed. He elaborated and said that during the Second World War about 2500 cases were admitted in • this station and when the war was over only about 400 of the 2000 remained and the rest died of starvation, lack of treatment and other amenities.

Dl the tuberculosis camps there were about 400 cases, 250 in one and 150 in the other. As regards treatment they still used traditional drugs. Mr. Karthigesu said that they had accommodation tor about 600 but they did net have the requiSite statf and water and other facilities. He said that last year they bought water and paid about Straits 150 000. The Government was pt'oviding a quarter of a million dollars to pt'ovide water. He conmented that when they were able to obtain statf and sufficient water frem Penang they would try to expand the camp. The statt cons:l.sted of one doctor, one sister, two statf nurses, eight aSsistant nurses, tive hospital. assistants and twenty-eeven hospital servants. There were also SClDe patients about to be discharged who were given seme light work and in turn they received some pocket money. In answer to a question by Dr. Nolasco, Mf'. Karthigesu replied that· there vere three reservoirs and the actual quantity of water required would exceed the quantity of water collected, in other words, there would not be • enough water to go round. The cost of bringing water trem Penang was about fl far 244 tons, consequently they had to ration water to patients. Another reason w~ they were not able to collect water was that there would not be much rain as this island was sandw1.ched between the island of Penang and the mainland of Mal.a¥a. In answer to a further question by Dr. Ten, Mt-. Karth1gesu • said that last year they had only 'fourteen inches of rain. Dr. Kanagaratnam aaked about the population and was into:nned that there vere 1000 and 200 statt. Mf'. Karthigesu mentiCl'led that due to scarcity ot water they had to ration the water supply; about ten gallons per patient per dq. In answer to a further question by Dr. nOrio, Hr. Karthigesu said that experts were trying to alleviate the problem of water scarcity by various methods, but so far they had not been successful. Mr. Karthigesu said that the Government was considering bringing water from the mainland.

The group was shown the tuberculosis camp. Dr. Lim explained that there ·wre·two camps, accOllllllOdating 250 in one and 150 in another. He said that patients were allowed to roam around the beach to get fresh air and exercise.

Dr. Florio asked in view of the difficulties as regards water supply and iJther amenities encountered by the settlement, whether they considered abandoning the island. The reply given was in the negative. .

Dr. Florio wanted to know whether they had 8lliY problem in getting • staU and was informed that there was. The cost of maintenance per patient was aboutldnet,y cents. Mr. Karthigesu said there was a contractor who supplied provisions, etc. In answer to a question by Dr. Florio as to whether the relatives of patients liked this arrangement due to inconveniences, • Mr. Karthigesu remarked that this settlement was started during the emergency and attbat time it was not expected it would continue to function. The - 34 -

II families of patients were not allowed to stay due to the disadvantages, nameq, • II transport, supply of provisions, school and other facilities. Dr. Florio commented that Pulau Jerejak could be converted into a holid~ resort.

The group then visited the radiography room and minor surgery theatre. Major surgery cases were sent to Penang.

In answer to a question by Dr. Shu regarding patients who had lived there for ten years, Dr. Lim said that the patients did not have any other place to go. In answer to a further question, Dr. Lim said they did have complaints from these patients as regards conditions and facilities, especially when a new officer took over. Dr. Ten Yoon Fong elaborated that point and said that it was the case everywhere.

The group then visited the recreational hall or the patients where there was a displ8¥ or handicrafts. Dr. Lim explained that there were free film shows once a week. He also said that the Red CroBs officials visited the settlement once a week.

7.2 Isper Settlement

The group then proceeded b,y boat to another part of the island where leper patients were accommodated. Dr. K. S. Dutta, who was in charge of the • settlement welcomed the participants. The t.ot.al number of patients was about 450, out of which 325 were accOlJ1lTlodated in One section and the rest in another. Dr. Dutta remarked that usually patients were kept for three years after which they were referred to the Social. Welfare Department who arranged their employment. The patients were doing farming on the island. When patients • were discharged the health officer would follow up these eases for clinical check up. The drugs used were sulphones in most cases. Those who did not respond to sulphones were given CIBA 1906.

Dr.. Florio enquired about the discharge rate and was infonned by Dr. Dutta that this was 40 per year out of 437. Dr. Dutta also said that admissions numbered about 40 to 50.

In answer to a further question, Dr. Dutta said that very little surgery was done in the .settlement. Dr. Florio asked whether they encountered any difficulty in making the patients leave after being cured. Dr. Dutta said that all new cases were willing but not the old ones. Dr. Dutta also said in repq to a further question by Dr. Kanagaratnam that there were about ten to twenty families. In answer to a further question by Dr. Kanagaratnam, Dr. Dutta said there was no actual tie up between Sungei Buloh and this settlement.

Dr. Dutta informed the group that the patients were growing vegetables and these vegetables were sold to contractors. In rePl¥ to a question, Dr. Dutta said that the cost of ration was about 95 cents per patient per da,y. • Dr. Florio asked whether the patients were doing their own cooking and Dr. Dutta replied in the affirmative. The group then proceeded by boat to the Quarantine Station and arrived at about II ,20 a.m. - 35 -

Mr. Karth1gesu, La;y Superintendent, again welcomed the group and gave • a brief history of the Quarantine Station. He said that. the Quarantine Station used to be in the present tuberculosis camp. In the past, every deck passenger from India and SCllle other countries were quarantined for about a week. The plssengers were brought here, given a bath and had tl'e ir belongings • disinfected. Atter this they were sent to canps. Married people with families were accommodated seplrate~. The quarantined passengers got their rations from the canteen. There was accommodation for 4700 passengers at a t:iJlle. Since 195~ due to public agitation and other reasons, the regulations were relaxed. At present, deck passengers on arriving by ships from infected local areas were quarantined for a week and also passengers who did not possess valid vaccination certificates.

Dr. Florio asked how ~ people they had actually at one t:iJlle. Hr. Karthigesu replied thai; in 1952 they had provided accommodation for about 4000 people and added that the nllllber was on the high side due to the arrival of two ships simultaneously. Dr. Florio asked how ~ people were quarantined at present and was informed there were 200 per month who bad come from China.

Dr. Yung asked ~ they are not accepting the vaccination certificates of certain countries and explained thai; all certificates conforming to the form II' esoribed in the International SalU.tary Regulations, lItien correctly issued, should be accepted.

Dr. Shu asked wb,y deck passengers were quarantined whereas first and seoond class passengers were not quarantined. Dr. Dutta replied that a first class passenger would feel the responsibility and visit the local health of'f'1cer, whereas most of the deck passengers were illiterate and could not be expected to report to the local health officer.

Atter refreshments, the participants visited the hospital ward. Dr. Kranendonk asked whether they had enough water and replied they bad. The group then proceeded to quarters allocated to the plssengers. R was explained that there were separate kitchens and bathrooms. There was a staff of' thirty-one. There was a midwife who attended the women passengers as well as patients of the camps.

Dr. Shu asked how this cost of rations was collected. It was explained that the passengers paid a sum usually in excess J when they bought their tickets and after their discharge from the quaran\;ine station, they would be ref'unded the balance.

The participants after a visit to the lavatory and kitchen proceeded to the launch to return to Penang.

• - 36 - ,I I I I The group proceeded by bus fr01l1 Butterworth to Alor Star. I, I, • I I 8. 29 A.ugust 1960, Alor Star

8.1 Jitra Rural Health Training School

t# II After lunch at the Kapala Batas Rest House the group proceeded to JUra Rural Health Training School. His Highness, the Sultan. of Kedah and his Chief Minister, the Mentri Besar, honoured the group with their presence. His Highness was welcomed by Dr. Ten Yoon Fong, Deputy Director of Medical Services (Medical) of the Federation of Mala,ya, and His Highness, in re~, extended a warm welc01l1e to the partiCipants and hoped that their sta;r in Kedah would be profitable and enjoyable one.

Following a tea break, the participants were conducted round the premises by Dr. Beri, Medical Officer of Health in charge of the School and Health Centre for Kubang Pasu District. The School itself was a training institution for teams of auxiliary rural health vorIers, under the Ministry ot Health am Social Welfare. The organisation and administration of the School was the responsibility of the Chief Medical and Health Officer, Kedah/ierlis, and the day-to-day operation of the School and the provision of health services were the responsibUity of the Medical Qrficer-in-charge. .A. very detailed and clear description of this School and Centre had alreaQy been provided. The School building was first visited and the various sections explained. It .. consisted of a block containing$

(a) Lecture hall. (b) Qrfices for the training staff. (c) A. clerical office.

Behind this block, which was attached to the Health Centre for Kubang Iasu District vere two hostels for the trainees, each containing accommodation for twelve trainees - one for male and another for female.

The Health Centre for the District of Kubang Pasu contained the following:

(a) Qrfice accommodation for the basic staff - i.e. the public health nurse, public health inspector, etc.

(b) A laboratory (run by a trained laboratory assistant).

(c) A dental clinic" equipped by UNICEF and run by a dental officer and a small staff of assistants, and dealing ma~ with school children and pregnant mothers. It also operated an extraction clinic for adults, at a ma.xiJn.um charge of $1 per patient. A dental nurse would .. la,er be posted to this unit to work under the super­ vision. of the dental officer. 1tJbile equipnent vas available for dental work in schools, etc, and each sub-centre was also provided with equipnent so that regular visits could be paid to each by the dental officer and his staff. The need for a school dental - 37 -

service was evident fran the fact that, according to the dental officer, 80 to 9'1' of all children, at school-entrance age, had dental caries. Topical apPlication of fluorine was carried out on a selected group of school chUdren •

• (d) jn out-patient clinic which consisted of a waiting-hall, with record section, a consulting room and an examination! treatment room. It was run by two hospital assistants, and dealt with 70 to 80 patients daily. (hce weekly, the Medical Officer held a session there. In-patients were referred to the Alor Star General Hospital, with which the Rural Health Centre maintained a close and frienci4 liaison.

(e) A maternal and chUd health section consist:ing of a waiting­ hall, also used for demonstration and lectures to pregnant women, given by trainee auxiliary health workers, an assessment room, where babies were weighed, etc., and an examination room. This unit was :in the charge of a health sister and provided tra:ining facUities for tra:inees from the school, in addition to its service. duties to the JUra Ma.:in Centre. Two midwives were • attached to the Cl:inic, and about 70 to 80 deliveries were conducted :in the area each month, i.e. about 25% of all births in the area. In addition to providing facUities for the post-cert1ficate training of auxiliary

I • rural health workers, basic tra:in1ng of a few Grade 2 midwives for Kedah, was undertaken. These trainees spent Irlx months of their two years basic course, in the Main Centre at Jitra.

The participants were then shown the hostels and staff quarters in the health centre compound before the question-and-answer session was held in the lecture room. A full report of this follows.

8.2 Discussion, Chaiman - Dr. K. Kanagaratnam

Dr. van de Linde : What part and to what extent does group training play in the training of midwives am public health overseers.

Dr. Ber! : Certain lectures were given on environmental Sanitation, public health education, and nutrition. They were also given external lectures by government departments such as Social Welfare, Agricultural, Rural Health Deve'lopnent, and Labour. Dr. Beri exPlained that about .3QC of the time was devoted to group teaching • • - 38 -

Dr. Kim S How do you select your trainees? •

Dr. Beri : The Government does the selection.

Dr. Kanagaratnam : Whatars the criteria for the selection of trainees?

Dr. Beri s The criteriaar9 that if possible the assistant nurses should have done general nursing training and worked in a health office. Preferably, she should have done midwifery training but it is not necessary, but experience in the health department is essential. Sanitary overseers should have done their basic training. The scheme is new and there. is no time for the overseer trainees to receive full training. II Dr. Nolasco : Asked whether this was in-service type of training and was replied in the aff:irmative.

Dr. van de Linde s Do the trainees go back to the districts where they came from? The reply was that it • was not necessarily the case.

Dr. Kim • Do you have any other training place in other parts o£ Malaya? •

Dr. Bed I No. II " Dr. Dickie : What exactly are the functions of the sanitary II overseers as compared to those of the health r: inspectors?

Dr. Beri and I The sanitary overseers are new appointments Inche Ismail created post-war. There was no such appoint­ ment pre-war. They go the kampongs with the idea of improving the health status of the people. The method of work is merely by advice and persuasion. They work through the community development that has been set up in the various kampongs. They are at present working in a pit-latrine campaign, improvement of water supply and of general health . sanitation in the kampong. They advise the people on growing vegetables for improvement .. of nutrition. They also advise and encourage the kampong people to send their babies f(%' vaccination. They also give health education. Recently, they came across a case of malaria and had an opportunity to prevent the spread of the disease. - 39 -

Dr. Wahab , Was there any evidence of improvement of the health in the district since the operation or the centre? The reply was that there has noli been very great improvenent but the maternity death has gone down a lot. This ma,y be due to • the posting of trained midwives.

