Angry Doctor

Wednesday, October 31, 2007

Always the last place you look

This letter is so classic, angry doc has to feature it even though it is from the Chinese newspaper.

You can get a passable version of the story by running the text through Babel Fish, but in brief, the writer related how she had sought medical advice (from both western and traditional Chinese physicians) for a total of 11 times for her symptoms of vertigo and vomting, but could not find a cure or relief. On the advice of a specialist, she underwent an MRI; while no pathology was identified, her symptoms continued.

Eventually she saw a TCM physician, who made the diagnosis of vestibular neuronitis and prescribed her with a five-day course of medicine, after which her symptoms disappeared and she was gradually restored to health.

The cure, as it turned out, was at the last place she looked.

Isn't it always?

Taken at face value the story is one of how one physician managed to cure a patient of her (until then) intractable illness while 11 others could not - from the way she told the story, this was probably what the writer wanted to convey - and certainly this could have been the case.

But those who know more about vertigo and the natural history of vestibular neuronitis may have a different take on the story. They will know why an MRI was done, and the significance of a 'negative finding' on the MRI. They will also know that the condition may run a course of several weeks, but be ultimately self-remitting.

The cure, eventually, will come from the last place you looked, or the last doctor you saw.

Still, angry doc would like to know what medicine the writer was given.


Tuesday, October 30, 2007

How NOT to argue for Alternative Medicine 9

An anonymous reader's comment on this earlier post on acupuncture provides angry doc with the material for the next exercise in our series.

"Your link at the start of your comments takes you to information on trials on acupuncture for back pain. These mention the use of 'sham' points - given that Ashi points do not lie neccessarily on meridians, its questionable whether the 'sham' points are in fact sham points. The reserach design seems to have been developed without much undrestanding of the modality. Still, each to their own. Personally, I'm not angry about patients using any modality that works for them to get better or maintain health. But then again, I'm not that randomly angry.... Perhaps you should try some acupuncture for your stress and then you wouldn't be so generally angry ?! As a doctor you should know its not good for your health-long term!!"

Let's examine the arguments one by one then.

1. "given that Ashi points do not lie neccessarily on meridians, its questionable whether the 'sham' points are in fact sham points."

angry doc has read many defences for acupuncture, but this one is new to him.

Now leaving aside the fact that the study specified that sham acupuncture in this study consisted "of superficial needling at nonacupuncture points" (emphasis mine), this argument tries to renders the theory of acupuncture non-falsifiable.

If we are going to identify every point on the skin which shows an effect when needled to be an acupoint (or Ashi point) and then attribute the effect observed acupuncture, then it becomes impossible to prove that acupuncture doesn't work.

However, if we do not shift the goal-posts during our study (i.e. an identified acupoint is an acupoint, and a point not identified as an acupoint does not become an acupoint), then the evidence so far is that sham acupuncture often performs as well as 'true' acupuncture, which calls into question the theories behind acupuncture.

2. "The reserach design seems to have been developed without much undrestanding of the modality."

The study states that the authors are from the following institutions and departments (emphasis mine):

Orthopedic Department, University of Regensburg, Bad Abbach, Germany (Dr Haake); Institutes for Medical Biometry and Epidemiology (Drs Müller and Schäfer) and Medical Psychology (Dr Basler) and Centre for Clinical Trials (Ms Schade-Brittinger), Philipps-University Marburg, Marburg, Germany; Departments of Pain Management, BG-Kliniken Bergmannsheil (Dr Maier) and Medical Informatics, Statistics and Epidemiology, Ruhr-University Bochum, Bochum, Germany (Drs Endres and Trampisch); and Centre for Clinical Acupuncture and Research, Düsseldorf, Germany (Dr Molsberger).

Without trying to appeal to authority, angry doc would venture to say that it would be rather unwise for a Centre of Clinical Acupuncture and Research to set up a whole centre for studying acupuncture, go through the process of recruitment and intervention, and then finally publish the study, without having first gained some familiarity with the modality.

Unfortunately, our anonymous poster did not specify how he or she arrived at the conclusion that the "reserach design seems to have been developed without much undrestanding of the modality".

3. "Still, each to their own."

Acupuncture either works the way it is said to work, or it doesn't - that does not depend on whether you or I believe it, but on what the evidence show. To use phrases like "to each his own" or "we are all entitled to our own opinions" is to try to hide a lack of evidence or convincing argument behind freedom of choice.

4. "But then again, I'm not that randomly angry...."

Well, angry doc hopes his long-time readers will realise that while he may be angry, he is not *randomly* angry.

