Angry Doctor

Friday, August 31, 2007


If you were given 4 million dollars to spend on HIV/AIDS education, how will you spend the money?

(emphasis mine)

Budget for Aids education hits $4m

THE Health Promotion Board (HPB) will spend $4 million on Aids education this year, an increase on the $3.3 million spent for the year end in March.

This is more than triple the $1.3 million budget it had in 2005.

The spending on Aids education was increased after the Ministry of Health (MOH) corrected a mistake in its 2005 report on the number of new Aids/HIV patients.

The reason for the spike?

The HPB had originally reported 255 new patients. But last September, this number was revised to 317.

With the new figure, the Aids education budget grew as well.

Responding to a Straits Times query, an MOH spokesman explained: 'The additional 62 cases were diagnosed in late 2005 and were retrospectively added to complete the picture.'

The correct number showed that there had been no fall in the number of human immunodeficiency virus (HIV) infections here and, in fact, the upward trend continued unchecked.

Last year, it rose again to 357 new cases, a 13 per cent increase from the previous year. Three in four people infected are heterosexual.

The HPB's stepped-up education efforts include placing advertisements targeted at specific groups, such as the one in The Straits Times last week aimed at young women who indulge in casual sex.

The HPB is also working with the Textile and Fashion Federation to promote more than 50 T-shirts designed by prominent personalities, such as TV actor Adrian Pang and MP Fatimah Lateef, to raise Aids awareness. The T-shirts will be on display at VivoCity from Oct 12 to 21.

Dr Roy Chan, president of the non-governmental association Action For Aids, was not impressed by the new tack: 'Giving information alone is not enough. Many people don't take it seriously because they don't think it applies to them.'

He said this is 'true for any medical condition, and is particularly true for HIV infection'.

People need to be encouraged to take control of their health. The stigma and discrimination against people with the disease also need to change, he added.

Prevention is much more cost-effective than treatment, as the cost of medicine alone comes to about $1,300 a month for each patient. This is on top of any other medical treatment patients may need due to their compromised immune system.

The HPB is focusing its campaign on three groups - teenagers, workers, and men who have sex with other men and illegal prostitutes.

In schools, the HPB runs Aids/HIV education classes for Secondary 3 and JC1 students.

angry doc wonders if the journalist realises the irony within his or her story...

Once again, the campaign is focussed on *them*.

Those people who get and spread AIDS.

Not *us*.

*We* don't gets AIDS.

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Thursday, August 30, 2007

"The Dawkins Delusion"

No, I haven't got anything to blog about today.

Yes, I think it's a funny video.

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Saturday, August 25, 2007

Death and Other Inconveniences

Looks like angry doc is not the only one to look at the issue of euthanasia from an 'economic' point-of-view...

The case for euthanasia
When thinking about our 'rights' to death, are there double standards?

DEATH is perhaps the only truly universal trait that we all share and thus, identify with — regardless of culture, status, or faith — and yet it is still taboo (if not impolite) to talk about it, much less debate it, in modern society.

If you've ever watched the Animal Planet channel, you've probably gawked in disbelief at how fortunate some pets are. Paris Hilton's pooch chows down on foie gras, while 3 billion people (that's half the world) live on less than $3 a day.

But if life is good for these pets, death might be even better — for when perceived to be in agony, at least they are put out of their misery.

Humans on the other hand, have no such option.

So, what is an aspiring economist doing questioning the legality of euthanasia? Aren't such matters best left in the hands of ethical philosophers and moral legislators?

The way I see it, the criminalisation of euthanasia is tantamount to a violation of the free market and individual property rights, and thus warrants a rational (read: economic) review.

The most common justification for the flagrant infringement of a basic human right — the freedom of choice — is that the average person often makes "bad" decisions, thus the need to relieve him of certain options.

However, if a decision bears little to no adverse effects on anyone but oneself, why should the government intervene?

To be sure, I believe most would find the mohawk a "bad" haircut; but the hair on someone's head is his, not mine, and his garish haircut doesn't waft into my eyes like second-hand smoke does. How he decides to treat his hair should be no business of ours.

By the same token, what a man chooses to do with his life should be treated with equal respect, for it is the individual's prerogative, and not the communal right, to decide.

Choice presupposes ownership. Therefore, central to the euthanasia debate is religion, for your belief in the nature of cosmic truth will ultimately determine who owns, and therefore controls, your life.

Euthanasia finds its strongest opposition in the annals of religion — and this is perhaps the reason why supposedly secular legislation is skewed so — because modern law remains primarily based upon Biblical canon.

To deny one the right of choice over his own life, is to presume that he had no ownership over it to begin with.
Followers of monotheistic faiths believe that life was bestowed by some supreme Creator, and thus, can only be rightfully taken away by Him.

Some might argue that our emasculation with regard to birth should follow into death, but such a fatalistic view is about as bright as saying that those born into poverty should not endeavour to enrich themselves.

Instead, Life, like an inheritance, is but an endowment, and has no bearing over what you may decide to do with it.

Let me concede that we have no say in our creation — our parents did.

Life is as much a given as Death is; but while (or perhaps, because) we have no control over the former, we strive to control the latter like we attempt of everything else around us.

Everything modern medicine has achieved might seem to be in contravention of a divine order.

Consider how — and this can be empirically proven — two identical people, with identical illnesses can experience vastly different life expectancies, when given, or deprived of, access to medical amenities.

To me, this is positive proof that we are either defying some heavenly instruction by our prolonged existence, or that perhaps such an order never existed to begin with.

If we assume, for the sake of argument, that such an order exists, it must then logically follow that if He does not find the extension of our mortal existence offensive, then why should the converse be so controversial?

If we try reasoning along an atheistic slant, then the argument becomes even more potent.

Many biologists argue that what differentiates humans from the rest of the animal kingdom is the capacity for emotion; and perhaps, what unites us, is the sensation of pain.

If pain truly is universal, then our double standard between animals and humans in this regard is not only hypocritical — it is downright perverse.

Consider this: An animal, with no means of communicating its true intent in a language intelligible by humans, except its display of perceived agony, is by default, put down if thought to be suffering; while a human, perfectly capable of communicating intent and/or visibly in pain, is by default refused any assistance for voluntary euthanasia.