Dr. Nolasco , Are all the deaths registered?

Dr. Ber! , In Mala,ya nobod;y can be buried or cremated i. without a permit.

Dr. Nolasco I What percentage of deaths are diagnosed by the doctor?

Dr. Beri , It is not possible to give any figures because they are outside his control.

Dr. Kanagaratnam = What progress has been achieved over the five years by the sanitary overseers?

Dr. Ber! and As a general experience, it is found very !nche Ismail difficult to persuade rural people to build new • type latrines and more important, to use them. However, within a period of four to five years the programme has been so effective that 70 to 8QC of the villagers have built and are using .. them. This is considered a remarkable achievement.

Dr. Dickie = Are there statistics available to indicate that the use of these latrines has resulted in better health conditions?

Dr. Beri , No organised survey but the total deaths have gone down.

Dr. Kranendonk • Is it done by persuasion or education?

Dr. Beri , By education.

Dr. Kanagaratnam : What was the population and the reply 300. Out of 70 houses, 52 latrines and most of these are being used.

Dr. Dickie = What did people do before these latrines • were built?

Dr. Ber! and ; Before construction of these latrines, people !nche Ismai J used to go to the bush. • - 40-

Dr. Wahab Are transport facilities adequate or should these be increased. .. Dr. Beri There is one vehicle given to each centre. There are four and three are stationed here. Dr. Beri remarked that when Mt-. Polak of TAJ.1 visited here the same question was asked for some bicycles.

Dr. Kim : There were 3700 births in 1959. Can you roughly s8¥ what proportion of these births are attended by qualified midwives?

Dr. Beri $ A qualified midwife attends to an average of about 70 cases a month and in all about 900 cases attended by qualified midwives and the others by untrained midwives.

Dr. Florio , What percentage of your staff now actually exist?

Dr. Bert , I have all the staff except the dental nurse.

Dr. Florio Are you turning down requests for qualified • midwives services at the present time? • Dr. Beri s May have to turn down about 5~.

Dr. Nolasco ~ are kampong midwives more favoured? Dr. Beri · Possibly because they were able to make the • · right psychological approach to the kampong people and they are able to meet the services of a trained midwife.

The recruitment programme for the future was geared to recruit persons who come from rural districts so that they would have a better approach to the kampong people.

Dr. Beri commented that five midwives were living right in the kampong.

Dr. Kranendonk , Are there any plans to provide refresher courses to trainees after the,y come back to start a new course?

Dr. Beri s we have refresher courses once a month for public health sisters, public health nurses, etc.

Dr. Kranendonk : Are refresher courses considered necessar,y? Dr. Beri : Not necessary. Dr. Florio : Asked about the scope of the dental nurses and was replied that her work covered cleaning, scaling, fillings and dressings. It was also pointed out that the centre had provision for one dental nurse. -41-

I 9. 30 August 1960, Alor star I • 9.1 Balla! Health Sub-centre

From Jitra the participants proceeded to the Banai Health Sub-{;entre, I • one of three operating under Jitra (main) Health Centre. This sub-centre ! , . was built at a cost of (M) f'J2 000 and opened two weeks ago. It was ,-1/2 I miles from Jitra and served a population of l3 000. The building consisted of I a central waiting room with rooms on either side each of which could be divided in two by curtains. Some or the equipnent for the clinic was provided by UNICEF. OIling to its isolated position the clinic had its own electric generator which also pumped water from a well in the compoun4, ,QUarters for all statf were provided at the back of the clinic within the compound. The resident staff consists of one health "team" consisting of midwife, assistant nuree and public health overseer. Three clinic sessions were held weekly by staff from Jitra main centre; a medical clinic held by the doctor, a dental clinic by the dental officer and child welt are clinic by a public health sister. The resident nurse took blood fUms from patients and the doctor brought a laboratory assistant on his weekly visits.

9.2 Padang Terap Irrigation Works

From Banai Sub-{;entre the group proceeded a short w~ up a narrow road • to the Padang Terap Irrigation Works. Here Mr. Duffy, the engineer in charge showed the participants the dam, built three years ago at a cost of fourteen million dollars to take the waters of a river a distance of five miles across the countr,y to irrigate an area of 80 000 acres of padcV land.

9.3 Buldt Pinang Midwives I Clinic

The next visit was to Buldt Pinan.e: Kidwives' Clinic. This was one of the twenty-five planned to canplete i;lle district health services based on JUra. The building cost $8000 and consisted of one room which was used by the midwife for clinical work and quarters for the midwife adjoining.

The public health nurse visited once in two weeks to discuss problems with the midwife and to conduct a clinic. The midwife in charge mentioned the low haemoglobin values found among some or the patients, particularly the lildians.

9.4 KBmpOOg Jeram Demonstration Area

The next visit was to Kampong Jeram Demonstration Area which was used by the JUra Rural Health Training School for practical work for their students in health education and sanitation. The village had seventy-rour families, all Muslims and engaged in rice growing and work on rubber estates. • The village had a piped water supply delivering to stand pipes. There were village schools and a children I s playground. The village was administered by a Village Council and there was a community deve10pnent cammittee or which the medical officer of health and public health inspector were members. • Two sanitary labourers are attached to the nearest health sub-centre for - 42 - , I I preliminary cleansing work and to assist in training and supervision of villagers responsible for sanitary wcrk. Much evening work was done by the • ! I students from the training school in order to make contact with villagers when they returned home fran work. Th. addition, villagers were taken to the training school for demonstration and education. The importance of maintaining close and ~on1ous relations with the village council and with the district officers was stressed in the training of the students. The main activity in the environmental sanitation programme had been the introduction of pit , , latrines and there were in all over forty in this village many of which were , , inspected by the participants. In addition to bore-hole latrines, with a simple stab and central hole, a new type of latrine with a water-seal I I incorporated in the slab was being tried. This appeared to be the ideal method. A village carpentel;' had been taught to construct the latrine superstructure and the total cost to the villager was between 40 to 100 dollars. Finally J the participants '1fere entertained by the :nnam and other personages of the village.

During the return journey, the group inspected the Tunjang Health Sub-centre which was identical in design with the one inspected earlier at Banai.

9.; Discussion, Chairman - Dr. Lloyd Florio

Dr. Nolasco • Why are the latrines far a~ from the houses? ..

Dr. Ber! and s The latrines have to be sited at a distance mche Ismail from the house so that they can be a~ from sources of water sup~ and also because of • the odour.

Dr. Nol.as co Does not the distance of the latrines from the house cause inconvenience to the people during the rainy season?

Dr. Beri : To a certain extent.

Dr. Wiasoo • From where do they get their water supply?

Dr. Beri , From JUra.

Dr. Nolasco , Is there aJ\1 other W8l' for the people to get water?

Dr. Beri , Yes. There are wells. Drinking water is taken from the pipes. Dr.. Kranendonk , Any plaml envisaged to extend the water • supply into the villagers r homes to improve general cleanliness?

Dr. Beri s People can get free water from stand pipes. If water is connected into the villager's house the owner will have to ~ for installation and water rate. Very few kampong people can afford this. - 4)-

The chairman explained that water-sealed latrines might be used instead of pit-latrines. The installation ot a water-sealed latrine would cost $40 to $100.

Dr. Florio , Has the health department an,y plans to help in this respect?

Dr. Beri : Not at the moment.

Dr. Florio : How about a drainage system?

Dr. ~1 : Our tirst project is to provide latrines. We have not yet embarked upon drainage.

Dr. Florio • The cost ot installing the latrine is $40. Do the village people have the mCClay to build?

Dr.Ber! • Not all of them.

Dr. Shu • Is a midw1te t s salary of $80 rising to t2~ per month cCCls:1dered good ~ in this country? • Dr. Ten • Yes. The average income of a kampong tolk is $50. (h advertisement of a vacancy tat.' midwives, there are more applicants than required.

Dr. Kim • What measures are taken to prevent typhoid tever?

Dr.Beri , The measures taken are t

(a) improvement of water supply (b) tood handlers receive regular vaccination (c) Jitra water is chlorinated

Dr. Wahab : Asked tor more particulars about tood handlers. It was explained that all emplo,yeea at Jitra who worked in connection with water supply should have a medical examination. They receive typhoid vaccinations.

Dr. Kim • Have you found many carriers?

Dr. Beri , In 1957 J two carriers were tound. • None recently • The Chairman explained that this practice had been dropped in marv places as it was con­ s-idered not worth the etfortJ time and money. -44-

Dr. van de Linde said that this practice was being carried out in Hong Kong for matij" years but was of doubtful value. It was required by law.

Dr. Truong : What are same detaUs of health education in the kampongs?

Inche Ismail : Quite a lot has been done to educate the people; talks have been given on healt h matters, organised classes have been conducted in the kampong as well as in this school and individual house to house visits by student overseers.

Dr. Florio : Are these visits effective?

II Dr.Beri : . Yes. Visits by the various heads cd: departments, leaders of the communities, religious heads, district officers, to the rural people are of great help to the success of the campaign. .. Dr. Truong I What is the part of a school teacher in the field cd: health education?

1m. Beri : Staff and trainees are made togo to the schools (not all the schools in the district) to educate the teachers and children on health matters. Then it is hoped that the teachers will carry on With the work.

The Chairman closed the session and thanked Dr. Beri and his staff for the excellent organisation of the tour which had been an enjoyable and memorable one.

10. 1 Seplielllber 1960, Penang

10.1 Dental. Nurse.s Training School

The participants were first shown around tb3 Dental Nurses and Dental M3charu.cs Training School by the Principal, Mr. C. J. Sundram. The School for Dental Nurses had about fifty pupils, and tb3re was a staff of one principal, two dental surgeons and eight staff dental nurses to train them. For the first four months, pupils worked in the section containing models, where preliminary work was done under close supervision, and the studentts manual dexterity and suitability for further training assessed. Then they • passed on to graded work on patients and to the producticn of health educa­ tion posters and exhibits, etc. There was a large children's clinic with twenty-nine chairs, in which the students wcr ked on school children. Attached was a waiting room where children read and played games, under the • supervision of two nurses. The lecture room and demonstration room, both air-conditioned, were also visited. - 45 -

The course of training in the school itseli' luted for two years~ following which students did one year and four months field work~ in outside clinics before being fully trained and qualified. Each student nurse on government service (E17 at present) was provided with a set of basic equipnent which was standard and cost about }o$1200 to $1500. The policy of the Government of the Federation was to post five dental nurses under the supervision of each dental officer.

1ll the Dental M:lchsnics Training Section~ there were thirteen students in training~ of whom eleven were pupils, and two trained mechanics back for a refresher course. The training was supervised by a senior instructor and one assistant.

1ll addition to the training school, there was an out-patient dental clinic attached to this section, staffed by a specialist and two dental officers.

The participants were most impressed by the excellent health education posters and paintings on the walls of the children's clinic and waiting roan and by the efficient organisation of a busy school of trainjng in ver,y limited acccmmodation. .

10.2 Health Visitors Training School • A visit was next paid to the training school for public health visitors~ housed in an old two-storeyed dwelling. This school gave a one- year course of public health nurSing to about twelve trained nurse/midwives each year. It was started in 1954 with the help of WHO and had reciprocity with the General Nursing Council Health Visitors Course in the thited Kingdan. Eum1 nations were carried out by the Overseas Eltamination Board of the Royal Society of Health, and examiners were chosen from a panel of examiners. fran Singapore and the Federation. Successful students received the Health Visitors Certificate and returned to their own States~ where they became Public Health Nurses~ and were eligible for promotion to the posts of PIlblic Health Sister and Matron in due course.

1ll this school also, emphasis was laid on health education work:~ and models and posters prepared by students were on display in the entrance hall and upstairs in the librar,y and demonstration room. Students lived in the nurses' hostel and not on the school premises. The Principal Matron of the Federation~ Hiss Hooper and the Health Visitor Tutor~ Mrs. G.M. Paranjot~, who was in charge of the training school, sholfed the participants around and explained the course, etc.

10.3. The School of Nursing

The Principal Matron next showed the participants round the School. of Nursing~ and nurses' hostels, which had accommodation for 285 nur8es~ and 45 hospital assistants. Tea was served :in the very attractive dining roan in the hostel by the Acting Matron, Mrs. Che Lah. The hostel offered ver,y attractive accommodation for otudent nurses who paid ~ $45 per month for their food. There was also a shop~ and II Perm Parlourll attached to the hostel. A staff of six tutors was available to train student nurses - two of them being males. The Principal Matron explained that, up till 1957, - 46 - there was a serious shortage of student nurses, but since then, with the improved living conditions provided and the general improvement in educational • standards there had been no shortage of applicants. This year there were over 400 applicants, all possessing the Senior Cambridge Certificate, for just over a hundred vacancies.

