WAGING WAR ON A president’s forum CHRONIC

Text byDISEASE Dr Wong Tien Hua

When former US president Richard This brings to mind In his Pulitzer Prize winning book Nixon took up office at the White House images of gun battles in inner cities tracing the history of , The in 1969, he inherited a raging war in between heavily armed police and Emperor of all Maladies, Dr Siddhartha Vietnam amid large-scale political roving drug gangs, or scenes from the Mukherjee wrote: “Cancer was missing unrest and resistance to the war at 1994 movie Clear and Present Danger, not merely a medical cure but a home. He was faced with the option of where military forces were sent south political cure.” A rallying call, such continuing with former president Lyndon of the US borders to wage a covert war as declaring a war on cancer, would Johnson’s policy of escalating the war, against the Columbian drug cartels. In hopefully overcome the perceived or finding some way to disengage reality, the war on drugs was about the lack of progress in cancer treatment, and get American troops home. He implementation of broad policies aimed divert much needed funds into cancer established what became known as at disrupting the production, distribution research and provide hope to millions the , which directed his and consumption of illegal drugs: from of Americans affected by the . administration to withdraw American the creation of the Drug Enforcement Critics of this strategy pointed out troops over the next few years and Administration that dealt with the supply that it was premature to concentrate all replace them with Vietnamese soldiers. side of the drug trade, to the federal- that energy on cancer treatment and funded treatment programmes that neglect other areas of research such While Nixon is now well known for helped to reduce demand. triggering US withdrawal from the as prevention. Mukherjee wrote: “The Whether the war on drugs was and ultimately closing rhetoric of this war implied that its tools, successful in controlling drug abuse is still this dark chapter in America’s modern its weapons, its army, its target and its hotly debated and highly contentious. It history, he is less well known for strategy had been assembled. , carries with it not only a heavy economic the discovery of the unknown, was declaring two other "wars" during his cost (it is estimated that the US spends pushed to the peripheries of this battle. term as president – the "War on Drugs" US$51 billion worth of taxpayers’ money Massive, intensively funded clinical trials and the "War on Cancer". annually on the war on drugs), but also with combinations of cell-killing drugs social costs such as the incarceration of would be heavily prioritised. The quest for The War on Drugs hundreds of thousands of drug offenders universal causes and universal solutions The War on Drugs was launched by – and yet the drug problem persists. – cancer viruses among them – would be Nixon shortly after he took office and highly funded." was partly a reaction to the rampant The War on Cancer In their paper published in the England misuse of drugs both among US troops Nixon also declared a War on Cancer Journal of Medicine in May 1986, Bailar in Vietnam and on home territory. when he signed the National Cancer and Smith showed that age-adjusted After all, this was at the height of the Act of 1971 into law on 23 December cancer-related deaths had increased, liberal “hippie” era where psychedelic 1971. This was against the backdrop of primarily due to increase in smoking drugs permeated popular culture and abysmal survival rates for cancer at that rates.1 They concluded that the war on mass media, and fuelled the rock and time, coupled with the woeful lack of cancer had been a failure and that more roll lifestyle. Nixon famously declared: knowledge about the pathogenesis of should be done for prevention rather “America's public enemy number one cancer. If Americans were able to put a than treatment, writing: “According in the United States is drug abuse. man on the moon in 1969, surely more to this measure, we are losing the war In order to fight and defeat this could be done in terms of technological against cancer, notwithstanding progress enemy, it is necessary to wage a progress to find the “magic bullet” for against several uncommon forms of the new, all-out offensive.” cancer cure. disease, improvements in palliation, and

08 MAY 2017 SMA News but Singaporeans also need to play their part by eating healthily, exercising often, and going for the recommended screenings and follow-ups.” Engaging diverse stakeholders The War on Diabetes cannot be fought by the Ministry of Health alone, which is why the Diabetes Prevention and Care Taskforce is co-chaired by the Minister for Health and the Acting Minister for Education, with representatives from Government agencies, the private sector, and patient advocacy and caregiver groups. The composition of this task force is a strong sign that the Government is serious in mobilising resources to tackle the burden of chronic disease in Singapore, such as inculcating good dietary and exercise habits in schools, providing healthy lifestyle programmes at workplaces, introducing more healthy Illustration: Dr Kevin Loy foods catered by the food industry, introducing an expanded screening extension of the productive years of life. A tandem with the ageing population. As programme for early detection of shift in research emphasis, from research seen in the examples on the war on drugs diabetes for at-risk individuals, and on treatment to research on prevention, and cancer, it is easy for detractors to introducing education and outreach seems necessary if substantial progress criticise intervention programmes when programmes to fill knowledge gaps. against cancer is to be forthcoming.” perceived objectives are not met. This will be a long battle ahead and However, despite the many challenges, the task force must be clear about the Declaring War on Diabetes there are many good reasons to launch a indicators that it tracks to monitor progress. It is important that the public is Singapore made a bold move to battle public campaign of the war on diabetes. kept informed of the measures of success, a chronic disease when Minister for Inciting urgency such as an increase in the early detection Health Mr Gan Kim Yong declared a “War of patients with diabetes, effectiveness of on Diabetes” in his budget speech in Declaring a “war” lends the campaign behavioural interventions, reduction in parliament on 13 April 2016. This was a sense of urgency and emphasises its morbidity and mortality of patients with a remarkable announcement because critical importance in public health. As diabetes, and improvements in quality to my knowledge, no country has ever Mr Gan reported in his 2016 budget of life. To conclude, I quote Mr Gan: “The declared war on a chronic disease such speech, about 400,000 Singaporeans War on Diabetes will not be a quick battle, as diabetes. Other than the above two are diabetic and the lifetime risk of but a long war requiring sustained effort. examples on drugs and cancer, similar developing diabetes is 30%. Of those who Results of our efforts can only be seen in declarations have been made against have diabetes, one in three Singaporeans the long term, but we must persevere.” tuberculosis (an infectious disease) and has not been diagnosed. And among tobacco (a carcinogen). those diagnosed, one in three has poor control of the condition. We hold the References Declaring war on diabetes brings unfortunate distinction of having one to mind some immediate challenges. of the world’s highest rates of lower 1. Bailar JC III, Smith EM. Progress against cancer? N Engl J Med 1986; 314(19):1226-32. Firstly, the “enemy” is hard to detect. extremity amputations. These statistics Symptoms of diabetes, such as polyuria are indeed worrying and serious enough and weight loss, can present late into to necessitate urgent attention. Dr Wong Tien the illness, and they are typically non- Hua (MBBS[S], specific. Early detection would depend Rallying the nation MRCGP[UK], FCFP[S], FAMS[Fam Med]) on regular screening. Secondly, diabetes A public declaration of “war” is a rallying is President of the is an invisible disease with multifactorial call not just for the involvement of 58th SMA Council. causes and is thus hard for patients and stakeholders like patients and healthcare He is a family the public to visualise and understand. providers, but for the whole nation. medicine physician Compared to pictures of a heroin- Every citizen has a part to play and can practising in filled syringe, an ulcerating tumour, contribute to this national effort. Mr Gan Sengkang. Dr Wong has an interest in a lit cigarette or an infective microbe, said: “The key to winning the war on primary care, patient diabetes is an abstract illness. Thirdly, diabetes is for all Singaporeans to be communication and you cannot “win” a war against diabetes engaged in the battle. The key partners in medical ethics. because there is no cure, at least not in this war are the individuals, his/her family the foreseeable future. The number of and the community. By working together, cases of diabetes is expected to increase we hope to create an environment that together with other chronic , in makes healthy choices an easy option,

MAY 2017 SMA News 09