Lastly, a country that has the death penalty has no right opposing euthanasia, for one of the most popular arguments against euthanasia is that its legalisation constitutes a government sanction for suicide and therefore cheapens the inherent worth of human life.

To digress a bit, there are other parallels to be drawn.

Some argue that the death penalty is justified in that it has a deterrent effect and that imprisoning a felon for "25 to life" is ridiculously expensive for the taxpayer to upkeep so heinous a criminal.

It should be obvious that the criminalisation of euthanasia has no deterrent effect on any individual, simply because it is not an act of frivolity, but one of desperation.

The able will still resort to messy alternatives or seek assistance in Holland, where euthanasia is legal. The unable must continue wallowing in pain. Even if the ban does preserve life, it most certainly robs it of dignity.

Also, keeping an unwilling patient on life support ties up precious medical resources and attention, which could otherwise be used to save patients with a will to live. An outright ban is not only just cruel, it also runs in direct contradiction to the logic behind many of our existing laws and beliefs.

The inconsistencies in our justification should compel us to question if our reasoning in support of the ban is valid, or if they are predicated upon traditional dogmas which are in serious need of intellectual review.

As an atheist, I find that the absence of an afterlife in my ideology reinforces my love for life.

For only when we concede just how short life really is, do we begin to cherish what little time we have left.

Depriving us of our right to death does nothing to that effect.

(The writer is currently studying for his MSc in Finance and Economics at the London School of Economics.)

Mr Tan's line of argument goes all over the place, but it is nevertheless a fun letter to read.

angry doc believes Mr Tan argument is basically this: people have the right to end their own lives.

To angry doc that is a non-statement - everybody dies, and there is very little anyone can do to stop someone who is truly determined to die from killing himself or herself. 'Right' is a social construct, and in the face of the bare realities of existence 'right' does not even enter into the equation.

We have no more the right to die as we have the right to live.

That aside, angry doc thinks that Mr Tan could have defined his terms-of-reference a little better.

An 'unwilling patient on life support' does not have to receive that life-support if he or she does not want to and can communicate that intention, and taking him or her off life-support then does not constitute euthanasia, or at any rate amounts only to 'passive euthanasia', which is not currently illegal.

(At least angry doc hopes it isn't, or he is in big trouble...)

The issue at hand is actually 'active euthanasia', and specifically 'voluntary active euthanasia'.

The debate about euthanasia isn't really about the right to end one's own life - if it was one could simply jump off a tall building or a pier, or step in front of a speeding train. Euthanasia is about wanting to end one's life with minimal discomfort, maximal certainty, and getting someone else to do the job of killing for you.

In other words, euthanasia is not about giving someone the right to end one's own life, but giving a class of people the right to end another person's life with his or her consent (or the consent of his or her guardian, depending on the specific legislation).

In most settings, this translates to physician-assisted suicide.

And that's what pisses angry doc off about the euthanasia debate.

Why do discussions of euthanasia always have to involve the medical profession? It doens' take five years in a medical school to learn how to kill someone effectively, I assure you.

We don't mind keeping people alive if that's what they want, but I certainly don't see why 'murder' has to be added to our job description.

But if you want a doctor's opinion, here's what angry doc's experience has taught him: nobody actually wants to die.

The man who is in debt does not want to commit suicide, he just wanted to be freed from his debts.

The woman with terminal cancer does not want to undergo euthanasia, she just wants to be freed from her pain and suffering.

Give either person what he or she lacks or wants, and death is no longer an attractive option.


Friday, August 24, 2007

Mental Capacity Act 5

Still logging the news on the MCA...

3-W poser for new Bill
Judging mental capacity is a complicated issue
Jasmine Yin

SHOULD the draft Mental Capacity Bill find its way into law, Singaporeans will get to handpick, in advance, their guardians, should they — through stroke, dementia or other unfortunate circumstances — lose the mental ability to make decisions for themselves.

To sign away one's rights to another person takes a lot of trust and judgement. And, as the State kickstarts the process to facilitate a matter as grave as this, every minutia has to be scrutinised and ironed out.

One of the biggest questions that will have to be answered is: How do you determine that someone has lost the capability to make a reasoned decision? When is mental capacity considered "lost"?

In the case of those with severe intellectual disabilities, the answer is pretty clear-cut.

For others, the draft Bill has proposed a two-stage test.

It states a person loses such capacity when he or she is unable to understand, use or weigh information relevant to a particular decision, and to communicate the decision.

But the authorities have not come to a decision on the "who, what and how" to carry out such a test, and they are seeking feedback from the medical fraternity.

What complicates matters further is this — as the Bill recognises — the loss of mental capacity can be permanent or temporary. And, as Dr Vivian Balakrishnan, the Minister for Community Development, Youth and Sports, pointed out, it "may change with time; it may even fluctuate".

In other words, it is not about simply declaring a person "mentally unsound", as the current law does, from one point on.

For example, Mr A, who is 60 and in the early stages of dementia, is still able to decide that he wants to live on his own at home — but he may not be able to manage his household finances. His guardian who takes over can make only money-related decisions on his behalf.

But a few years down the road, Mr A's condition worsens. It may be necessary for his donee to make other, more vital decisions, such as whether to put Mr A in a nursing home, where he can get better care.

So, at which stage does one decide what and how much decision-making power to accord the donee?

One of the issues authorities are reportedly also mulling over, is whether the graver the decision to be made, the more rigorous the assessment of the patient needed — should it be carried out by a psychiatrist instead of the family general practitioner?

But then, what if Mr A's condition gets better, instead? Unlike a victim of permanent brain damage, dementia patients can improve.

If Mr A were to regain mental capacity at some point, would it be incumbent on the guardian to — in Mr A's best interests — encourage him to engage in decision-making once again? But who is to say the guardian would willingly do so?

According to Dr Ang Yong Guan, a psychiatrist, a temporary loss of mental capacity may also arise from conditions such as clinical depression and acute schizophrenia. And the patient may regain mental capacity following treatment.

Hence, Dr Ang feels, the Bill should "only apply" to those suffering from an irreversible condition.

But this raises more questions: Should judgement on whether to transfer decision-making power to the guardian, then, be postponed until the person recovers?

If so, how long should the deferment be?

Another kink that needs to be ironed out is who can be appointed a donee.