The school itself, which was official~ opened at the end of 1958, was a very attractive and well planned modern building with three floors. ~ the ground floor were situated the offices of the Tutors, General orfice and Conference Hall. ~ the first floor were situated the pt"actical demonstra.. tion room, lecture room No.1, the laboratory and kitchen. On the second floor were the library, lecture room No.2 and a large room used for lectures, film shows, etc. In this room, the participants were shown two interesting films taken of a pageant of nursing, staged in Penang in 195;. , There were three training schools in the Federation, the other two being newly opened in Johore and Kuala Lumpur.

10.4 Penang General Hospital

A tour of the Penang General Hospital was made in the afternoon, with the Chief Medical and Health orficer, Dr. S. Nadarajah and the Hospital Administrator, Che Yusoff aIXl Matron, Miss Lim Sang Yeap in attendance. The hospital buildings, erected in 1936, were old-fashioned in design and now obviously inadequate, particular~ the out-patient accommodation.

(h the ground floor were situated the chest clinic, with its chest screening unit and BeG clinic, the dispensary and store, the casualty .. admission cem.re with minor operation theatre, and consulting rooms. At one end of the long central corridor was situated the admission hall and waiting­ room. This department had to deal with an average of 700 to 800 out-patients daily, and it was obvious from the congestion in the central, and ill-ventilated COrridor, that the accommodation was now inadequate for this number of patients. Six doctors and thirty nurses and hospital assistants were employed in this section.

On the second floor was situated the Dental Nurses Training School visited in the morning and also consulting rooms for the two ~sicians, the paediatrician and the medical. officer in charge of the Skin Clinic.

On the third floor, the X""I'ay Department was viSited, and the Eye Clinic which had its own operating theatre and was in the charge of the Ophthalmologist, Dr. Wong Foh Lam. (h the same floor were situated the operating theatre Suites, with two surgeons, Mr. Alha~ and Mr. OtMalley, in charge. The pQysiotheraP,r department was attached to this department. The blood bank was situated on the fourth floor, and again it was apparent that the accarunodation allocated to this important unit was inadequate. « About 220 donors per month were bled, and of this number about 3e· were relatives of the llltients, and the rest, servicemen and other voluntary donors. There were three bleeding sessions weekly, conducted b,y the duty medical officer. ~ the same floor were situated the first-class female wards, where paying patients are accoDllllOdated in single rooms (~5), double rooms (~) or in four-bed wards (~O) per day. A psychiatric "ward" and - 47 -

isolation room are also attached to this floor.

em the top floor, the first-class wards were situated.

In an adjoining wing, the third..cl.ass accamnodation was visited, and a large male surgical and orthopaedic mit of over seventy beds, inspected. Attached to this mit was an air-conditioned "Tetanus" room, with full facUitie s for the treatment of cases of tetanus, using the method of total paralysis, and positive pressure artificial respiration through a tracheotOlQ' tube perfected by the surgeon, Mr. Alhady, who gave delegates a most interesting accomt of the treatment used.

A visit was then paid to an exhibition on s,ystems or recording hospital statistics and records, organised b,y the WHO Hospital Records Officer. Specimen fol1llS from III8l\Y hospitals in other countries were on display. Following this, a viSit was paid to the hospital records office, where the methods used in the Penang General Hospital were described by tlB statf. Final.ly, before adjourning for tea, the participants paid a most intereBt~ visit to the Sea Snake and Venom Institute, where specimens of local SIlE es, both harmless and poisonous were on view, and a mal t efficient displq of hON' to milk the venom or a pit-viper was given b,y a member of the statf.

• 10.5 Discussion I Chairman - Dr. K. Kanagaratnam Dr. C. Nadarajh started with a description of the geographical and climatic cOnditions in Penang follON'ed with an explanation of the medica. and health services as outlined in the sUllllllal'y sheet provided.

Dr. Kanagaratnam • Wlv is rural 11m work carried out b,y a public health nurse and not by a medical officer?

Miss Hooper • (a> Because the work is mostly prevenliive and medical cases can be sent to hospital;

(b) Because of shortage of medical officers. However, one medical and health officer is provided for every 50 000 people in future planning.

Dental School

Dr. Wahab • What allowances are paid to students in training?

Mr. Sundram • The Federal Government pays ~'J7 fran which the student. must pq for her accamnodation.

Dr. Chang • How are trainees recruited?

HI:'. S1.Uldram • By the Federal Government from a general " pool. - 48 -

Dr. Truong = What are the responsibilities of an • assistant dental nurse?

Mr. Sundram = There is no such staff but only chair-side assistants who do no treatment.

Dr. Kim : Where are dental nurses posted after training?

Mr. SundrSlll : Five nurses are allowed to one dentist and mq be posted to schools or to health centres.

Dr. Dickie r What percentage of work is devoted to schools?

Mr. Sundram r Ninety per centj but because accommodation is not available for dentists, only dental nurses work on school. premises.

:rt; was added that only a few schools provide sick rooms.

Dr. Nolasco : Are school nurses under the department of education or health?

Dr. Tan = Ministry of Health.

Dr. Dickie : What is the cost of equipping a dental nurse?

Ml'. SundrSlll ; Basic equipnent - ,Mi286; Chair - *00 and • foot-operated engine - Mi200.

Dr. Wahab : Are there plans to replace the dental school by a separate building?

Ml'. Sundram = No. although this is desirable. However, there are long-term plans for a new building.

Nurses r Training

Dr. Nolasco I What are the education requirements for nurses?

Miss Hooper : Form 4, but most students new have Senior Ganbridge. Midwives and assistant nurses have a lower standard but must have knowledge of Malq and sane English. , Dr. Chang : Who supervises the field work of the public health student nurse?

Mrs. Paranjotb¥ The Health Matron and the Health Visitor Sister Tutor. - 49 -

Dr. Nolasco : Why does a nurse have no midwifery in her • training? Miss Hooper : The nurse does her midwifery as a separate course after her general training. It is not compulsor,y but it is necessary for promotion to sister.

Dr. Wahab • Is it possible to send nurses for training in health education alone?

Kiss Hooper • No separate course is g:IYen but health education fCll'DlS a major part of the training of health nurses.

Dr. K1JIl s What percElltage ot deliveries are pertcrmed by qualified midwives?

Dr. Ten , statistics are not available but probabl¥ Kiss Hooper ,qe in urban areas and 25% in the rural areas.

Dr. Chang t Who is responsible for ante-natal am post­ natal care? • Kiss Hooper : The district midwife under supervision of the public health nurse. The Public Health Sister is in administrative charge.

Dr. Wahab : Has the Midwives t Ordinance been eri£orced yet?

Kiss Hooper • Not yet. but steps are being taken to register unqualified midwiVes. There are not yet enough qualified midwives to replace all the unqualified.

Dr. Kimagaratnam : What is the training ot Hospital Assistants?

Kiss Hooper • The same as temale nurses except; that; they do dispensary and laboratory wCIl'k instead of midwifery.

Dr. OBald. a What is the staff of the governmEll t hospital?

Kiss Hooper • 44 medical staft including 9 specialists and others (2 surgical. 2 medical, X-..r/i¥, eyes, dental, gynaecology, tuberculosis J clinical pathology and children. 2 posts are unfilled). The VD specialist is part time. 1 matron, 2 assistant matrons. 20 nursing sisters. 56 staft nurse, and 300 probationers. There are 400 attendants. - 50 -

Dr. Wahab : What are the allowances for sisters?

Miss Hooper : Details should be obtained from the Ministry but the scale is approximately ~oo to ~5B5. Emoluments vary according to the grade but two increments are paid for the public health oertificate.

Dr. Kanagaratnam : In Singapore the starting salary is i325 with an allowance of ~30 for a public health nurse doing public health work.

Dr. Kim • What is the control of health work in George Town?

Dr. Ten • Health services including medical treatment and infectious diseases are provided by the Federal Government but the City Council is responsible for environmental sanitation. IDcal councils throughout the Federation are encouraged to run their own affairs but the Govermnent will help those who cannot do so.

Dr. Wahab : Is there advantage in central control in Singapore? •

Dr. Kanagaratnam : Yes, but it would not be practicable in a large country such as the Federation. .. Dr. Shu mentioned two WHO projects;

(a) Hospital Records, and (b) Hospital Administration.

Che Yusoof described the training in hospital administration.

Dr. Kanagaratnam , What are the requiremnts for and the salary scale of hospital administrators?

Che Yusoof' : Higher school. certificate. - Scale is 1IP50 to ,700 but superscale positions will be provided for larger hospitals in due course.

Dr. Wahab • Will the position of medical superintenden~ become unnecessary when more hospital administrators are trained? , Dr. Kanagaratnam , Defnitely not. The non..medical hospital administrator must always be subordinate to the medical superintendent although the latter might be able to work part time only in future. - 51 -

Dr. Kim : How are free cases assessed in hospitals?

Dr. Ten c By almoners. There is no means test" and patients must be treated free if they state that they cannot pay.

Dr. Kanagaratnam thanked all those responsible for making the visit to l\:Inang so successful~ in particular~ the Chief Medical and Health Officer and Che Yusoof. In particular~ Dr. KalUlgaratnam referred to the excellent facilities far all forms of training which were available in .fenang.

11. 2 September 1960~ ICuala Lumpur

Before the meeting started~ it was announced that a decision had been made to curtail the official programme far the day due to the death of His Majesty the King. The visits to the Public Health Inspectars'Training School and the Malaria Eradication Project would be followed immediately by the usual question-and-answer session~ following which the final session of the conference, attended by the Honourable Minister of Health and Social Welfare~ would be held.

11.1 Public Health Inspectars' Training School

The medical officer in charge of the school~ Dr. Livera, welcomed the • participants to the PUblic Health Inspectors' Training School, and referred them to the document already handed out, which gave a full description of the history of the school and details of the syllabus, etc. This school, which started in 1959, was training the second batch of students who were at the time sitting their examinations. There was a close liaison with the Ro,yal SoCiety of Health in Singapore which conducted the examinations leading to the Ro,yal SoCiety of Health Certificate of the Society. The staff of the school consisted of one medical of£icer-in-charge~ one chief public health inspectar and several subordinate staff. In addition~ there was a panel of visiting lecturers who gave lectures and instruction on various subjects covered by the syllabus.

The course of training was divided into three terms of twelve weeks each. At the end of the first term, an examination was held by the Royal Society of Health of Singapore and successful candidates passed on to the second term. Those who failed were allowed a resitJ but if again unsuccessful, they were asked to leave. Part II of the examination was held at the end of the third term and comprised five written papers, four oral examinations 8ld two practical tests. During the course, each candidate was required to make a health and sanitary survey of a village, and to sulnit a report which farmsd part of the examination.

The participants were next shown a very good exhibition of photographs, • models and gra}ils, which gave a wide picture of the wark of the Health Department. It consisted of:

(1) graphs and pictures showing the progress ih the health services during the emergency, i.e. birth rates, infant mortality rates, the incidence of diseases such as di}iltheria, typhoid, malaria, smallpox and ~sentery, etc. - 52 -

(2) an excellent mechanical model which gave a clear picture of the Rural Health Scheme. •

(3) Pictures showing the work of the ante-natal clinics, th3 maternal and child health services including immunisation, the dental services, school health services, introduction of " exhibits, travelling dispensary services, rural sanitation wcrk and new resettlement villages.

(4) A display of malaria posters and pictures, showing the main vectors and graphs showing the falling incidence of the disease, over the past ten years.

Next, an exhibition of three types of water-aeal latrines, was inspected. These three models were all very similar in type witb the following differences I

(1) A simPle type, with a concrete alab~ with concrete water-aeal leading to a pit at the side. Superstructure of attap. Total coat about ~O.

(2) The Siamese type with a porcelain pan and water-seal, and the pit directly below. Superstructure of wood. Total coat about *50.

(3) A more permanent type, similar to (1) but with porcelain pan and permanent wooden superstructure. Cost $100.

In all cases, the pits were dug to about fifteen to twenty feet, unless the water-table was higher.

1l.2 Malaria Eradication Pilot Project

This project which was in the charge of Dr. Hassan, Malaria Eradica­ tion Officer of the Federation, assisted by a WHO malariologist, entomologist, and sanitary engineer, had ~ been operating for a ver,y short time. The pilot project area was situated in north Selangor and in it four of the five anopheline vectors in Malaya were found, i.e. A.. sundaicus, rraculatus, letifer, and Barbirostris (black winged variety).- The fifth vector, !: ~rosus had not been found. Contrary to expectations it bad been discovered b,y meang of blood parasite surveys in school children that the incidence of malaria was highest in the coastbJ. areas (up to over 5~ podtives) while in the inland areas, malaria was practically non-existent. The principal vector in the coastal areas was A. sundaicus with a few A. barbirostris also present. A. letifer was only found occasionally, and A:. maculatus was also scanty and found in the more inland districts. No. A. umbrosus had been found. It was intended to carry out D.D.T. spraying • of houses in the pilot project area, twice yearly and at the same time to give each personal dose of an anti-malaria drug, Le. 300 mgm. Chloroquine - 16.5 mgm. of pyrimethamine - 3 tablets per adult, 2 per child and 1 for infant. I I I I I - 5.3 - I I • 11 •.3 Discussion

Public Health Inspectors I Training School

Dr. Diclde : What field work do the trainees do apart from their report?