This statement is a form of ad hominem attack; angry doc does not think acupuncture doesn't work because he is 'angry at acupuncture', angry doc is 'angry at acupuncture' because it doesn't work.

5. "Perhaps you should try some acupuncture for your stress and then you wouldn't be so generally angry ?!"

angry doc is not sure whether this is another ad hominem attack, or an argument that subjective experience or anecdotes trump statistics and evidence.

In any case, if angry doc tried acupuncture and it didn't work for him, it does not prove that acupuncture doesn't work. Conversely, if angry doc tried acupuncture and it did work for him, it would not prove that acupuncture works - that's why we are conducting all these studies with blinding and controls.

(angry doc would like to thank his anonymous reader for providing the material for our discussion today.)


Sunday, October 28, 2007

Them 6

angry doc had drinks with his friend G yesterday...

angry doc: So what do you think of the proposed amendments to the Infectious Diseases Act?

G: Not much - won't affect people like me anyway.

angry doc: Huh? What do you mean? The ministry plans to label all men who have sex with men as 'high risk', which means that if you have sex with someone without declaring yourself 'high risk', you are committing an offence! Do you even read my blog anymore?

G: Certainly; but it is precisely because of that that it won't affect people like us, but it will affect people like you.

angry doc: How is that?

G: Well, if all MSM are 'high risk', then every time I am going to have sex with another man, it is presumed that we are both 'high risk', right? And if it presumed, or automatically clear that we are 'high risk', then we won't actually need to declare ourselves as being 'high risk', right? And if we don't actually need to make that declaration, then we can't be faulted for not making it, and so can't be charged under the Infectious Diseases Act, right?

angry doc: Gee... I never thought of it that way, but you might be right.

G: Furthermore, if a man engages the services of a prostitute, he automatically identifies himself as a 'high risk' person - and the prostitute is of course also clearly 'high risk' herself, so neither of them needs to make a declaration either, and thus neither can be charged for not making it, right?

angry doc: Er...

G: So really the only people who need to actually declare themselves as 'high risk' are lesbians and heterosexuals who have "multiple sex partners with unknown HIV status".

angry doc: And drug addicts.

G: Yes, but drug addicts who are "sharing needles to abuse drugs" will of course never declare themselves to someone who don't already know they are abusing drugs, since that is already an offence in itself, right?

angry doc: OK...

G: So like I said, the people who actually have to make the choice of declaring themselves as 'high risk' or not are lesbians and heterosexuals with "multiple sex partners with unknown HIV status".

angry doc: Uh-huh...

G: So at the end of the day, the law will not affect the very people specifically mentioned in the law, but will affect heterosexuals and lesbians, who must now declare themselves as 'high risk' or not before sex.

angry doc: So being specifically mentioned in the law actually makes you immune to being charged under it?

G: Yup. Suck it, breeder!

angry doc: I wish you wouldn't say that.

G: Homophobe!

angry doc: Fruit!


Saturday, October 27, 2007

Cow Dung 5

angry doc was planning to write about this letter to the ST Forum today, but 'I must be stupid' beat him to it.

angry doc has been aware of for a while now. He had previously thought that the site had done a good job of cautioning readers against unproven therapy, but this letter shows that Ms Lee is not quite critical when it comes to Traditional Chinese Medicine (TCM).

There are studies that show that acupuncture is effective at reducing nausea and vomiting in patients undergoing chemotherapy, but as we have seen previously, this probably merely demonstrates that sticking needles into people may relieve certain symptoms, and does not validate the theories behind TCM.

In other words, it is one thing to say that certain therapies used traditionally in TCM work and can help some cancer patients, and another altogether to say that TCM works and that its inclusion in cancer care is "the greatest gift to people living with cancer".

The failure to make this distinction allows a whole host of unproven therapies under the umbrella of TCM to be passed off as proven therapies, and the failure to make this distinction clear to patients when we offer TCM therapies in a conventional hospital gives them the erroneous impression that the theories behind TCM are scientific and validated.

Is there a place for 'alternative' therapies in the care of cancer patients in a western medicine hospital? Certianly - any therapy that proves itself to be effective and beneficial it will cease to be 'alternative', and will simply be called proven therapy.

Conversely, any therapy that has not been proven to be effective and beneficial should not be blindly accepted and practised just because it belongs to the same family from which an effective therapy has come from.

It is not about the 'supremacy' of western medicine, but about intellectual honesty and having a critical mind in the kind of healthcare we offer people who seek it.