You can choose to appoint more than one donee to make decisions on your day-to-day needs — such as handling your savings, property matters and certain healthcare issues. But there are certain barring criteria.

For instance, the authorities are proposing that a donee cannot have been convicted of any sexual or violence-related offence, fraud or dishonesty; nor be an undischarged bankrupt.

The idea is to ensure that someone given such power over your life is a person of character.

But what if, say, Mr A insists he can trust only his son, who was previously convicted of molest? Is it right to presume that the son, because of his record, is unable to care for and act in the best interests of his father?

Also, will there be checks to ensure that the appointment of a donee is not made because of pressure placed on the applicant?

And what if the donee, having taken up the burden of care, is one day unable to handle it anymore? Can she opt out of her legal duties?

Every Singaporean stands to be empowered or limited by the proposed law, given that we all share the risk of growing old and having our minds deteriorate.

In the same vein, the answers to these questions will one day concern you and I.

Hence, it would be a great pity if people do not share their views with the lawmakers — the extended public consultation on the Bill ends on Oct 31 — before the Bill becomes law.

After all, the best way to live out the end part of our lives — even when we are losing the ability to understand the world around us — is to decide how we want to, right now.

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Wednesday, August 22, 2007

"The Enemies of Reason" Part 2

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Monday, August 20, 2007

It's not a disease...

angry doc learnt something new today - apparently, epilepsy is not a disease.

Epilepsy talks soon for professionals and the public
Letter from GRACE TAN Chairman, Singapore Epilepsy Foundation

We refer to the letter, "Boy with fits just left to rest" (Aug 14) by Mdm Yue Lai Theng.

The Singapore Epilepsy Foundation (SEF) agrees with Mdm Yue's concern about the importance of promoting public awareness of epilepsy (commonly known as fits or seizures).

Epilepsy is not a disease, and it is not contagious. It is a common neurological disorder that causes sudden, uncontrollable electrical surges in the brain. These brief interruptions in brain activities cause periods of altered awareness, known as seizures, whose nature and intensity vary from person to person of any age.

One of the SEF's objectives is to promote greater awareness and information on epilepsy and its management to the general public especially to teachers at pre-schools (including childcare centres), mainstream and special schools.

The basic understanding of first aid for epilepsy will help provide comfort to the individual who has a seizure and will ensure minimal harm during and after the occurrence of the seizure.

In the coming months, the SEF, in collaboration with the medical teams of public hospitals and professionals in neurology, will be organising a series of talks on epilepsy awareness and management for healthcare professionals, teachers, caregivers and the public. Please visit our website at for details to be announced or email your enquiries to

angry doc was wondering why all his patients with epilepsy were coming to see him and taking medication if they weren't suffering from a disease.

Turns out they have a *disorder* and not a *disease*.

The SEF is not the only organisation to state that 'epilepsy is not a disease'; google the phrase and you will find literally hundreds of sites proclaiming the same.

Epilepsy may not be a single disease entity with one single causation or pathology, and you can even argue that the term epilepsy is properly a sign and not a diagnosis; s
o why do angry doc and his colleagues continue to use the term epilepsy?

Well, a lot of it is probably 'historical', but a lot of it is because the term is convenient and useful in daily practice - whether you call it a disease or a disorder, patients with epilepsy first require a work-up, then monitoring, and in many cases treatment.

angry doc is all for promoting awareness of the condition and its management, but he doesn't really see the point in making the point that epilepsy is not a disease.

Maybe he just needs to attend one of these awareness talks...


Sunday, August 19, 2007

Two Years

Seven hundred and thirty-one days.

Four hundred and eighty-four posts.

Friends made, friends lost along the way.

Still angry.

Thanks for reading.

Friday, August 17, 2007

Mad Scientists

As Professor Dawkins said in the video, science is under attack.

Even long-dead scientists do not enjoy immunity, as evident from an anonymous poster's comment on this earlier post:

In the same vein, let's not forget the possibility of mad scientists out there who are so obsessed with advancing science that they disregard ethics? Think eugenics, think cloning. Also, without planes, there is no 9/11.

The Wright Brothers may have been 'mad scientists' in a way, but angry doc thinks it's hardly fair to think of them as abetting terrorists.


"The Enemies of Reason" Part 1

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Wednesday, August 15, 2007

It's all personal

"Tom, don't let anyone kid you. It's all personal, every bit of business. Every piece of shit every man has to eat every day of his life is personal. They call it business. OK. But it's personal as hell."

angry doc would like to look at a letter on a different topic today:

Sick service workers should stay home

I REFER to the report, 'Gastric flu cases in school traced to food handler' (ST, Aug 9).

A few weeks ago, I patronised a '$10 haircut in 10 mins' salon chain in a well-known shopping centre.

It soon became apparent that the cutter was suffering from a severe bout of flu as she was wheezing and sneezing away.

By then it was too late for me to abort the haircut.

I asked her why she turned up for work despite being sick. She explained that their compensation scheme penalises absenteeism from work, even for medical reasons, i.e., no show, no pay.

This sort of wage structure is fairly common in the retail sector. One can sometimes see obviously ill order takers, cashiers, food handlers and shop assistants at work.

While such a structure may discourage malingering, the risk of flu and other infectious diseases spreading rapidly in a densely populated city-state such as Singapore through contact points in the numerous shopping malls is clear and present.

My other question to the hair cutter was whether she had thought about putting on a mask. She told me the company did not permit them to put on a mask as doing so may scare customers away.

Besides customers and co-workers (it could be in the hundreds), sick workers could also spread diseases to other commuters when they travel in public transport.

One way to prevent such workers from turning up for work is to ensure that they are compensated fairly when they stay away due to medical reasons.

Another way is to have shopping-centre owners prohibit retailers from deploying ill workers.

Could the Ministry of Manpower and the Ministry of Health look into this matter?

Huang Xun Xian

It may be an anecdote, but it is by no means an isolated occurrence.

angry doc suspects that the people who wrote such staff policies never had to see a man close to tears because he is ashamed of not being able to afford his own healthcare, and not daring to take medical leave even when they are too ill to work because that would mean 'no pay'.

Healthcare may be a big business, but like Don Corleone said, every bit of it is, at the end of the day, personal as hell.


Mental Capacity Act 4

Just keeping the news on the MCA logged.