Dr. Livera I Four mornings a week in visits to food­ handling establishments and environmental health projects.

Dr. Nolasco • What is the cost of training each student?

Dr. Livera and a $16 000 was spent last year tor twenty-tour Dr. Karagaratnam students. This does not include salaries of the medical otticer-in-charge and the Chief Health lhspector. The basic cost was $1500 for each student.

Dr. Yung and = Are trainees in-service personnel. or new llr. Nolasco recruits? • Dr. Livera : In-service personnel. Staff are put through the course one or two years after recruitment but there is now a considerable backlog.

Dr. Chang : Are therE) plans to increase the training facilities and reduce the backlog?

llr. Din and • Soma staff are being trained at Singapore llr. Kanagaratnam and this school will be extended to torty students.

Malaria Eradication Pilot Project Dr. Dickie s What time has been allowed for this pilot project?

llr. Hassan I Eighteen months but this is too short and two to three years will be necessaxy. The pilot project includes spraying and drug treatment throughout the project area.

11.4 General Discussion

Dr. nm said he was most impressed by the training programme and by the Rural Health Scheme with its great expansion of medical tacilities. He I • felt that too much stress had been laid on dental services rather than on other camlDludoable diseases. He asked whether &I\Y insurance scheme had been considered in view of the high cost of the proposed work. - 54 -

Dr. Din replied "I agree that dental work has been gtven priority • and it is mostly concentrated on school children. Friori~es will be sorted out as the scheme develops. An expert from the International Labour Organization has investigated the probl.. em of costs".

Dr. Dickie said he was most impressed by the integration of preventive and curative services and especially by the well thought out "master plan". He was also struck by the fact that health education was being taught to all workers in the service. He felt it would be necessary to rely on hospital assistants for some years in rural areas. They should be suitably trained to treat minor ailments.

Dr. Din replied that it was important to stress the fact that the public must pay their part in preventive work. He agreed that hospital assistants were valuable in certain fields.

Dr. Nolasco asked whether the rural health service work in liaison with other agencies. Dr. Din replied that there had been little l1a1son in the past but this was being remedied.

Dr. Shu said that in China many years ago the missionaries had first trained worHers of the hospital assistant grade. There was a danger that their limitations might not be known and their position misunderstood.

Dr. Din asked whether it had been found in othe:r ."Wltries that the extension of rural health services meant a greater or a lesser load on urban hospital accommodation. ... Dr. Nolasco, Dr. van de Linde and Dr. Kanagaratnam replied that at first hospital accommodation would be very heavily taxed but later it would be possible to treat more cases in outlying areas so that the pressure on urban beds then become less. In additio~ as rural health services were given, it was possible to discharge patients to rural homes earlier. Dr. Estrada said that the criteria for admission of patients.to hospital from rural areas needed careful consideration.

Dr. Din asked whether the general experience of travelling dispensaries was valuable or not.

Dr. Dickie, Dr. Nolasco and Dr. van de IJ.nde said that travelling and float:ing dispensaries were of value in pioneer work in outlying islands and remote areas. Their value was limited because the time spent in eaoh place was inevitably short. As rural health services were extended, travelling dispensaries might be withdrawn. , Dr. Din asked whether, as the midwife was the first line foroe in rural health services, she should be responsible for BCG programme work. • I Dr. Kanagaratnam and Dr. van de Linde said that both in Singapore and Hong Kong, considerable use had been made of private and government midwives to carry out BCG inoculation. In Hong Kong, 45%01 .. babies delivered by midwives had been so inoculated. - 55 - PART m

ANNEXES

LIST OF iU.TICIaNTS

BRUNEI Dr. Abdul Wahab bin Mmamed Ariff state Medical Officer

CHINA. (TAIWAN) Dr. C. K. Chang Director Department of Health Administration Ministr,y of Interior Taiwan

Dr. Mohd. Din bin Ahmad Director of Medical Services Ministr,y of Health and Social Welfare Kuala Lumpur

Dr. Ten Yoon Fong Co-leader • Deputy Director of Medical Services (Medical) Mln1str,y of Health and Social Welfare Ifual.a Lumpur

Dr. S. Parampalam Dewt;y Chief Medical and Health Officer Selangor

HONG KONG Dr. P.A.M. van de Linde Medical Officer of Health (New Territories) Medical and Health Department

Dr. Y. Ozald Chief National Hospital Section Medical Affairs Bureau Ministr,y of Health and Welfare Tokyo

Dr. Y. S. Kim Chief, Public Health Section Ministr,y of Health and Social Mfairs • Seoul - 56 -

NE'lRERIANDS NEW GUINEA. Dr. J. O. M. Kranendonk Rapporteur Inspector of Preventive Services • and Deputy Director Public Health Service

NORTH BORNEO Dr. J. A. B. Nicholson Deputy Director of Medical Services Medical Department Jesselton

HlILIPPINES Dr. J. Nolasco Rapporteur Director of Health Services Department of Health Manila

RlRTOOUESE TImR Dr. M. G. Gomes Chief of Health Services Timor-DiU

SARAWAK Dr. R. Dickie Rapporteur Deputy Director of Medical Services Medical and Health Department Kuching • SINGAPORE Dr. C. Marcus Permanent Secretary to Ministry of Health and ... Director of Medical Services Singapore Dr. K. Kanagaratnam Assistant Director of Medical Services (Health) Ministry of Health allTED STATES OF AMERICA. Dr. L. Florio Leader Chief, Health Division United States International Cooperation Administration Manila, Philippines VIET NA.M Dr. te-Cuu Truong Direotor-General of Health and Hospitals Seoretariat of state of Health Saigon • - 57 -

• SINGlU'ORE HEALTH Hr. T. F. lore MINISTRY OFFICIAIS Public Health Engineer

Mr•• M. Knight Health Education Officer

WHO STAFF Dr. W. W. Yung Area Representative

Dr. C. Y. Shu Regional PUblic Health Administrator WFRO/Manila

Dr. Remedios Estrada Public Health Administration (Rural Health) Adviser Kuala Lumpur

Ht-. J. Sala Interpreter/Translator WPRO/Manila

Mt-. K. S. Krishnan Epidemiological Intelligence Station Singapore (Administrative Assistant)

Mt-. H. S. Mony Epidemiological Intelligence Station Singapore (Secretary)

•

.. ·- .;

- 58 - ANNEX n

rrINERARYFOR PlBLIC HEAL1li CONFERENCE AND Sf®! fOUR

Part I: Singapore, 2C>-25 August 1960

Sat~, 20 A.ugust 2155 Arrival at Singapore by PA831 from Manila. Checking in at Hotel Biltmore as arranged b,y Conference Secretariat.

Representatives of Ministry of Health will meet delegates and see to their accQlllDlodation. Official transport will pick up the participants from airport to Hotel Biltmore.

SundqJ 21 August 0050 Assemble at Master Attendant's fier to take launch.

OJOO-1200 Leave for St. John's Island. Tour of Quarantine station. Tour of Opium Treatment Centre.

1200-1400 Picnic lunch on st. John's Island.

Conducting Officers:

P.H.O. to conduct party around Quarantine station.

M.O. i/c O.T.C. to conduct party around Opium Treatment Centre.

High Tide at 10r30 a.m.

Please bring your swim suits as the tide is suitable. In the event of bad weather, M:ldical Officer's bungalow at St. John's Island to be used for entertaining the participants, otherwise, open-air function in the sw:imming pagar area.

1500 Leave st. John's Island for Singapore •

• 1900 Cultural evening "Aneka Ragam Rayat" - arranged by the Ministry of Culture at Hong Lim Green.

.. Monday J 22 A.ugust 0050 Guests to be seated in Conference Hall.

OJOO Arrival of the Minister for Health. - 59 -

orficial opening of the conference and stuctr ! ! tour at the Institute of Pathology by the • r I Minister for Health, Inche Ahmad Ibrahim. i I

I I

0915-1000 Report on Developnent of Medical and Health I I Services in Singapore b,y the Director of , , Medical Services, Dr. C. Marcus. • II

1000-12.)0 Visit to Institute of Health. School Health Service, including School Tuberculosis. I I Clinic and School Dental Clinic. Public Health Inspectors I Training Centre. Maternal and Child Health Clinic. D.P.H. Course - lhiversity Department of Social Medicine and Public Health (WHQ-assisted project completed). Public Health Nurses t Training Course (VIIO/ UNICEF-assisted project).

1400-1500 Visit to School of Nursing.

1500-1600 Visit to thiversity Department of Dentistry and Dental School in General. Hospital. •

1600-1645 Visit to Institute of Pathology.

1645-1745 Question-and~swer session at the Institute of Pathology.

2000 Dinner at King Edward vn Hall b,y tm Dean of the Medical. Faculty J thiversity of Malaya.

Q8sday, 23 August 0830...Q915 Visit to Department of Chemistry.

0915-1015 Visit to Medical Faculty, thiversity of M81~a. Department of Bacteriology. (WHO Influenza Centre and WHO Foli~elitis Centre) •

1015-1245 Visit to General Hospital., inoluding visits to Administrative thit, Out-patient Department, Medical, Surgical and Paediatrio thits, and other units.

Medical store and drug manufactory.

Fost-.basic Nursing Training (WHO-assisted project). - 60-

1400-1700 Visit to Trafalgar Home and Woodbrldge • Hospital. Leprosy Settlement.

~ntal Diseases Hospital. ~ P8,ychiatric Nursing Training (WHO-assisted project) •

1700-1730 Question-and-answer session at Woodbridge Hospital.

Lecture Theatre.

2000 Official dinner by the Minister tor Health to participants of the conference and st~ tour at Sri Temasek.

Wednesday J 24 August 083Q0.0915 Visit to City BacteriOlogist and City ~st Laboratories.

0015-1030 Visit to Kandang Kerbau Hospital. • Maternal and GynaecOlogy Service.

DomicUiary M1.dwi.tery Service (WHO-assisted project) •

lO30-10t+5 Visit to Pegu Road Out-patient Clinic.

1Ot+5-l2oo Visit to Thomson Road District Hospital.

1200.. 1230 Question-and-answer session at the Institute or Health.

1400-1500 Visit to Royal Singapore Chest Clinic (SATA).

1500-1700 Visit to Tan Tock Seng' s Hospital (Tuberculosis).

1700-17.30 Question-and~er session at the Institute of Pathology.

17.30 Tea party by the Singapore Medical Association to the participants at the Alumni ~dical Centre.

ThursdayI 25 August O}OO-lOOO Visit to Singapore EpidemiOlogical Intelligence • Station • .. - 61 -

1000-1045 Visit to Middleton Hospital.

1045 -l2.3 0 Visit to Middle Road Hospital (Social ~giene).

Tanjong Pagar Clinic (Social ~giene). • hsir Panjang Maternal and Child Health Clinic. l2.30-1300 QUestion-and-answer session at the Institute of Pathology.

1430-1700 .Public Health Conference at Institute of Pathology.

Summary and review. General discussion.

1700 Conclusion of conference.

2200 Departure tor Kuala Lumpur by train. •

• - 62 -

.. Part n • Federation of Mal~a, 26 A.ugust-2 September 1960

FridayJ 26 August CIllO Arrival at Kuala Lumpur by train trom Singapore.

~ 0930-1030 Opening ot oonferenoe and st~ tour at Institute tor Medioal Researoh (00) by the Honourable Minister of Health and Social Welle., Dato' Cklg Yoke Line, P.M.N., M.P. Report on DevelolJllent ot MadioalandHealth Servioes in Federation of Malaya, with partioular emphasis on Rural Health Services.

1030-1045 Coff~ break.

1045 -.1.200 Visit to Institute for Medioal Researoh - Research and traini ng faoUities of lMR.

1200-1230 Queation... nd-answer session at DlR.

]300-1400 Lunoh by Minister of Health and Sooial Welfare at the Lake Club Orohid e Room. 1400-1630 Visit to Sungei Buloh Leper Settlement. Medical care and rehabilitation of lepers.

170()..,l715 Tea break.

1715-1800 Queation-and-answer session at 00.

Saturday, :n August CIlOO Leave hotel tor field visits.

C173 ().()8J0 Seaport; Estate - Estate Health.