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Friday, October 26, 2007

Life's Little Law Lessons...

... brought to you today by Mr Heng:

Ear-piercing gone awry - determining if an operator is negligent

MS FELITA Teo Siew Eng's letter, 'Shop staff nonchalant even after ear-piercing for kid went wrong' (Online forum, Oct 24), raises two issues.

a) Is the ear piercer's gun a suitable instrument for piercing a person's ears?

b) Is he liable for a job done that has subsequently gone awry?

It is well-known that gun piercings can cause excess scar tissue. The reason lies in the method of creating the hole. Unlike a needle piercing, guns puncture the skin by brute force. Instead of a sharp object cutting a slit into your skin, studs are dull and put intense pressure on the outside tissue which forces it inside your ear until a hole is made. This blunt trauma is more painful and can cause excess scar tissue and aids in infection. These so-called piercing guns were originally used to tag the ears of dairy cows. Yet many of these shop assistants use a gun to pierce ear cartilage even though this could cause lots of problems - including deformities and shattered cartilage. Many of these guns are not sterile and can spread diseases like hepatitis and HIV.

You can easily get viruses from a simple piercing. At a high-class piercing studio, where everything is sterilised, you will not get such viruses. Also rubbing alcohol does not completely sterilise things. While rubbing alcohol will kill some bacteria it also leaves behind bacteria as well. The only safe method is the use of an autoclave. Autoclaves are expensive 'ovens' that work by using intense heat and pressure.

In the case of Angela M Williams et al v Inverness Corporation (1995), a customer whose ear became infected as a result of ear piercing brought an action against the supplier of a ear-piercing system, asserting claim for negligence under the theory that the supplier held out as its agent a person to whom the system was supplied and who actually performed the ear piercing. The Supreme Judicial Court of Maine held that evidence supported the finding that the supplier held the person out as its agent such that the supplier could be held liable under the theory of apparent agency.

In this case, Margaret Barrera owned and operated a jewellery cart at a shopping mall. She sold items produced by Inverness, a corporation headquartered in New Jersey. Barrera also offered ear piercing using the Inverness Ear Piercing System.

Angela Williams , a 17-year-old high-school student, had visited Barrera's stand on several occasions. In 1991, Angela asked Barrera to pierce her left ear high in the cartilage area. Barrera produced a release form furnished by Inverness and on the form was stated 'the only completely safe, sterile ear piercing method' and in smaller print, the form states that 'ear piercing should be limited to the earlobe area as piercing in the cartilage can result in swelling and infection'. Angela testified that she signed the release form after Barrera pierced her ear and that Barrera did not tell her ear piercing should be limited to the earlobe area.

Within two weeks, Angela's ear swelled, became hot and discharged green pus. She was admitted to hospital where she received intravenous antibiotics. She was discharged after five days but continued intravenous therapy at home.

In tort law, consent may be an excuse and prevent the defendant from incurring liability for what was done. Where a person does ear piercing, there is always a risk of infection which is why a competent ear piercer would always sterilise the needle. Clearly, a duty of care does arise and this is based on the standard of a reasonable skilled person in ear piercing. Where the shop assistant is negligent, the employer may be vicariously liable for the tort committed by his employee.

The test is an objective test, that is, based on an average person. It does not require perfection but takes into account that an average person does not foresee every possible risk. The average person is not assumed to be flawless. Action or omissions of skilled professionals might lead to a tort of negligence. Due to their special education and certification, a higher standard of care is required. This means that if a car mechanic repairs a car, the standard of care required would not be that of a reasonable person but that of a reasonable car mechanic. You cannot reasonably expect a goldsmith's assistant to be as competent as a surgeon in a simple job like ear piercing.

If a person claims to have special skills of a trade or profession, then the standard is the standard of the ordinary reasonable member of that trade or profession, not the ordinary standard of the man in the street. If the defendant acted in accordance with the common practice of others, this will be strong evidence that he has not been negligent (Gray v Stead 1999). The burden of proof is on the claimant to prove that on the balance of probability the defendant was negligent.

The court will decide if the defendant fell below the standard of the reasonable man. In general, the law imposes a duty on everyone to behave at least as carefully as a reasonable, ordinary, prudent person in a similar situation. If a court determines that a defendant had acted reasonably, even though his actions caused injury to another, the defendant is not negligent and not liable for damages. Doctors and surgeons must meet a higher standard of care based on what is recognised as acceptable and appropriate by reasonably prudent health-care providers in similar circumstances.