When you can't make the call
Proposed Mental Capacity Bill lets you pick who you want to make decisions for you
Jasmine Yin

OFTEN disoriented, the 80-year-old woman with dementia would complain of "neighbours who wanted to kill her".

Her five children took it in turns to care for her. But as the burden grew, two of the siblings suggested an old folks' home. The other three argued against "dumping" their mum — and a bitter split ensued.

"Had she stated clearly her wishes when she was mentally capable of doing so, this disagreement among her children would unlikely have arisen," said psychiatrist Ang Yong Guan, who recounted this story to Today.

But a proposed law could soon help avert such family feuds — and give Singaporeans a crucial say in who should make the decisions for them, when they themselves are no longer of fit mind to do so.

If passed, it means you will get to appoint the person or people you trust — called a donee — to act on your behalf, in areas as wide-ranging as managing your household budget for buying groceries, to deciding where you would live, to certain healthcare decisions.

You can also spell out your wishes on such issues in advance, to be taken into consideration when the time comes.

The draft Mental Capacity Bill — in similar vein to legislation such as the Advanced Medical Directive (AMD) — gives individuals the power to make such choices before they become unable to do so because of dementia or brain damage, for example. This will not be mandatory.

The proposed law is "much more flexible and ... allows people to tailor-make plans for their requirements," said Minister for Community Development, Youth and Sports Vivian Balakrishnan at a press conference yesterday.

Currently, under the Mental Disorders and Treatment Act, the court appoints a committee for someone who has lost his or her mental capacity.

The Bill spells out a checklist of how decisions must be made in the person's best interests: Such as, taking into account the person's "past and present wishes and feelings" and consulting other caregivers.

Decisions the donee cannot make include consenting to marriage or sexual relations on the person's behalf or making a Central Provident Fund nomination.

Also — since the situation presents opportunity for abuse or exploitation — tough action has also been mooted against donees who flout their responsibilities.

A jail term of up to 12 months or a fine not exceeding $7,000, or both, will be levied on those found guilty of ill-treatment or wilful neglect of their mentally incapacitated charges. This is a new criminal offence created under the draft Bill.

A new Office of Public Guardian would investigate complaints and supervise court-appointed guardians, among other functions. Anyone wishing to challenge the decisions made by a donee would find it easier to do so, instead of having to go to court.

"If we are creating the framework which confers responsibility and power in the hands of the donee or the (court-appointed) deputy, it also makes sense that the person be made accountable," said Dr Balakrishnan.

Welcoming this was Mr Navin Lobo, a lawyer with Harry Elias, who said the safeguards would give family and friends who aren't donees of the mentally-incapacitated person a "certain measure of comfort".

He has seen cases in which court-appointed kin have pilfered the bank accounts of their charges, leaving little for their day-to-day expenses.

The Ministry of Community Development, Youth and Sports had studied similar laws in Britain and Hong Kong. The draft Bill is now up for public consultation and because of the issues involved, Dr Balakrishnan said, "this is not a Bill that we need to rush through Parliament".

But there is some degree of urgency. In five years, there will be an estimated 20,000 people with dementia in Singapore. The number of court cases involving decisions made for the personal well-being and finances of the mentally incapacitated has gone up, too — from 188 in 2000 to 228 last year.

Getting Singaporeans to sign up once the law is passed, however, is another challenge. Since the AMD Act was passed in 1996, only 3,840 people have signed up as of last October.

Acknowledging that there are "many end-of-life issues that we would rather avoid", Dr Balakrishnan nevertheless urged Singaporeans not to "wait till disaster has befallen you".

The authorities, on their part, plan to make the process of appointing a donee "affordable" and easy, such as simply filling up a standard form.

Retiree Tan Siew Kheng, 67, for one, is interested in this, having had to care for a parent who had dementia. He even suggested that this new legislative framework may even help reduce cases of elderly abandonment in the future.


Monday, August 13, 2007

Gays spread AIDS, Malay kids are dumb

Yes, the title is deliberately provocative, but bear with me...

Every year the Ministry of Education releases "data on the performance of the major ethnic groups", with the purported aim of "provid[ing] feedback to the communities on how their children fared in the national examinations".

Now take a look at these charts, which give the performance of children in the PSLE exams by their ethnic group.

You will find that with the exception of Mother Tongue, Malay kids consistently perform worse than their Chinese or Indian counterparts.

Given that this is the only way the data is presented, one is tempted to conclude that Malay kids are dumb, and do poorly in every subject except Malay.

Now is that an accurate interpretation?

There are several problems when we present data this way. First of all, as soon as you draw an average or overall score, chances are one or more race will score above the average, and one or more race will score below the average.

Someone is going to look dumb.

Secondly, for any data to be useful, the classification must tell us something about causation, and hopefully give us a clue about a solution.

Now imagine you were a Malay 'community leader'. Just what exactly are you supposed to do when presented with data like that above?

Well, you can either accept that the classification used reflects the true cause of the problem, and conclude that Malay kids are dumb because they are Malay, in which case there is not much you can do except perhaps to encourage inter-racial marriages or hope evolution will do its best.

Or, you can decide that race is only a correlation and not a cause in this case, and that the causation is likely to be multi-factorial and not something as simple as what colour your skin is, and ask for more data.

How do children from families of different income groups fare compared to each other? Do children from single-parent families do worse, and do children who have a parent at home full-time do better? Does the langauge spoken in the child's home make a difference?

Don't you think all these factors are likely to influence how well a child does in school?

With such data, we might be able to find out how we can help the children who are not doing well - Chinese, Indian or Malay - to do better. Without such data, people are left to conclude that Malay kids are dumb.

(Of course, at the level of the individual teacher, this sort of data is even less meaningful: if a Malay child is scoring above 80% consistently, there is no reason why I should worry that he will do poorly in his PSLE just because he is Malay, is there? Conversely, if a Chinese child is barely passing his tests, I woldn't assume his Chinese-ness will make him ace his finals.)


So what does all this have to do with gays and AIDS, you ask?

Well, plenty.

Locally, HIV is seen predominantly as a MSM disease because while they make up only a small percentage of our total population, they account for about 30% of the total HIV cases here.

(The MOH site also breaks down the cases by age, marital status and ethnic groups, but we almost never hear people say that HIV is a Chinese disease, or singles' disease, do we?)