0900-1000· Petaling Tin - Mine Health.

lO3()..UOO Sungei Way New Village.

1130-l200 RID! Training School.

1200-]300 Housing Developnent, Petaling J~a.

]300-]400 Imlch by Medioal Offioers of Health Association.

1430-1530 Question time • • 1650 Leave for Penang by MI.. 152. , 1840 Arrive in l'enang. Sundq,28A.ugust CIl30-1200 Picnic excursion :including a visit to Quarantine Station, Leper Camp, TS Sanatorium at Pulau Jerejak organised by Medical Sports Club. - 6.3 - iondll¥, 29 August 083()-()930 Maternal and Child Heal. th Clinics in Penang Island.

1000 Departure for Kapala Batas by bus.

1300-1400 Lunnh at Kapala Batas Rest House. • II II 1400 Leave for Jitra. II 1420 Arrival at Rural. Health Training School. ~ I 1450 Arrival. of Hon'ble Mentri Besar, Kedah.

1500 Arrival. of H. H. Sultan of Kedah.

1505 Address by Director of Medical Services.

1510 Address by H. H. the Sultan of Kedah.

1520 H. H. the Sultan of Kedah leaves.

1530-1630 Tour of Rural. Health Training School.

1715 QuestiCl'l time. •

1930 Reception and Cocktiail Party by H. H. the Sultan of Kedah. .. 2145~345 Cultural show at JUra Rural Health Training School.

Tuesdq, 30 August OS15...()900 Visit to Banal and Padang Terap D. I.D. H"aciworks

~3O-1000 Kampong Jeram Demonstration Area.

1100.. 1200 Tunjang and Kodiang Health Centres.

]230-1.300 Question time at Jitra R.H.T.S.

1300-1400 Lunch at Jitra. -

1500 Leave Alor Star for Penang by bUB.

1700 Arrive in Penang.

Wednesda¥, 31 August MERIIEKA. HOLIDAY - MERDEKA CELEBRATIONS • Thursd~, 1 September ~00...()930 Meeting with Chief Medical and Health Officer, Penang, at School of Nursing.

Introduction to the State Medical and Health Services in Penang. -64-

• Visit to School of NurSing, Penang • 10.3 0-1100 Visit to Dental School, .Penang. 1120-1200 ViBit to Public Health Visitors' Training School.

1200-1230 Question-and-answer session at School of Nursing.

1430-1630 Visit FBnang General Hospital.

(i) Out-patient and in-patient facilities. (ii) Hospital Administration. (iii) Hospital Records.

1630-1730 Question-and-answer session at School of Nursing.

2CX25 Leave for Kuala Lumpur by train.

Fr1~ I 2 September 0712 Arrive in Kuala Lumpur.

093 0-12.30 Visit to Public Health Inspectors' Training School. • Malaria Eradication Pilot Project.

1400-16.30 Public Health Conference, (i) General discussion.

(i1) Summar,y of visits. (iii) Closure of conference and stuQy tour by M:l.nister of Health.

19304130 Buffet supper at Le Coq d'Or - Official reception.

1 - 65 - ANNEX III

LIST OF INSTIT~IONS AND PROJECTS VISITED

A. SINGAFQRE

I. Government medical and health institutions

1. Institute of Health

2. Public Health Inspectors' Training Centre

3. Hlternal and Child Health Clinic

4. University of ~a

(a) Department of Social and Preventive Medicine, including WHQ04ssisted Public Health Nurses' Training Course

(b) Institute of Pathology

5. School of Nursing

6.· General Hospital, including WHO--assisted Post-Basic Nursing. Training

7. Trafalgar Home

8. Woodbridge Hospital, including WHQ-assisted Psychiatric Nursing TrS:'n1~

9. Kandang Kerbau Hospital, including RHCl-assisted DomicUiary Midwife17 Service

10. Pegu Road Out-patient Clinic

11. Thomson Road District Hospital

12. Tan Tock Seng Hospital

]3. Middleton Hospital

14. M1.ddle Road Hospital

15. Hltemal and Child Health Clinic at Pasir Panjang

II. Voluntary Agency

I , Singapore Anti-Tuberculosis Association (SATA) , -66-

III. WHO projects$ 1. WHO Epidemiological Intelligence Station

2. 'WHO-designated Influenza and Poliomyelitis Centres

B. FEDERATION OF HAIAYA •

muA LUMPUR

I. Government medical and health institutions and projectss

1. Institute for Medical Research

2. Sungei B\U.-Oh leper Settlement

3. Public Health Inspectors I Training School

4. Malaria Eradication Pilot Project

II. Other institutions and projects:

1. Seaport Estate

2. Petaling Tin Mine

3. Sungei Way New Village

4. .f9taling Jaya Housing Developnent ..

5. Rural Industrial Developnent Authority Training School (RmA)

Government medical and health institutions and projects:

1. Tuberculosis Sanatorium

2. leper Camp

3. Quarantine Station

4. H::H Clinics

5. The School of Nursing

6. Health Visitors r Training School • I 7. Dental Nurses Training School

8. Penang General Hospital, including ltiO-assisted Hospital Administration and Hospital Records projects • - 67-

ALOR STAR • 1. Jitra Rural Health Training School

2. Banai Health Sub~entre

3. Buk1t Pinang Midwife Clinic

4. Kampcmg Jeram Demonstration Area

5. Padang Terap Irrigation Works

•

,

• -68- ANNEX IV

ADDRESS OF MINISTER CF HEALTH, STATE OF SINGAPORE AT THE OPENING CEREK>NY OF mE PUBLIC HEALTH CONFERENCE AND STUDY TOUR IN SINGAPORE, K:>NDAY, 22 AtXH5T 1960 • Ladies and Gentlemen,

The occasion of an international conference such as this WHO Public Health Conference and Study Tour to which our Government plqs host is a privilege md a great cheer to us. Today, we have here gathered from fifteen countries in the Western hcific Region. from Tok;ro to Timor, from *nila to Kuala Lumpur, delegates who are senior members of the health services in their territories.. To them it is our intention to show the medical and health develoJlllElnts in Singapore and to this aL m, the officers of my .M1nistzy have worked out a programme of visits and tours interspersed with discussions. You will see from the pt'ogramme which you have all received that it is a heavy pt'ogramme - into which a certain amount of light relief and entertainment has been thrown. (b tbe occasion of a conference such as thiS, not only is tbe formal programme of importance, but also the opportunity for personal contact among the worle rs in the public health field and through such informal contacts for the exchange of news, views and ideas on various problems. These oontacts will serve as a valuable oontinuing link, and • I hope will be of some stimulation.

lD the limited time available for the conferenoe, it is natural that everything we wish to show could not be sandwiohed into the prograae but the discussions that will take place daiJ¥ will help considerabl¥ to fill the gap.

The medical and health developnents of Singapare call for some comment. S1ngapare has been free from major infectious diseases - amaJ.:Lpox, cholera and plague - for over ten years except. for a localised outbreak of ten cases of amallpax following the introduction of an :lJllported case in AprU 1959. Halaria. has been non-existent. although nearl¥ $2 million are spent for anti...mal.arial services. Other infeotious diseases are being taokled but some of them do present a problem at the moment. Tuberculosis for instanoe, is the major problem faoing the health administration and measures to carry out a oase-finding programme in the last quarter of this year, as well as the introduction of oompulsory BeG immunisation programme for infants are in hand. So, too compulsory measures against diphtheria. of which some 500 to 600 cases occur in Singapore annually are being planned. While l8¥ing the emphasis on preventive health servioes, plans for the physical expanSion of both the preventive and curative services are in hand to meet the growing demand - made up by two factors, the population increase and the growing confidence of the people in our modern medical. service - increased eUnics, new district hospitals and health centres are all being planned. Training of staff receives the highest priority and both oversea and local training of staff have been stepped up. Steps to bring • about a functional integration of preventive am curative services through cc:amon units are being considered. , - 69 -

A significant feature of recent developnent in the health field has been th. unified direction that is now possible to give the health services in the • St!\te. .All health services, curative or preventive, central as well as local, as well as quasi-health services like the town cleanSing, frematoria, abattoirs, et~ are now all placed under the unified direction of the Ministry of Health. Th:I.. follows the Peoples I Action Party go.v.ernment's plan fGr unified administra­ tion and the take-over of local authorities by the Central Government. This will enable direct effective and uniform measures to be applied throughout the Island in every facet of the health services.

I must take this opportunity to express my own and that of the Government fS appreciation of the work of the World Health Organisation which have assisted us in the large-scale contribution they have made in the field of international health. Not on4r have they through periodic conferences of this nature but also through exchange of scientific information through the regular transmission of data and through direct assistance to governments have made possible the great 'strides in the improvement of the health of the people of the world as a whole. 'In newly emerging countries such as in Singapore and other parts of this region lbere a pressing need for trained personnel eXists, the World Health Organba1iion has given considerable assistance in training programmes. Here in Singapore, we have developed the basic, as well as post-basic nurse training programmes in general nursing, tuberculosis nursing, psychiatric nursing, public health nursing, midwifery and other allied branches and you will see some of these projects in op;tration during the course of your visits. A post-graduate COUl'se for tm .. Diploma in Public Health initiated with WHO assistance draws students from far­ flung ,countries like Korea, Japan, the Philippines and New Guinea. We have received assistance in the way of fellowships for medical officers and in the reorganization of our hospital records service. This aSI*at you will also see. • I wish to take this opportlmity to express our gratitude in the continued aBsistance which we have received. In this respect I must mention that we have received assistance not only from the World Health Organization, but from kindred organizations such UNICEF, which have equipp;td certain dep8.rtments of the Institute'of Health which you will see in your programme of visits.

I WOUld like to take this opportunity to state that the Government of Singapore is detennined to improve the standards of medicine and the state of health of our people. We are taking steps to improve the doctor-patient ratio in the long run. In the meantime, we intend to recruit doctors from Japan, Israel and countries of the Commonwealth into our service. This recruitment Will 9ftQble us to release more of our own doctors for post-graduate studies. We are grateful to the Governments of Japan and Israel for their valuable assistance and I wiSh to state that we are pleased to have among us here 1;odq Professor Rachmilwicz and Professor Pr,ywes of the Hebrew College of Medicine who have come down to appraise for themselves the medical facilities available here with a view to providing us with the specialist personnel.

I will conclude b,y expressing the view that the del~beratiQns ~ this conference will prove to be fruitful to all the participants and will stimulate .. an increasing interest in the health problems of our region, I note that the second part of the conference will continue in the Federation of M8l~a and the tie-up between Singapore and the Federation of Mal~a in a conference of this nature again emphaSizes the basic homogeneity and unity of Singapore and the • Federation of Malaya as a countr,y with a common set of problems and a commOn experience. I now have much pleasure in deolar;i.ng this conference open. -.~. .. ~a- ANNEX V

• ADDRESS CF DR. r.. FlDRIO, LF.A~ OF THE GROUP, M:>NDA.Y, 22 AIDUST 19 ')

• Hlnister, Ladies and Gentlemen,

we have just completed our Eleventh Session of the Regional Committee meeting for the Western Pacific Region in Manila.

Now, ~ of the group find themselves in Singapore and soon we will be in Malaya on the Public Health Conference and Study Tour for a two-week period as gueat.s of these two Governments.

rn 1957, a similar group visited Taiwan and Japan and most certaiJl4 other study tours will be arranged in the future to visit other parts of the WHO Western Pacific Region.

We are here not to advise but to learn and exchange experiences for Singapore and Malqa illustrate the differences between urban and rural health problems.

The WHO western Pacific Region offers interesting contrasts ranging from the • newly developing countries at one end of the spectrum to fully developed areas that are in the forefront on a world-wide basis ot the health services being rendered throughout the world today.

It the Regional Committee, which meets annually and formulates policies for such a contrasting region is to work effective~, it must have a first-hand knowledge of the health situation as it exists in this part of the world.

This visit is one step in our attempt to become generally acquainted with the health problems of the Western Pacific Region for the participants in the regional meeting and in this study tour are senior members of the health services of the various governments that they represent.

we were eapecially pleased to have Dr. Marcus, a member of the l.iU.ted Kingdom delegation, as one of the official delegates to the WHO Western Pacific Regional Meeting in Mantia and as one of our hosts and leaders of the delega­ tion now visiting this area.

(b behalf of my conference and members of the study tour, I want to express our sincere thanks for this most cordial and friendly reception and tor your efforts to make our visit both an enjoyable and profitable one. You are magnificent hosts and we are delighted to be here as your guests • •

t ! , ,

REPORT BY DR. C. MlRCUS, DmECTCR OF MEDICAL SERVICES, SDrGAPORE • ON MEDICAL AND HEALTH DEVELOftoIENT Dr smGAPCI!.E

In this report or the health services in Singapore, its deve1.opnent will be related to the social, economic and political factors which have influenced it in the past and will. continue to influence it in the future.