Heng Cho Choon

Well, it wasn't about medicine, healthcare, or pseudoscience directly, but Mr Heng addressed several principles in tort and liability laws, a subject we have been looking at this past two weeks.

We know that we can expect a higher standard of care from doctors and car mechanics (well, most of them anyway) because there are scientific bases behind their knowledge and training, and that the result of their intervention/services can be measured objectively.

Can the same really be said for feng shui and exorcism?

How do we know whether feng shui 'experts' are really better than the man in the street in detecting flow of qi, or if priests are really better than the man in the street at recognising and exorcising demonic possession?

Or is it a coincidence that both qi and demons happen to be invisible to people like angry doc and you?


Thursday, October 25, 2007

Hex, Lies, and Videotape

Fresh Brainz covered this story yesterday, and angry doc thinks it's worth a mention too:

Sick victim or slithering snake?
Lawyers give contrasting views on woman suing church over alleged exorcism
Leong Wee Keat

A FORMER national athlete who was strong and fit but whose health deteriorated after an alleged exorcism. A woman with a history of mental illness who may have met infamous murderer Adrian Lim, drinking his blood and entering into a trance together.

Such contrasting portraits of the same woman — 50-year-old Madam Amutha Valli — emerged on the first day of her civil suit against Novena Church over an alleged exorcism. Yesterday's hearing also drew vastly different accounts of what happened in the church on the night of Aug 10, 2004.

Mdm Valli is suing the church and eight people for damages arising from what she believes to be rites of exorcism. According to Mdm Valli, the alleged exorcism, performed by two Catholic priests with the help of seven church helpers — one of whom has migrated and against whom no charges will be pursued — had left her traumatised and unable to work.

Opening his client's case yesterday, lawyer R S Bajwa said this "is not a case against freedom of religion". Rather, this is about the imposition of a religious ritual on Mdm Valli, without checking her medical condition, he argued.

"We are not saying the defendants acted with malice or wicked intentions," Mr Bajwa said.

"They may have wanted to help the plaintiff. But what they did they should not have done ... they have caused damage to her."

But lawyer Tito Issac, acting on behalf of Novena Church and Father Simon Tan, one of the two priests, called Mdm Valli's allegations "unbelievable". He said Mdm Valli had been "slithering like a snake, shouting and screaming like Satan and marching like a soldier" before the alleged exorcism at the church.

Father Tan, who had been approached by Mdm Valli's family, had to help her in his duty as a priest to conduct a prayer session, argued Mr Issac.

Senior Counsel Jimmy Yim, who is defending Father Jacob Ong, the other priest involved, also described Mdm Valli's allegations as an "incredible story".

Mr Yim sought to draw parallels to what happened to Mdm Valli some 20 years ago. Between 1986 and 1989, he said, she had sought treatment at National University Hospital (NUH) for a psychiatric condition.

Mr Yim told the High Court that Mdm Valli's condition was so serious she had to be relieved from her job and compensated $30,000 by her telco industry employer.

He said evidence would be produced during the course of the civil suit that Mdm Valli had allegedly told a doctor she no longer was suffering from depression and suicidal thoughts, barely a week after leaving the firm.

Calling her current allegations a part of "a well-hatched scam", Mr Yim urged the court to consider Mdm Valli's previous conduct. Two days after the alleged exorcism at the church, she had apparently remarked to doctors she felt the defendants "were all silly" and that she "(was) enjoying the stupidity of the situation".

Extended surveillance, conducted by private investigators for more than 1,000 hours, would also prove Mdm Valli was putting on a false front, said the defendants' lawyers.

Video footage recorded after the civil suit was filed showed that Mdm Valli was able to walk independently, and visit the gym and public bathrooms alone. She would only appear frail, weak and pale during her medical appointments, they argued.

Lawyer Anthony Lee, who is representing three of the church volunteers, also painted an unflattering picture of Mdm Valli. He said she had apparently met convicted murderer Lim — described in reports as a medium — twice in the early 1980s, drinking his blood and entering into a trance together. She even received electric shock treatment from Lim, Mr Lee said.

After her bout of mental and psychiatric disorders in the late '80s, Mdm Valli turned to alcohol in 1990, downing a bottle of gin a day, Mr Lee said. Ten years after she developed the habit, she suffered another breakdown and had to be admitted to the Institute of Mental Health. She later developed another dependence in 2003 on a powerful sleeping pill, he added.

But Mdm Valli's daughter, Ms Subashini Jeyabal, testified that she "did not know" her mother had been battling alcoholism and health problems.