Granted the type of sexual act correlates with orientation, but is anal sex between men any different from anal sex between a man and a woman?

Would not other information like number of partners and consistency of condom use be useful to us?

With such data, we may find that HIV spreads because of promiscuity and failure to practise safe sex. Without such data, people are left to conclude that HIV is a gay disease.

The Ministry continues to look at the HIV/AIDS problem as a MSM problem, and so continues to politicise and moralise the issue, as evident from the front-page article on Today today.

To its credit, Today also published this article from Helen Epstein, in which she relates:

People always ask me: "Fighting Aids requires a social movement. How do you generate a social movement?" Well, one thing that always galvanises people is a common enemy.

Too many donor-funded Aids programmes have divided people: HIV-positive from HIV- negative, "moral" from "immoral", high-risk from low-risk. Such programmes send the message that people with Aids are the enemy.

Ugandans and gay men knew early that the enemy was HIV itself.

Do read the whole article.

(angry doc would like to thank palmist for inspiring this post.)

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Sunday, August 12, 2007

Why there are no ghosts

An anonymous poster made this comment on an earlier post:

what dawkins is doing is to eschew all forms of inquiry that do not conform to the scientific method. if this isnt narrow-mindedness i don't know what it is.

angry doc asked the poster what exactly it was that Dawkins eschewed that the poster thought should not be subject to the scientific method, to which our poster replied:

How about ghosts for instance? I'm not saying for sure that they exist because honestly I haven't had any encounters with the supernatural. But there have been reported sightings. People have claimed to have seen them. To Dawkins, this wouldn't count as knowledge because you'd find it incredibly difficult to conduct experiments to investigate the veracity of the claim due to the inconsistency with which such sightings occur. But why should you disregard this claim simply because by scientific standards it fails to qualify as knowledge? Isn't there a possibility that the eyes of these witnesses were not playing tricks on them? Isn't there a possibility these people were not lying when they swore they had seen ghosts? Isn't there a possibility that there are indeed ghosts?

Of course it is possible.

By the same argument it is also possible that unicorns, leprechauns, and the chupacabra exist, and that Elvis lives. Everything is possible, except that the existence of all those things we’ve mentioned are unlikely and unproven.

Well, maybe not Elvis.

But what does Dawkins have to say about the subject of ghosts?

As it turns out he *had* heard a ghost as a child, and he touches briefly on the subject in his book The God Delusion, part of which is reposted here.

angry doc abstracts the relevant parts:

One of the cleverer and more mature of my undergraduate contemporaries, who was deeply religious, went camping in the Scottish isles. In the middle of the night he and his girlfriend were woken in their tent by the voice of the devil — Satan himself; there could be no possible doubt: the voice was in every sense diabolical. My friend would never forget this horrifying experience, and it was one of the factors that later drove him to be ordained. My youthful self was impressed by his story, and I recounted it to a gathering of zoologists relaxing in the Rose and Crown Inn, Oxford. Two of them happened to be experienced ornithologists, and they roared with laughter. "Manx shearwater!" they shouted in delighted chorus. One of them added that the diabolical shrieks and cackles of this species have earned it, in various parts of the world and various languages, the local nickname "Devil Bird".

The argument from personal experience is the one that is most convincing to those who claim to have had one. But it is the least convincing to anyone else, especially anyone knowledgeable about psychology. Many people believe in God because they believe they have seen a vision of him — or of an angel or a virgin in blue — with their own eyes. Or he speaks to them inside their heads.

You say you have experienced God directly? Well, some people have experienced a pink elephant, but that probably doesn't impress you.

[The formidable power of the brain's simulation software] is well capable of constructing "visions" and "visitations" of the utmost veridical power. To simulate a ghost or an angel or a Virgin Mary would be child's play to software of this sophistication.

Once, as a child, I heard a ghost: a male voice murmuring, as if in recitation or prayer. I could almost, but not quite, make out the words, which seemed to have a serious, solemn timbre. I had been told stories of priest holes in ancient houses, and I was a little frightened. But I got out of bed and crept up on the source of the sound. As I got closer, it grew louder, and then suddenly it "flipped" inside my head. I was now close enough to discern what it really was. The wind, gusting through the keyhole, was creating sounds which the simulation software in my brain had used to construct a model of male speech, solemnly intoned.

Had I been a more impressionable child, it is possible that I would have "heard" not just unintelligible speech but particular words and even sentences. And had I been both impressionable and religiously brought-up, I wonder what words the wind might have spoken.

That is really all that needs to be said about personal "experiences" of gods or other religious phenomena. If you've had such an experience, you may well find yourself believing firmly that it was real. But don't expect the rest of us to take your word for it, especially if we have the slightest familiarity with the brain and its powerful workings.

Well, angry doc has something to add to that:

We all require evidence of one sort or another to believe; we just happen to have less stringent criteria for accepting someone's claims as valid evidence when we want or wish for them to be true, and vice versa.


Friday, August 10, 2007

Sick, sick people 15

Dr Chin's latest letter brings a few letters in response today, two of which made angry doc smile.

Ms Tamsyn thinks Dr Chin "needs to quote his sources".

Ms Li obliges us by telling us that the figures Dr Chin used were "from the book by Alan P. Bell et al, Homosexuality: A Study Of Diversity Among Men & Women (1978)", and that "[o]ther studies on the number of partners of gays have contradicted the figures". She urges that "readers who write to the ST Forum be more careful with regard to their selection of studies to back up their arguments".

Well, the studies Ms Li quoted don't actually 'contradict' the figures, but they just happen to have found lower percentages of homosexual men with more than 500 partners than the first one. Still, 500 partners sound like a lot to angry doc, homosexual or heterosexual.

Nevertheless, angry doc finds it encouraging that Ms Tamsyn asked for the source of Dr Chin's data, and that Ms Li actully took it upon herself to find the source of Dr Chin's data, and also other similar studies.

Everything you read in the media (old and new, and that includes this blog) is there because somebody wants to influence the way you think and act. We need to recognise that statistics have to be interpreted in their context, and that evidence vary in quality.

Added: There is actually an interesting story behind Ms Li's letter, recounted in this post from Yawning Bread.

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Wednesday, August 08, 2007

The sexiest man alive...

... just got sexier.

angry doc will be looking out for this documentary.