2. The Island of Singapore which, untU early in the 19th century WAS a malarial swamp with a few hundred inhabitants, is now a vigorous and healt~ metropolis with 1.6 million inhabitants and reputed to have the highest per capita incane in Central and Eastern Asia. Iqing astride one of the busiest East4iest seawqs, Singapore prospers from manufacturing and processing, but above all from its busy free-port for shipping fran and to all corners of the world. The population is predainantl¥ Chinese, forming approximately 75% at' the total.

3. The acceptance of Western medicine into a community of people who had their own medical beliefs and prejudices was slow. At first, because the facilities were limited and also because traditions died hard, the local population depended on the Chinese physiCian, the Indian herbalist or the Malq "bomo" for its medical care. Even to this day when the benef'its of modern medicine are accepted and considered superior, a section or the population continue to patronise the • unregistered native pQysician. The presence of Chinese medicine shops dotted everywhere in Singapore bear test~ to their popularity. The people otten have recoursed not only to several different doctors but also to several differing systems of medicine in their search for a cure for their ailments.

4. Western sanitation and medicine were introduced because it was essential for the safety of European trade and for the economic developnent or the country. The demonstration of their effectiveness and gradual appreciation b,y the local population led to the eventual acceptance of modern methods of public health and medical treatment. After World War II, widespread demand for health services anerged from al.l racial groups overwhelming medical. resources. The expansion of health services began to demand increasing funds and these demands came to be met without the use of contributory insurance or earmarked taxes. The apprecia­ tion of the effectiveness of modern medicine is illustrated b,y the fact that during the poliomyelitis epidemic in 1958, 200 000 children were vaccinated b,y Sabine vaccine. During the smallpox epidemio in April 1959, 1..1 million were vaccinated voluntarily within twenty-eigbt days. The general population has accepted and grown to expect the prOViSion of medical care through government­ sponsored clinics, hospitals and domiciliary services. The demand for indiviclua1 medical care through private medical. practitioners and private consultants remains limited.

5. until 1959, the responsibilities for health were divided but co-ordinated • between the Ministry of Health, the City CouncU Health Department and the Rural Board. These agencies were suppl.emented b,y the Public Works Department and the City Council. Department which ,J;ere responsible for the water supP4', sewage disposal, drainage, town cleansing and refuse disposal. Among these t agencies, they provided the customary health services. -'11.-

6. thder the present Government, the City Health Department and the health sections of' the Rural Board have become integrated into the Ministry of Health • including the responsibilities of town cleansing, refuse disposal and the control of markets and hawkers. In the process of reorganisation the Department of Chemistry and the City Analyst were also included within the Ministry. • 7. The medical services have now become predCll1inantly, though not entirely, a responsibility of the Government, with the mass of the population entitled to it without personal cost. The medical personnel are salaried employees of the Government, and most of the hospital facilities are governmental - all these are financed fran general revenu.es. Private practice persists for a small upper­ income segment of the population, especially in the City Area. The present pattern which had been initiated in the interest of the economy of' a dependent Coloqy is a Simple organisational scheme which facilitates the co-ordination of preventive and curative health services. The Director of 11edical Services, under the Minister for Health, is directly responsible for overall guidance of the national programme and .for national operating function, like international quarantine, recruitment, tra:ining and assignment of staff, the managemEilt of hospitals, sanitary and preventive services, operation of hospitals, clinics, dispensaries, health centres, etc. This pattern can, by developnent, provide a ·smooth transition to a comprehensive integrated service.

8~ At present, there are 680 doctors registered in Singapore, making a ratio • of one doctor per ~OO of' the population. or this number, ~6 are in the public service. The present output of' the lhliversity of MalB¥a is about 80 doctors, 20 dentists, and 15 pharmacists per annum to serve the needs of' both Singapore and the Federation of' MalB¥a, where the needs are greater. The position is .. likely to be eased when a medical faculty is established in Kuala Lumpur. Meanwhile, the State will depend on graduates from outside universities to augment the services. It will be interesting to note that approximately one-third of the persons registered during the five-year period fran 1955 to 1960 were qualified outside the local university.

9. The Government has set up training establishments for auxiliary medical workers, nurses, assistant nurses, health personnel and laboratory technicians as part of the in-service training, and it is estimated that the requirement. of auxiliary medical personnel for all governmental health projects will be met from these training programmes.

10. It is customary to measure a country's hospital services by the ratio of' beds to 1000 of population. There are 7379 hospital beds in Singapore, of which over 9~ are under government control. This gives a ratio of 4.6 beds to 1000 of the population. It would perhaps be more useful to examine these figures under two categories , the ratio of beds for the acutely ill and the ratio of beds f

between 4.4 and 4.7 per 1000 for the acutely ill and 2.3 and 2.6 beds per 1000 of popul8liion for the chronic sick making a total of' • between 6.7 and 7.3 hospital beds for every 1000 persons in -7~ _

the Thited States. (b these high standards, Singapore would have a deficiency of about 5000 beds for the acut.eJ.y ill persons and would require an additional 365 beds to meet the annual increase in population.

li. Maternity Services

The maternity services offer hospital facilities at the government maternity hospital at Kandang Kerbau and domiciliary deUvery services in the city and rural areas. The Kandang Kerbau Maternity Hospital has 316 beds at which 216 are used for maternity cases. In 1959, 33 6~ deliveries were conducted in th:ls hospital while the damiciliar,y deliver,y services had 19 175 deliveries. This, together with domiciliary midwifer,y services operated by the Rural and City Council Maternal and Child Health Clinics accounted for 67% of the total births. This, I think, is a world record and ll'andang Kerbau Hospital could be justJ.y called a "Baby Factory". Expansion of the domiciliary lllidwifery services and establishment of additional maternity beds in maternity homes and in district hOSpitals is a pr'essing necessity.

12. The Maternal and Child HeaJ:l;h Services today operate a network of :n main clinics, 22 Visiting centres and 8 midwife centres. or these, 7 large clinics serve the City Area. These services are the most extensive in this part of the world, but even so, there is need to expand, particularly in the CitY,Area, and • to extend further the ante-4latal and post-natal services operated at the Kandang Kerbau Maternity Hospital on an island-wide basis. More maternal and child health centres are planned to be developed to meet the demands for infant and child care up to pre-school age. Health education, closer integration of home visiting and district nursing services will bring health activities to the home to form part of the cCll1ll1unity services in which health is an essential canmodity.

l3. School Health Services

In order to pr'ovide a continuation of health supervision of the young, the school student is next brought under consideration. Today, there are 340 000 . students in pr'imary and secondary schools. While consultant services are supplied fran main hospitals and close liaison established with the TuberculOSis Control Thit, further augmentation of the School Health Services and closer integration, both in capacity and scope, will be necessary to supl>l¥ a more cClll1prehensive cover and will be the a1m of future developuent.

14. The Out-Patient Clinic

The static out-patient dispensary and the mobile dispensaries which have been primarily established to provide curative care, have become recognised as an essential part of the preventive health service. In these • clinics, were a person D1BiY attend at no personal cost, it has become a means of detecting early disease so that it is possible to effect ambulatory and domiciliary treatment and case-finding for major disease, i.e. tuberculosis, venereal disease, infectious diseases, leprosy, etc. The increasing pressures • on out-patient services throughout the island has led to the unification of control of all curative care outside the hospitals with headquarters in the -73- -

Out.-pat.ient.s Department. at the General Hospital. This arrangement offered man;y • advantages. It prevented the re-duplication of services and establish~d closer contact with the consultant services. It made uniform procedures possl.ble and by the rotation of medical staff kept them up-to-date on the lat~st developments in modern medical techniques. The mobile dispensaries operate Wl.thin this framework making it possible for a patient in the remoter part of the island to • benefit by the advice of the specialist at the General Hospital and to continue ambulatory treatment at the clinic closest to his home. It has also been recognised that as these clinics play an important part in the prevention and early discovery of disease and the more extensive and comprehensive the services~ the less need will there be for hospital care. What is now needed is a closer relationship between the maternal and child health and the curative care in conjunction with the dOmiciliary services in home visiting and district nursing to form organised units to carry on both prevention and cure within a section of the community. Altogether~ about 9000 pa:liients are seen da:i1y in all out-patient clinics and dispensaries, and it is estimated that this figure will rise to 12 000 per day, Provision for an additional increase of 400 per dq each year must be made. Plans to develop a number of clinics are in prepara:liion where preventive and curative activities will be provided within one establishment.

15. It will follow as a consequence that as more and more of preventive/cura- tive clinics develop, the demands for special investigation techniques and specialint consultation and skills will arise, and it would be necessary to .. develop new establishments to meet these needs. In the long-term planning it would be more economical and convenient to regionalise these facilities to serve a number of these clinics within a region and to associate these developnents with district hospitals. It is envisaged that these poly-clin1os, as the,y are • called, will serve both the preventive and curative services and could include the headquarters of health administration, environmental sanitation, health laboratories and other health and para-health activities within a district.

16. Of the special diseases which constitute a serious social and economic burden, tuberculosis is occupying the special attention of the health authorit:ie s in Singapore. The recent surve,y conducted by the Australian experts under the Colombo Plan has set the prevalence of this disease at J."'1% of the general population, 1.5% in the rural areas and 4% in the urban districts. Special legislation has been enacted to establish control. A Tuberculosis Control Unit is maintained for the co--ordination of the campaign against this dreaded disease. A Tuberculosis Registry, follow-up clinics, health visiting, contact clinics, chest clinics and a hospital of ll44 beds come within its control. BCG vaccina­ tion campaigns are at present conducted on a voluntary basiS, but new legislat100 is Planned to make it compulsor.y. Vaccination in the new born is conducted at the Kandang Kerbau Maternity Hospital and in the Maternal and Child Health clinics and in the young children through the School Health Service. Altogether 60 000 vaccinations against tuberculosis was done in 1959. The Singapore Anti-Tuberculosis Association, a voluntary organisation supplements Government fS efforts. It maintains a static centre and mObile clinics for the prevention and • treatment of tuberculosis on an ambulatory basis. Case-finding is mainly through the out-patient clinics and dispensaries, and some of the follow-up and ambulatory treatment of tuberculosis is conducted through these clinic systems. It is obvious that more energetic campaigns in case-finding are necessary. A • mass X-ray case-finding programme is being planned and will be :iJnPlemented before - ~-

the end of the yes:r. A city static X-r~ unit and mobile X-ray units in the rural areas will accept initially 50 000 persons per annum. Limitation of staff and hoSpital accommodation will hamper a more intensive programme.

17. Lepros,y is another disease which is receiving the attention of the local authorities. With the advent of more effective chemotheraP,y it has been possible to allay the traditional fear of the disease and patients are now reporting earlier for treatment before major disability has occurred. A hospital, a Bettlement. an out-patient and follow-up clinics have been established. Case-finding is again mainly through the general out-i8tient and dispensary services.

18. Mental disorders are treated in the Woodbridge Hospital of 1869 beds. Psychiatric clinics operate within the framework of the out-patient system. Child guidance has been initiated in conjunction with the School Health Service. :rbe Government plans a training programme for assistant nurses in psychiatry at the Woodbridge Hospital with WHO assistance in order to replace the present ward attendants, whose main function is custodian.

19. Consideration has been given to the cs:re of the plvsical4 haildicapped and the chronically ill. In the reorganisation of the medical resources it is planned to develop an institution for the care of the chronically ill in the area adjoining the Woodbridge Hospital. These s:re five blocks containing 180 beds for chronic cases. Voluntary organisations look after the blind, the deaf " and the si8stic.

20. Meanwhile, vigilance against the importation of disease continues to be maintained. With quicker air travel, the hazs:rds of yellow fever have become real. Aedes Aegypti, the vector of this dread disease, is prevalent in Singapore. Campaigns against the mosquito and plans to set up a yellow fever hospital at the International Airport are at present under active consideration.

21. Dental Care. Dental care programmes s:re directed primaril,y towards dental health in the mother and child and in school students. There are altogether six dental huts attached to the Maternal and Child Health Clinics and four dental establishments attached to the schools. The headquarters of the School Dental Service is sited in the Institute of Health. Acute dental conditions are treated as ps:rt of emergencies and are dealt with in the casuAlty department of the General Hospital. Mobile dental clinics serve the out4ring schools and maternal and child health clinics. These services will be augmented by the establishment of a Dental Nurse Training Centre at the Institute of Health. This training project is being initiated under the Colombo Plan and will be modelled on the New Zealand pattern.