Mr Issac then suggested that the 22-year-old knew her mother had been drinking, but had "put on a brave front for the public eye".

Ms Jeyabal replied: "This is very far from the truth. I am here to speak the truth."

An ex-sports star, a murderer, demonic possession, mental illness, secret surveillance video, the occult, drugs, alcohol... a potent mix and a tabloid journalist's dream, but underneath all that a sick woman who probably needs help.

But what interests angry doc about this case, however, is the parallel he once again sees between medical malpractice, and unproven modes of treatment.

It seems that the priests, by undertaking the ('alleged') exorcism, have agreed to take on a duty of care to Mdm Valli. The plaintiff's lawyers are trying to argue that the priests are guilty of negligence, since the rite of exorcism should not have been performed, while the defendants' lawyers are trying to argue that no harm has actually resulted from the ('alleged') exorcism, and hence there is no case.

As we have discussed before, in order to decide whether the priests were right in performing the ('alleged') exorcism, we need to first prove that exorcism works. To even begin to consider exorcism, however, we need to first make the 'diagnosis' of possession.

How does one make a diagnosis of possession? It's probably not an easy diagnosis, and the church acknowledges that organic or mental illness should be excluded before proceeding with exorcism. (This makes exorcism a 'diagnosis of exclusion'. )

And of course, we all know that if a strange behaviour is not known to be cuased by an organic or mental illness, it must be due to demonic possession.

Or alien mind-control?

Or ghosts.

Yup, definitely ghosts.


Tuesday, October 23, 2007

Them 5

Finally, angry doc learns the official definition of 'high-risk' individuals.

(emphasis mine)

Testing leftover samples: Confidentiality preserved

IN THE letter, 'Curbing the spread of HIV: Criminalisation is not the solution' (ST, Oct 18), Mr Ashok Narandran expressed two main concerns over the proposed amendments to the Infectious Diseases Act.

His first concern is that power to acquire leftover patient samples could compromise patient confidentiality.

The Ministry of Health (MOH) would like to assure the public this would not be the case, as the intention here is not to determine the identities of those who could be infected. Rather, this provision is to allow MOH to have aggregated statistical data on the prevalence of a particular infectious disease in Singapore or the level of immunity of the population against emerging infectious diseases which could pose a public-health threat to Singapore. We can then devise appropriate and effective action plans to protect the nation on a timely basis.

His second concern is over what constitutes 'reason to believe that (a person) has been exposed to the risk of contracting HIV or Aids' and whether HIV prevention education and testing are easily accessible.

Activities that expose one to higher chances of contracting HIV or Aids are well-established. These include having unprotected sex with someone infected with HIV or at high risk of being infected with HIV, such as men who have sex with men, sex workers and their clients, or having multiple sex partners with unknown HIV status, or sharing needles to abuse drugs.

The challenge lies in getting individuals who engage in high-risk sexual behaviour to act responsibly by going for regular HIV testing or using condoms for protection when engaging in casual sex.

We therefore agree with Mr Narandran that MOH must step up public education on how HIV infection is transmitted, the risk behaviours and how the infection can be prevented. We have done so and will intensify our efforts.

Confidential HIV testing is widely available at most, if not all, medical clinics. Anonymous HIV testing is also available at three sites in Singapore. Information on where to go for HIV testing is available at the website

Karen Tan (Ms)
Director Corporate Communications
Ministry of Health

angry doc notes that drug abusers are added to the list of *them*, while healthcare workers, who are at an oh-so-high risk of being infected by their patients that we need to subject all male inpatients to an opt-out HIV test so as to protect them, are not.

As angry doc had feared, the ministry has classified all men who have sex with men (MSM) as 'high-risk', choosing to ignore the fact that there are MSM who may not have sex with multiple partners, and that the reason why some MSM, prostitutes and their clients are at higher risk of getting HIV is not because they are MSM, prostitutes, or clients of prostitutes, but that they have "multiple sex partners with unknown HIV status".

It would have been sufficient to classify all those who have "multiple sex partners with unknown HIV status" as 'high-risk' and left it at that, but why waste an opportunity to stigmatise certain groups of people who are not like us while we are at it, right?

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Monday, October 22, 2007


Even though we may disagree on the subject of limb-regeneration, angry doc still reads Mr Wang's blog regularly, although these days he reads them for the readers' comments as much as for Mr Wang's posts.

Some comments from this post from last weekend were a source of mirth for angry doc. Do have a read yourself.