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Sick, sick people 14

Beyond a certain point, we are no longer having an discourse, but merely repeating the same tune...

Beware the high-risk 'gay lifestyle'

IN THE article, 'Most with Aids virus don't know they have it' (ST, July 18), Senior Minister of State Balaji Sadasivan announced that a study of 3,000 blood samples in government hospitals showed that 1 in 350 samples was positive for the human immunodeficiency virus (HIV) which causes Aids. The male to female ratio of these cases was 15:1.

What conclusions can we draw?

The 15:1 ratio means that the HIV epidemic is still confined mainly to the high-risk groups (concentrated epidemic) and has not spread to the general population (generalised epidemic). If it were already in the general population, the ratio would be much closer to 1:1.

Therefore we still have time to do something before the situation gets worse.

Who constitutes these high-risk groups?

Data released by the Ministry of Health on HIV last year showed two groups of men were responsible for approximately 83 per cent of HIV cases.

53 per cent of the cases were men who contracted HIV via unprotected high-risk heterosexual sex. This group was infected overseas or by local unlicensed prostitutes; our licensed prostitutes are screened for HIV.

30 per cent of the cases comprised men having sex with men (MSM). Based on the prevalence of 2.8 per cent of men being homosexual or bisexual, there are about 67,000 men in Singapore who engage in MSM.

I highlight this second high-risk group as it is a matter of public interest and concern, given the ongoing debate on the review of the Penal Code relating to Section 377A.

Extrapolating from the infection rate of 1 in 350 and 15:1 ratio of males to females, the conclusion is that among men who indulge in MSM, about one in 20 has HIV and does not know it.

This means that someone who indulges in MSM and has 20 sexual partners would have exposed himself to HIV.

A survey conducted in the United States has shown that 75 per cent of homosexual men have more than 100 sexual partners and 28 per cent of them have more than 1,000 partners.

I feel that not enough has been done to warn our youth that leading a 'gay lifestyle' is not cool. On the contrary, it is very unhealthy. There is a very high risk of contracting not only HIV but also a slew of other sexually transmitted diseases.

Dr Alan Chin Yew Liang

angry doc does not have anything new to say about Dr Chin's argument, because apparently, neither has Dr Chin.

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Tuesday, August 07, 2007

Sick, sick people 13

I guess it's too much to hope for that Dr Chin will pass up on an opportunity to give his professional opinion on how we should control 'this scourge of HIV', isn't it?

Law and public education should go hand in hand in dealing with HIV

I WRITE in response to the letter by Mr Paul Toh, ' 'Bug chasers' or 'gift givers' will not be let off lightly by the gay community' (ST, Aug 2),

His statement that because of our laws, especially Penal Code Section 377A, the message of 'safe sex' cannot be effectively communicated to those at risk is flawed.

Take the example of heroin drug abuse; laws prohibit its use. Using the same line of argument as Mr Toh's, it would then not be possible to effectively communicate the message 'Do not use drugs'.

However, the message against drug abuse has been effectively communicated to all segments of society. Everyone knows that it is wrong to use drugs and if you are caught you will be punished.

In the United States, 99 per cent of the population understands that you can get HIV through unprotected sex. In the United States' CDC Mortality and Morbidity Weekly Report, June 24, 2005, Issue, a study of 1,767 MSM men showed that one in four men had HIV. The number of MSM men getting HIV continues to rise despite all efforts.

This shows that education and awareness of HIV by itself cannot bring down the infection rates of HIV. If it were so, then data from the US should show falling rates of infection rather than rising rates.

An example of the inadequacy of public education and awareness alone is the phenomenon of 'bug chasing' and 'gift giving' at 'bug parties'.

This reckless behaviour is found among men who engage in anal penetrative coitus. Men, who knowing that they have HIV, yet still engage in unprotected anal penetrative coitus. This practice of having deliberate unprotected anal sex has the potential to cause widespread HIV infection. These men know that it is wrong and yet persist in doing it.

The number of MSM men having HIV in Singapore is about 1 in 20. It is still unacceptably high. However, compared to the US, we have a five times lower rate of infection.

It is our society's stance against such immoral and socially irresponsible behaviour and our laws, especially Penal Code Section 377A, that account for this difference.

Evidence in point:

1) Some time ago, the then Senior Minister of State for Health, Dr S. Balaji, stated that the relaxation of our laws against 'gay' events led to a spike in the number of HIV cases among MSM men from 2003 to 2004.

2) We have the lowest rate of heroin and drug abuse in the world because of our strict laws and tough stance against drug abusers.

Sometimes tough love is needed for those who, despite their being aware of their irresponsible and reckless behaviour, do not want to change.

The law and public education should go hand in hand in dealing with this scourge of HIV.

Dr Alan Chin Yew Liang

angry doc wonders if Dr Chin is trying to confuse the issue, or if he is just confused over the issues at hand.

The spread of HIV in Singapore is neither exclusively by men having sex with men (MSM), nor is it predominantly by men having sex with men.

We recognise the 'wrongness' of knowingly subjecting another person to the risk of a serious infectious disease like HIV, which is why it is an offence to do so under the
Infectious Diseases Act, which states that:

Sexual intercourse by person with AIDS or HIV Infection
23. —(1) A person who knows that he has AIDS or HIV Infection shall not have sexual intercourse with another person unless, before the sexual intercourse takes place, the other person —

(a) has been informed of the risk of contracting AIDS or HIV Infection from him; and
(b) has voluntarily agreed to accept that risk.

(2) Any person who contravenes subsection (1) shall be guilty of an offence and shall be liable on conviction to a fine not exceeding $10,000 or to imprisonment for a term not exceeding 2 years or to both.

The law does not discriminate between homosexual and heterosexual intercourse, and indeed if you go on the read the whole section, it does not discriminate based on age, and is in fact that it is meant to cover both heterosexual and homosexual sex (angry doc is just to shy to quote the sections here...).

So why does Dr Chin attribute our lower rate of HIV infection in MSM compared to that of the US to Section 377A, and not Section 23?

More importantly, if it is 'the HIV scourge' Dr Chin is so concerned about, shouldn't he be championing the enforcement of Section 23, which covers HIV-positive persons of all ages and orientation, rather than Section 377A, which covers even MSM who are HIV-negative?