22. It will now be necessary to examine the social and economic conditions in Singapore as these will largely influence the direction or future developnent of the medical services in Singapore. The birth rate in Singapore is at • approximate4 40 per thousand persOlls, and the crude death rate at 6.4 per thousand persons. The rapid increase in the population in the post.....ar years has lead to a situation where about 43'1> of the population is under fifteen years of age. If the existing rate of fertility is maintained, this proportion I will more or less continue. Sim11ar4, those in the age group 60 and above will continue between 4% to 5% of the population. In addition to children and - 7., - the aged, house-workers and full-time students in the age grou~ 15 and 59 years form apprax:imately 22% of the population. In all about two-t.hirds of the popula­ tion are dependent on the productivity of a third - this ratio or dependency is • higher than in most countries.

23. Entrepot trade and manufacturing form the main economic activity of the a Island. Industry is restricted generally to small undertakings primarily for local consumption and the processing of raw materiaJ.s for export. A large section of the economically active population is self -employed and in casual worker groups. The average earning of the economically active person varies from $100 to ~OO per IOOnth.

24. These then are the basic problems posed to the medical services in Singapore. Firstly, a soaring increase in population and secondlyJ an eco~ which has to increase in proportion. Each of these factors is self perpetuat1n$ and results in a vicious cycle. The increasing population means that the medical facilit:1e s must be expanded. It has been mentioned that these faoilities are running behind by a deficiency of about 5000 beds. Over-orowding in unhealthl" surroundings will add to the difficulties of eradicating tuberculosis in the cammmity. If the econCl!lijT does not keep paoe the resources available for an expanding healt,h programme will not be able to meet these demands.

25. Arry expansion of heelth and medical care programme must therefore be directed towards the younger age group since this constitutes about 45% of the .. population. The care of the mother and child and the student will occupy priority in all expansion schemes. Thus, the maternity and child health clinics, sohool health service, advice on nutrition, and the offering of immunisation measures will plSiY an iJnportant role in the prevention or disease in this - the largest group of the population. •

26. The services in Singapore, howver, have one outstanding advantage in comparison with the health services in other countries. This is the integra­ tion of almost every health activity under one ministry. Recently, the integra­ tion of the City Health Department and other City Council services such as the cleansing department, markets and abbatoirs have brought all health services under a singlo control. This integrated service has immense potential advantages allowing for unified control and direction and efficiency by prevention of duplication of work and of staff. These advantages will be exploited in full in the developnsnt of the service.

27. I hope this survey will serve to indicate the patterns of the health services in Singapore. The problems that had first to be solved when the British introduced Western medicine and public health dictated a unified preventive and curative health service. It is traditional in some parts of the western world to believe that in a unified health service the pressures of curative care would invite neglect of the preventive service. In Singapore, the administration has been able to keep the preventive and curative services in tandem and in balance, and has been able to achieve much with limited resources through a unified programme than through separate programnes of prevention and cure. Where resources of' personnel~ f'acilities and funds are sharply limited, the hope for long-range achievement lies in giving priority to preventive services whioh are an :inVestment in future health, assigning to • these functions the res~ces they need. -76 -

28. :m 1959, ~7.5 millions representing 15% of the national revenue was spent on the total health services. There was a revenue of ~.9 million. It it is planned to provide a comprehensive preventive and medical. care progr8lllll18 for the island, an expenditure of ~5 per capita per annum, the mounting cost would rise 1n proportion to be provided as at present from general revenues.

29. Very rapid development in social capital is necessary to keep pace with the population growth if the standard of the services hitherto provided is to be maintained. The need for maintaining a high standard of health services is not purely based on humane and civilised recognj,tion of the value of h1.UUan life, nor is it purely a desire to alleviate h1.UUan suffering. It is also based on sound economic consideration.

30. :m BUIIJDIU'y, the trends for developnent of the medical services 1n S1ngapore will be made under the following basic principles,

(1) The co-ordination and reorientation of the medical and health services on an island-wide basis made possible by the integration of the City Health Department, Local Health Authorities with the Ministry of Health.

(2) Closer integration of the curative and preventive health • in the Maternal and Child Health services • (3) Closer integration with the daniciliar,y services and the curative services.

(4) The expansion of the medical care progr$l\llle 1n the provisi. on of additional out-patient clinics and hospital beds and augmenting training facil~ties.

(5) Regionalisation of the ~th and medical services in the districts. (6) The implementation of an expanded Tuberculosis Case-Finding Programme with pravi8~on for additional therapeutic services •

•

! ANNEX VII ADDRESS OF MINISTER CF HEUTH AND SOCIAL WELF.ME, FEDERATItIl OF HAIAD. AT THE OPENING CERJ!H)NY OF PlBLIC HEtJ.TH CONFERENCE AND STtmY TOUR IN KUAIA LtlMPUR, FRlDA.Y, 26 AIDtST

• Hl'. Cha1rman, Distinguished Delegates,

l't. is ~ great pleasure aLd privilege this mc:,rning to extend a very warm welcome of the FederatiCXl of Halqa to all of you, distinguished delegates from so !IISl\Y cOuntries in our region. I sincerely hope that your short; stsoy in our country will be interesting and enjoyable. I am sure that the gathering here are so many experts, leaders, who are actively connected with the administration of publio health in their respective countries but this would provide an opportunity for useful exchange of ideas and experiences and for seeing the work that we are carrying out here. I hope the programme that has been drawn up for you will prove to be interesting but not strenuous. I note that you had a very strenuous conference and subsequent tour in Singapore and here as the Direotor of Medioal Services· said still a lot:. more to be discussed and to be seen. I am sure your visit to our oountry will help to stimulate interest in and understand­ ing of publio health problems in this country and in Q1r region.

I might say a few words here which might be interesting. The policy of my Ministry is to give priority to the expansion of medical and health services to our rural areas and to the training of more staff ~ for rural areas and most of our existing hospitals and the rebuilding of the General HOSpital right here in the Federal capital. We set up a new medicsl faculty of our thiversity of Malaya in Kuala Lumpur. This is also one of the priorities of our Government. As regards our rural health, our 1.mmed1ate plan for this programme is to build the network of health oentres throughout the rural areas of the country. Each of these lDlits will serve approx:1_tely 50 000 people. at' course, a large proportion of our population is already served by existing hospitals in the big and small towns am we have in the same wsoy to start building rural health centres. Each of these units as I said, serving a population of 50 000 people will be staffed with one medical officer, one dental officer, health sister, bealth nurse, bealth inspector and attenclants and so on. There will be four health sub-ocentres each of which will be staffed by a health nurse, two assistant health nurses, health inspeotors, and other attendants. Then, there will be one midw1te, with quarters and a olinic to serve a populatico of around 2000 people. There will be rougllq twenty-five such midwives t quarters and clinics.

No doubt you are aware in tlB Federation of Mal.,a that we have not had 8Z\Y case of clangerous infectious diseases for the past M8Z\Y years. Incidence of malaria, however, can be considered to be low. We have as you may know started a pilot:. project aimed at discovering a practical, effective and economical CIl8 for the eradication of this disease. In this we have assistance fran v.H0 and lIHtEF. For example, the Institute for Medical Research is to :1JI1prove the developnent of our services in this country. Besides.Icing useful contribution to the control. of typhus levar throughout the wcrldJ it is hoped to establish an additional division for virus disease with particular emphasis on poliomyelitis. In addition to this research activities, this institute also trains laboratory ! U81stants who work in the laboratories in the ~ hospitals thro~hout the country. - 78 -

I note that you will be visiting two leprosy institutions, one Sunge! Buloh and Pulau Jerejak in Penang. Besides these, we have introduced a scheme whereby discharged leprosy patients who are no longer infectious are referred to their home town clinics and we have set up in Kuala Lumpur and Penang, clinics for treatment of suspected or early cases. We are giving publicity to try and eradicate public prejudice against this disease and to make it known that this disease can be cured now if treatment is obtained in its early stages. •

In the field of medical health we have set up psychiatric out-patient clinics in the country for cases which do not require admission into mental institutions.

As regards tuberculosis, unfortunately this disease is still considered the major public health problem in our country. The national programme far"!the elimination of tuberculosis is considered follOWing the report and recommendaticm of Sir Harry WUnderly who was a consultant ot the World Health Organization.

As regards yaws, there was a project as far back as 1954 with assistance ot WHO and mICEF. The incidence of yaws in this area has been reduced to an absolute minimum and I think I can say that this disease 1s absolutely under control throughout the whole of the country.

As regards filariasis, a lot of work has been done to tackle this ugly disease. Here again the spread at this disease has been checked and brought under control. However, in areas where the disease is still prevailing, annual campaigns are organized to control it and mass programmes are carried out. F1lar1asis research still continues at this institute and Kuantan at our east coast.

You will be visiting our Federal Dental School in Penang and this school has been expanded and is now training pupils trom the neighbouring countries, t like Brunei, Burma and Hongkong. Our dental service is provided to treat school children and those below school age in ante-natal and out-patient clinics at our hospitals.

Distinguished delegates, I now have much pleasure in declaring the conference open.

•

• - 7,. - ANNEX VIII

OPENING ADDRESS OF DR. TEN YCON FONG CO-LEADER, AT Jrl'RA, 29 AOOtBT 1960 • Your Highness, Honourable Mentri Besar of Kedah, Honourable Members of Parliament, Honourable Members of the state Assembly, Delegates, Ladies and Gentlemen,

First of all I must express regret at the absence of our Director of M3dical Services, Dr. Ibhd. Din bin Ahmad. It was his original intention to be with us today and to address us but cirCUlll8tances have prevented him from coming and he has requested me to tender his apologies to Your Highness and you, ladies and gentlemen.

Now a few words about our delegates. The Conmittee of the Western Pacific Region of World Health Organization meet.s every year. This year the meet.ing was held in Hanil.a. Usually following such a meeting there is a public health conference and study tour in either the country where the meeting takes place or in another country. This year the public health conference and study tour takes place in Singapore and the Federation of Malaya. We are happy that the Federation of Malaya has been chosen for the purpose of the study tour. We • are proud and honoured to have so man;y distinguished delegates visiting us. These delegates come not to criticise or to advise. They come to see to observe, to listen, to discuss and to exchange views with us and to learn. In short they come to see how we tackle our problems and then to discuss with us, and , with one another, how they tackle similar problems in their own countries. Such a tour can be of benefit not only to them but to everyone of us. I have been associated with this group of delegates for more than two weeks; when I say . associated I mean closely associated, and if I am ask8d to describe them I only have one word, that is, they are grand'

And now, those of you who know the working of this school I hope you will bear with mE':':ff'I try to give a very brief hiBtory and account of the working of this school. Our Government has a very big programme of social and econanic developnent of the rural areas. The Rural Health Service is an integral part of this Government. It was considered that tho~h we have trained personnel this personnel are not properly orientated to work in rural areas. It was on such a background that the idea of this school was cQ'lceived. World Health Ol-ganization and UNICEF have rendered a lot of help - WHO in providing the personnel for the staff of the school and in giving technical adVice, and lIlICEF in prOViding equipnent not only in the school but slso in our other rural centres.

Training was begun in 1959 and to-date we have completed the ninth course. Actually, the ninth course was finished only a few days ago. Each course caters for six teams. Each team consists of three, what we call, medioal auxiliaries, that is - 1 assistant nurse, 1 rural midwife, 1 sanitary overseer. In all we have trained about 180 of our staff. The tenth course ! will begin very soon. Other cout'ses which w:U1 be held here are, one-illOnth orientation course for health sisters, health nurses, health inspectors and hospital administrators to give them an idea of what a rural team is like and to properly orientate them. Besides thiS, the school is visited by students /'

- so -

frau the Public Heal.th Course given to Sanitary Inspectors in Kuala Lumpur. The nurses receiving the Public Heal.th Course in Penang also spend one week here. The doctors who take the diploma in public health at the University of Malaya also come here for a day or two for observation. Besides this we alW8¥s advise our officers to visit this place periodically so that they can acquaint them­ selves as to how the school is run and what is being done here for the Rural Health Services.

I do not propose to apologise for the accommodation that we have given the delegates tod~. I hope they will make the best use of the accommodation available. Our delegates, including myself', have been used to the air-conditioned luxury of the Biltmore Hotel in Singapore, the almost equally good comfort. of the station Hostel, Kuala Lwnpur, and the sea breeze rooms at the Eastern and Oriental. Hotel at Penang. I want to tell my friends and the delegates that this is a rural area. We know what a rural area is, but to define it is another matter. One of our delegates put what I consider to be a very ideal definition, and that is: a rural area is one in which there are no electric lights, no water supply and no 'nothing'. To me, I would 8.c:ld another definition. A rural area is an area which cannot accommodate al.l the World Health Organization delegates in the country.

We are here in Jitra. For this function a lot of trouble has been taken and it is my duty to thank thee e who have in one way or another contributed to the success of' this function, in particular J the State Government.. the people of' Jitra, and the COllllllittee at Pekan Rabu f'or the assistance they have given in making this function a success.

Your Highness, we feel greatly honoured that you have so k~ consented to grace this function with Your Highness' presence. Your presence here and * the presence of' so mazv high officials of the State is ample evidence that a very keen interest is taken in the State health matters. To us medical men .. this is indeed very gratif'ying.

I shall detain you no longer. I shall now call upon His Highness to address you and al so to declare the conference open. -81- ANNEX D.

,. AmRESS OF HIS HIGHNESS THE SULTAN OF BEW ClImE OOCASION CF THE OPENING OF THE WHO PUBLIC HEALTH CONFERENCE AND STUDY TOUR, JI'l'RA., KEI».H, 29 AtDWT 1960 • Ladies and Gentlemen,

It is our great pleasure to welcome you all this afternoon to our Negeri Kedah Darul AmaD. We are proud of this occasion when sO m8l\Y distinguished guests from Member Countries in the Western Pacific Region of the World Health Organization are gathered in our State. Ihdeed it is the first of such occasicm and we hope it would be the forerunner of many more. To all delegates we extend our warmest welcome and hope that they will enjoy their short stay here. The institution you have come to visit is the oa4r one ot its type in the Federation of Malaya. It was completed at the end of the year 1955 and the first batch of trainees was taken in, in January 1956. It has since trained nine batches of Auxiliary Health Workers who are now serving in the rural areas in the various parts of the Federation. You will also see the Rural Health Services Scheme of the Ministry of Health being implemented in this area through the Kubang Pasu District Rural Health thit. After completion of the last Sub-District Health Centre at 4er Itam, work on whioh has already started, the Rural Health Training School, Jitra, will have an almost oomplete serving Rural Health attached to it. .. We feel that an institution of this type should have a complete serving unit so that trainees may understand its organization and work and benefit therefrom.

On the 31st of July this year, the emergency created by war against , m11itant communists was l11'ted. But in Ma1a;ya today, another emergency has been declared, -"An Emergency for Rural Developnent", and we are determined to win . .. this new battle. Along with other developnents and improvements which will be carried out in the rural areas, raising of health standards of the rural populace, is also being given top priority and provided eonditicms remain normal, we will be able to push over the Rural Health Services Scheme to the remotest corners of theeountry. Our soheme is highly ambitious but it is only by setting lofty ideals that a headway in progress in this field oan be made.

We are confident that during the discussion which will be held during your stay here our publio health personnel will have a lot to gain fran your vast experiences in the field of public health and at the S8IIEI time impart to you all the information regarding conditions here, which you would like to have. This mutual exchange of experiences and information will greatly help us in health measures being carried out by us here.

This is the first area in this State where the Rural Health Scheme is operating and fran the statistics collected so far it appears that oonditiODs are improving. But there is a lot yet to be done in this field. However, the selection of J1tra as a part of your programme in Malaya will give great enoouragement to the looal health workers and Will spur them to greater efforts. It also shows that their good work here baa not remained unrecognised. - 82.-

We take this opportunity to personally thank the World Health Organization and UlyrCEFin organizing and equipping the Rural Health Training School, the District and the Sub-District Health Centres and we are also glad to learn about the assisted yaws and malaria eradication projects which will be launched in this area in the near future.

We hope that the purpose of your visit to Malaya has provided useful, that you have had an insight into the conditions in this country and that you carry back happy memories of this visit.

• - 83 - ANNEX .1

• At the beginning of the closing session of the Public Health Conference and Study Tour in the Federation of Malaya, the Chairman, Dr. Kanagaratnam asked the group to rise and stand for two minutes' silence in memory of His Majesty, the Yang di Pertuan Agong.

Dr. Kanagaratnam said that the leader of the group had left two days ago due to urgent duty and therefore it was his very great pleasure, as co-leader, to take the opportunity to make a few remarks at the concluding session of the Public Health Conference and Stud,y Tour.

"We began the study tour on 20 August in Singapore and since 26 August until today we have had a very extensive programme covering practically the whole of this country starting from Kuala Lumpur to Penang and then to Jitra rig):lt up at the northern border. During this scientific and technical tour, the members have expressed various views and in particular, general discussions which provided JnaIV members to express considerable appreciation of IIl8JV features of this conference and st~ tour.

"First of all, on the technical side, we have seen, in particular, the tremendous training programmes which have been pursued and which promise a a very bright future of medical services. At Jitra, as one of the participants said, it was one of the highlights of the tour in the Federation. After visiting Jitra and seeing the main centre and sub-centres and the midwives and public health inspectors r training courses and the excellent work done there, we have a clear idea and are cert~ convinced that this scheme would be easily transferable to' ~ other countries and territories. It is a scheme which is intended to meet the needs of the rural population. Besides the technical discussion, we have enjoyed the hospitality of the Minister, the Chief Medical and Health Officer, Penangj and of the Chief Medical and Health Officer of Kedah. We are very grateful and in the course of the programme which had been arranged, the participants had the opportunity to see the functions of the, political systems, both local and central governments.

IIHonourable .Minister, we wish to assure you that this conference has been h1gh4 educational and all at us derived experience and wish to take back and we Will watch with considerable interest and take every opportunity to see programmes which you have kind4r instituted. I would not complete this brief talk without expreSSing our thanks to the Minister, the Director of Medical Services, and to the two participants who were travelling with us, Dr. Ten Yoon Fong and Dr. Parampalam and all the officers of the staff as well as others who made our visits profitable.

nonce again I thank you". -84-

SUMMARY OF SPEECH OF THE MINISTER OF HFALTH AND SOCIAL w'ELFARE AT THE CLOSlNG CER.EMONY, INSTITUl'E FCE MEDICAL R.ESElRCH, KUAU LUMPUR FRIDAY, 2 SEPrEMBER 1960

The Minister welcomed the group after the conclusion of the conference and study tour of the Federation of Malaya. He told the group that the Federation was embarking ona Development Programme which involved among others, the tra:ining of health personnel. It was hoped that the training of nurses could be increased from 400 to 900. The Rural Health Centre in Jitra was the pattern for other rural health units. The plan would be worked out as to meet local needs and problems. He anticipated no difficulty in the construction of the centres.

The Minister said that a new faculty of the lhiversity cL MlJ.aya in Kuala Lumpur would be established in 1%3. Plans far this were being worked out in conjunction with the lhiversity of Malaya authorities. A Board of Study at the lhiversity had been set up. Authorities in this field, such as Professor Sunderland, Dean of the Uhiversity of Melbourne, Dr. McCqy of the China Medical Boar~ and others, had been invited to study and plan the new faculty. ~omises of assistance from friendly countries and organisations had been received. At the moment, the Federation was receiving assistance from the Colombo Plan countries in the way of personnel, equipment, etc. He assured the group that such personOOl would in no way adversely affeet the services and promotion of local officers. The Ministry was in close touch with the senior government officers' association.

He hoped that the group had the opportunity of seeing a bit of the country besides medical and health facUities and services. He said that the health problem was one of the aspects of the nation's development. He was proud of the fact that the medical and health services had been able to maintain high standards in spite of the shortage of staff and equipment. The I'1inistry had been able to ke ep up the standards through training.

The M1nister expressed regret that due to the national bereavement, the programme previously arranged had to be cancelled.

He wished everyone a. safe journey home and expressed the hope that the group would return to the Federation in the future. .. 85 -

,-.. REiORT BY THE TEADER OF THE GROUP, m. L. FLORIO (U.S. PARTICIPANT) • It was II\Y privilege to be the Group !sader of the WHO stud;y tQ1r to Singapore and the Federation of Malaya following the Eleventh Session of the Regiqnal Committee held in Manila in August 1960.

The group was a most congenial one and found the opportunity to visit these two countries a profitable and interesting one. Special thanks are due to the Governments of Singapore and the Federation of Malaya as well as the staff of bo~ the WHO Regional Office in Manila and the, Epidemiological Intelligence , station in Singapore for a very well planned and executed tour albeit a tightly scheduled one that scarcely gave the participants and our hosts a sufficient / opportunity to pursue our discussions and quest for information in depth. It is our sincere hope that the host governments profited from the opportunity to ~~- - exchange views aa did the group in acquisition of new ideas that will certainly prove useful in our own work in our respective countries.

The hospitality was superb. Our hosts were most kind. The group cannot adequate~ express its appreciation for the gracious manner in which we were : always received and the numerous functions that were planned for our entertain­ ment and relaxation.

We grieve with the people of Malaya at the untimely death of the Yang di , Pertuan !gong. His Ulness and death was a distressing feature of our visit. The group also regretted the reSignation of Dr. C. Marcus, a CO-leader, short~ after our arrival who, consequently, could not accompany us on the rest of the tour.

Singapore faces a very serious problem in staffing its expanding health services. It will need to give long and serious thought to the solution of this problem, and approach with caution short-term expedients that might lull it into a spurious sense of well being. It appears to me that the expansion of the health and medical services is outstripping the supply of professional personnel. This can only lead to a deterioration of service and a loss of confidence on the part of the populace. The best of intentions, unfortuna~, could seriou~ damage the fine reputation the health services of Singapore have obviou~ enjoyed up to the present time. The question can logic~ be asked whether the rapid expansion of free medical service is re~ necessary. Cannot much of the population affcrd to pay for at least a certain amount of medical care? While Short-term solutions for the lack of staff may have immediate appeal, they should be approached with great caution, for such seemingly attractive "solutions" could jeopardize the long-range objective of , a caref~ conceived health and medical service. Progress must ultimately depend on s!)unl planning seared to steady, dependable growth within the means of the government fonance adequately. -86-

Perhaps I may be a.:Lawed a few other observations, trust:mg that they will be accepted for what they obviously are meant to be, namely, the hope of a fellow worle r in the field of health that his associates in this humanitarian endeavor mq avoid some of the pitfalls that beset all of us who strive so earnestly to bring health and well being to our fellow:men.

Plans are progressing toward the opening of a medical school in Kuala Lumpur by the Ihiversity of Malaya. There seems to be no dispute by those in a position to know that the country needs more medical and para~edical personnel to staff its expanding health services. A good medical school can help meet these needs. The long tradition of excellent medical education must be continued. Of'ten the pressumfor mere phySicians leads to a relaxation of standards, result­ ing in poorly educated ~sicians whose mediocrity will be a drag on the country far hs.l£ a century beyond their date of graduation. Good medical education requires most of all a top faculty not only in the clinical sciences \ but in the pre-clinical. or basic medical. sciences as well. Presumably, the lIleCiical school is assured of an outstanding faculty or it would not be proceed­ ing with its construction plans. Medical education is about the most expensive of all the educational disciplines. While the costs of building and equipping a new medical school and teaching hospital ma;,y loom large, the year by year operational cost is the one that must receive the greater consideration, for it is this recurring cost that will require a significant percentage of money available to the University to keep the school in operation. The paramount consideration, however, is the faculty. Without it, fine builctings and equipnent will be only a fayade, hiding a skeleton that will reflect discredit on a fine medical tradition. These are probably unnecessary words of advice since there was not sufficient opportunity to delv e into and discuss the plans for the medical center, but I am so acutely aware of the effort that had to be exerted by nv own country in imprOVing its medical education that I cannot refrain fran a bit of preaching.

Our Sunday visit to the Island of Pulau Jerejak was meant to be a combined pleasure and professional trip. The Tuberculosis facilities and Quarantine Station are wortqy of comment.

It was evident that the problems of recruiting and maintaining staff in this relatively isolated facility as well as the patient reaction at being inaccessible to their family and friends, as well as the logistics of supply and water, make one wonder if it might not be better to discontinue this as a Tuberculosis facility and find a more suitable site where not only the previously listed objections might be minimized, but also accessibility to other specialized medical services, a necessity in present day treatment of tuberculosis, might be more readily available.

One is impressed with the immensity of the Quarantine Station and the relatively 18[' ge staff needed to maintain it. In this modern age, when the scourges of the past are rarities indeed, one wonders if there is need for a facility of this character. Other nations have recently concluded that they are an anachronism and have discontinued their operation. Perhaps Mala;,ya could come up with some alternatives that would be less expensive and serve the needs t just as well. - En -

Everywhere we went, we fOWld a real concern for the health and wel.:t'are of the people of Singapore and Malqa. The concern with problems of rural health is particularl\v" worthy of commendation.

Ever,ywhere the facilities were excellent, if frequentl\v" overcrowded, as is inevitable in this modern world of rapid4r increasing populations and rapidly expanding medical knowledge that constantl\v" requires more personnel, money and facilities to insure its proper application.

Malajya and Singapore can indeed be proud that they are among the most progressive cOWltries in Asia in their provision of health and medical facilities. I am sure that the contributions made to our knowledge and Wlder­ standing which will result in more effective work in our own cOWltries outweigh the benefits that Singapore and Malaya may have derived fram our visit •

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