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How I Learned to Stop Worrying...

... and Love Mandatory HIV Testing.

What a glorious day on the ST Forum page.

Two letters supporting the move to implement 'opt out' HIV testing for patients admitted to hospitals!

Bring a tear to angry doc's eyes, they do.

Mr Goh believes that:

To protect our health-care workers, all patients admitted to a hospital should be subject to a mandatory HIV test.

In this way, they could take extra precaution in handling patients who have been diagnosed as having Aids or HIV infection.

Mr Goh also believes that we should take it a step further and make HIV testing mandatory, a belief shared by Mr Koh, who wrote that:

This should not be interpreted as ignoring civil rights. We are talking about protecting lives - especially those of our health-care workers.

angry doc predicts that a year after we implement 'opt out' or mandatory HIV testing, the number of healthcare workers who become infected with HIV in the course of their work will fall to zero.

From the current rate of zero case per year.

But of course, even though such a scheme will protect the lives of healthcare workers, it doesn't mean that everyone will support it, like say Mr Szeto here, who obviously hates doctors so much he dares question the benefits of 'opt out' HIV testing:

Protect health workers from all blood-borne ills

I REFER to the article, 'HIV tests may be part of hospital admission process' (ST, Aug 4).

I am very pleased to see the Singapore Government placing the safety of healthcare workers at the top of the agenda.

Health Minister Khaw Boon Wan identified the potential transmission of HIV via accidental injuries as a problem, but one has to question if HIV testing is the solution.

By identifying a patient as HIV positive, we have not decreased the risk of accidents. It is through the implementation of strict safety protocols and stringent training that the risk of injuries can be minimised (e.g., wearing protective gear when handling sharp objects).

Implementing a separate set of protocols for dealing with HIV-positive patients will not only highlight what is already a much stigmatised group in society, but could also compromise the standard of care delivered.

Furthermore, why the focus on HIV? Health-care workers may come into contact with many other serious blood-borne infections while on duty.

Should we not have a set of protocols that will effectively protect them from, say, Hepatitis A as well as HIV?

Matthew Szeto

Shame on you, Mr Szeto, for trying to shift the responsibility of infection-control from HIV patients to healthcare workers!

Added: angry doc did a bit of googling to try to find any documented incidence of healthcare workers being infected wiith HIV in the course of their work, but was unable to find any reference.

He did manage to find this rather recent and informative article on HIV/AIDS Prevention published in the Singapore Family Physician though. Well worth a read.

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Saturday, August 04, 2007

Take your rights? Don't mind if I do...

A rather serious topic to end the week on, but something we should all think about, I think...

(emphasis mine)

Aids stats point way to HIV tests
Health Minister 'seriously considering' opt-out scheme to stem tide

WITH recent statistics pointing to a worrying Aids trend here, the Government is thinking of extending the opt-out scheme to HIV-testing, too. So, if you are male, admitted to a hospital and have not opted out, then don't be surprised if you are asked to take an HIV test.

The Ministry of Health (MOH) is looking into an opt-out system for HIV testing as statistics show that one in 350 hospital patients is HIV-positive. A recent MOH study of more than 3,000 anonymous blood samples collected in hospitals showed that 0.28 per cent of those who thought they were free of the disease were in fact HIV-positive.

Also, a record 357 Singapore residents were diagnosed with HIV last year, up 12.6 per cent from 317 cases in 2005. Of the new cases, about 91 per cent were males.

Since then, a voluntary welfare organisation has called for mandatory HIV testing for those in high-risk groups — which some have described as intrusive.

Health Minister Khaw Boon Wan said on Friday that while mandatory screening is good from a public health point of view, there are objections and difficulties in implementation.

"The minimum is, I think, we have an opt-out scheme," he said.

For example, it could be administered when a patient is admitted to the hospital as part of standard tests.

"So, you can opt out if you want to, but otherwise people would just take it as a routine exercise like taking high blood pressure (and blood sugar)," said Mr Khaw on the sidelines of a National Day Observance Ceremony at Tien Wah Press.

Mr Khaw added that he was "seriously considering" the move to routinely test adult males on an opt-out basis.

He said: "If you take this rate of 1 in 350. Every day, the public hospitals probably have about 5,000 in-patients ... so at this rate, that means there are about a dozen unknown HIV patients whom we have very close contact with every day.

"As healthcare workers, we have proper infection control — (we wear) double gloves and so on — but accidents do happen ... so it's a problem I cannot ignore."

Of the new HIV cases last year, 78 per cent were detected when they were tested for HIV while receiving other medical care. Only 13 per cent were detected as a result of voluntary HIV screening.

The MOH's opt-out screening for pregnant mothers, implemented in 2004, has been successful in saving babies, with just one case of mother-to-child transmission occurring, and that was because the mother refused her HIV test until very late in her pregnancy.

Less than 1 per cent of pregnant mothers had opted out of the scheme.

While HIV testing "makes a lot of sense", Mr Khaw admitted that a lot of planning would have to be put into the exercise, such as bumping up counselling services for those found to be HIV-positive.

Mr Andrew Tan, a 27-year-old engineer who is single, said: "I am okay with it as I don't think I'm at risk, but I think it may be uneasy for you if you know that you have engaged in risky behaviour (like unprotected sex)."

The chairman for the Government Parliamentary Committee on Health, Mdm Halimah Yacob, described the opt-out HIV testing as an idea worth exploring .

"If you test by selection saying that people are in higher risk groups then one can say that you're passing judgment on lifestyle, choices, et cetera," she said.

"But if it applies to everyone subject to their right to opt out ... then I think it's all right."

Mr Tan Thuan Seng, director of Focus on the Family, which had suggested mandatory HIV testing, said the MOH's move is in line with what it is proposing.

"I think once people get used to the idea that HIV testing will be routinely conducted, they will get used it and eventually most will not opt out," said Mr Tan.

angry doc was brought up in the era when the HIV test, far from being something mandatory or 'opt-out', was a test that required pre-test counseling, on the grounds that it was a serious infection with many implications, that there was no cure for it, and that it was a notifiable disease.

Things may have changed somewhat since then: there are now effective treatment for the disease (although not yet a cure), and testing can now be done anonymously.

Still, as he has mentioned in a previous post, angry doc is not convinced that the figure of 1 in 350, assuming it is representative, necessarily means that the general population is at a high risk of becoming infected with HIV.

Moreover, angry doc questions the reasons for making HIV testing an 'opt-out' test given in the article.

According to the MOH HIV Statistics page, the incidence of perinatal transmission was 1 or 2 per year from 2000 to 2003, rising to 4 cases in 2004 (the year 'opt-out' testing for pregnant women was implemented), 3 cases in 2005, and 2 cases in 2006.

As for the problem of protecting healthcare workers which we 'cannot ignored'? The Ministry's HIV Statistics page does not record any incidence. In any case, Universal Precaution applies for all patients - just because someone is not HIV-positive does not mean you don't need to wear gloves when handling his or her body fluids. Accidents do happen, except they haven't resulted in any patient-to-healthcare worker transmission locally, nor can we eliminate accidents totally even when we know if a patient is HIV-positive. In any case, post-exposure prophylaxis can and is given to healthcare workers involved.

The fact is, the majority of HIV patients are actually adult males who become infected through sexual contact.

Will an 'opt-out' testing system reduce the rate of new infection amongst this group of patients? Probably, if we give them access to counseling, education, and affordable treatment.

Will it reduce the rate of perinatal transmission and transmission to healthcare workers in the course of their work? Well, these groups of people constitute less than 1% of the new infection cases each year, so even if you eliminate them altogether, you will barely put a dent in the total HIV infection rate.

So why use them as the justification for implementing an 'opt-out' system? Well, because if we are going to give up our rights, we would rather be told that we are doing it to protect babies and doctors, and not men who catch HIV from gay or paid sex, wouldn't we?

(Added: See insanepoly's take on this subject here)


Thursday, August 02, 2007

Confidence Goods 11

The Health Minister continues his quest for the 'perfect' healthcare market...

(emphasis mine)

An injection of innovation
That's what health plans here need at the micro level, says Health Minister
Tan Hui Leng

WITH the three Ms — Medisave, MediShield and Medifund — in place and many Singaporeans covered by health insurance, the country's overall health care system is doing fine. But when it comes to issues at the micro level, such as providing more competitive health care, a lot more work needs to be done.

That was the assessment of Health Minister Khaw Boon Wan.

"Micro means, on the provider side, how do you make sure the market works well?" he said at the opening ceremony of the South-east Asia Health Insurance Conference yesterday. "That part is not easy at all. I would say we are 20 per cent of what I hope we can achieve."

For a start, the Health Ministry has, since 2003, been publishing hospital bill sizes for common conditions and procedures as part of its efforts to give patients more choice. But there is still much to be done to get hospitals to improve their services and address the current imbalance in the health system, such as the vast difference between a general practitioner's and a surgeon's fees.

"The conscientious GP who advises and nags at patients ... he gets maybe $20 per visit," said Mr Khaw. "Whereas with a dramatic surgery, I get $10,000, $15,000. So, in an ideal world, the big-time surgeon ought to be paid $1,000 and the GP should be paid $50 or $100 or at least $200 — but how do you bring that about?"

Insurers can help by coming up with more innovative health policies.

"Give doctors and hospitals the incentive to focus on the health outcomes of your policy-holders. Try piloting pay-for-performance measures that reward doctors based on the health of patients they care for, not the number of procedures performed," said Mr Khaw.

For example, a doctor looking after a diabetic patient could be paid by an insurer for ensuring that the patient controls his diet and exercises regularly.

Aviva's assistant general manager of employee benefits and healthcare Christopher Crowe said the company gives refunds in group policies and works with doctors to ensure effective outcomes for patients.

NTUC Income's group and health general manager Chan Tee Seng said it will see if the ideas can be implemented.

Mr Khaw believes the situation would be a win-win one.

"If my policy-holders all stay healthy or keep chronic illness in good management (resulting in fewer) complications, I save money (due to) less payouts," he said.

Agreeing with with Mr Khaw's analysis of the current situation, chairman of the Government Parliamentary Committee for health Halimah Yacob said: "Many people are comfortable that the big picture is in place but it is the micro issue, how to implement the policies, that is the challenge.

"There have been so many changes but the individual still feels concerned that when he falls ill, he can't take care of himself."

So, while Singapore's healthcare system has improved in the past five years, there is still a long way to go — especially when many patients tend not to be concerned about saving costs since they know they are being subsidised, either through insurance or government subsidies.

Mr Khaw told of how a hospital patient demanded the doctor prescribe two years' supply of a health supplement for him, as the bill would be paid by his employer.

"A pharmacist called the doctor to double-check the prescription, which was then amended. The patient left the pharmacy angry!"

While it may be difficult to achieve the perfect healthcare market, "we are so imperfect that even if you halve the gap, we will have brought about a lot of benefits to everybody", he said.

angry doc is still not convinced that making the healthcare market more 'perfect' is the solution to our problems.

Certainly at the one end of the spectrum when demand is totally divorced from cost to the patient/consumer by the presence of a third-party payer we get a situation where a patient will ask for two years' supply of a health supplement.

However, angry doc believes that the situation where the conscientious GP gets $20 per visit while the surgeon gets $10,000 to $15,000 per surgery is actually an example of where the market is closer to a 'perfect' market - each doctor is being paid for the perceived value of their service.

Or to be more precise, each doctor is being paid for the perceived value of the service which they have performed (i.e. 'fee for service'), as opposed to being paid for the perceived value of the results of the service which they have performed (i.e. 'pay for performance').

(Nevertheless, angry doc thinks it may be pushing it a bit to call for GPs being paid $200 per consult, or a surgeon $1000 for a 'dramatic' surgery.)

The common point in both cases (imperfect market and nearer-to-perfect market) is that healthcare providers and healthcare consumers/patients have very different perceptions on what constitutes value when it comes to healthcare: patients see value in tangible things like drugs, health supplements and surgery; healthcare providers see value in results, which may not be immediately apparent.

Can we put a value on the results of non-pharmacological, non-surgical intervention in the form of behavioural modification brought about by doctors' advice (aka 'nagging')? Certianly some people are trying to do so.

Will having a 'perfect' market make patients see the value of such non-pharmacological, non-surgical intervention when there is evidence to show their efficacy, or will they see it as 'talk only'?

angry doc is not too optimistic on that.