Tuesday, October 16, 2007

Cow Dung 4

angry doc is not going to say that the law is an ass, but he wishes it would at least be consistent.

(excerpt, emphasis mine)

One rule for all?
Legal eagles split over accommodating differences or adopting universal values
Loh Chee Kong

THE feng shui, or geomancy, fad of the 1990s might have brought Lady Luck to many, but the authorities here certainly were not smitten.

Speaking as part of a panel at the International Bar Association Conference 2007 yesterday on how lawyers should deal with different cultures and traditions, Chief Justice Chan Sek Keong recalled how Singapore laws were challenged by the sudden revival of the age-old practice of feng shui.

CJ Chan said: "Chinese astrologers would dispense advice to all and sundry, and they would place advertisements in all the newspapers. There was a proliferation of feng shui experts in Singapore. Everybody would tell you how to make a fortune in shares, business, whatever."

As a result, although it was an offence for any person "pretending to tell fortunes", there were "a lot of fakes and a lot of people were defrauded", said CJ Chan.

"The Government had to either enforce the law that we had or they had to change the law," he said.

In the end, cultural considerations won — the Government relaxed the laws in 1996 and feng shui consultants were allowed to practise their trade, provided "it was not used to cheat the consumer and the activity was not a public nuisance", said CJ Chan.

In a multi-ethnic and multi-religious society such as Singapore's, laws have to "accommodate" to certain cultural practices, he noted. These include exempting male Sikhs from wearing helmets while riding a motorcycle, or when they are in the army.

But in general, offenders cannot use cultural practices to defend their criminal actions, said CJ Chan, who added that society "must have certain core values in relation to crime".

angry doc wonders how a judge will decide if a 'feng shui expert' was a fake and if he was trying to 'cheat the consumer'.

The fact is, as we have discussed earlier, there is "no precedent that would hold someone liable for practising an art or belief that cannot be proven scientifically". If you can't prove that feng shui works, then you cannot prove that anyone purporting to be a 'feng shui expert' is a fake or that he is trying to cheat consumers.

The absurdity of this 'accommodation' policy can be seen when viewed against the recently-amended Health Products Act: if you sold someone a product purported to improve his or her health when in reality it did not, you face a fine or jail term; if you received money for advice which you claim will improve his or her health, when in reality it did not, the law is powerless to stop or punish you.

Why should one form of fraud be immune from prosecution and the other not?

What is the difference between the two?

That the one consisted of a physical product, and that the second consisted only of words? If that was the case, then angry doc would never be liable for malpractice.

That one is backed up with evidence and the other was not? Certainly the article suggests that the law does not take the view that feng shui actually works.

Or is that, as suggested by the article, feng shui is a part of Chinese culture and that it is acceptable to the law for consumers to be defrauded by someone claiming that feng shui works, but not by someone who tries the same trick with new-fangled health products which are not part of our traditional culture?

Still, angry doc finds some comfort that not all 'high-powered legal minds' agree with this type of 'cow dung' reasoning. Do read the whole article.

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Friday, October 12, 2007

Quackbuster: Singapore 6

Still tracking the Health Products Act...

Regulation of all medical devices by 2010

REPORTING to the authorities problems relating to medical devices sold. Keeping complaints and distribution records of such devices.

These are among the legal obligations that dealers of medical devices will have to adhere to from Nov 1 as the Health Sciences Authority (HSA) begins implementing the regulation of such products.

Medical devices, which range from syringes to artificial hearts, are the first category of health products to be regulated under the Health Products Act, which was passed by Parliament in February.

The control measures will be implemented in phases, from next month, to "minimise the impact of the supply of medical devices and to provide sufficient time for the industry to meet the new standards and requirements", said the HSA yesterday.

At the same time, action will also be taken against dealers who engage in "fraudulent advertisements".

The next phase, from next April 1 to Oct 1, 2009, will involve the licensing of dealers, including manufacturers, importers and wholesalers, as well as registration of medical devices.

The final year-long phase, which will end on Oct 1, 2010, will require all parties dealing with medical devices to be licensed and for all such products to be registered.

By the time all the regulatory measures are in place, it will be illegal to manufacture, import or supply "unregistered medium and high-risk devices" — from Oct 1, 2009 — and "low-risk products" — from Oct 1, 2010 — the HSA said.

With these new regulations, consumers can expect better protection from unsafe or poor quality products and more objective information to help them make better decisions.

angry doc dares not imagine that the Health Product Act is enacted primarily to combat quackery, but he hopes that it will have an impact.

In an ideal world we won't need such a law - people (consumers) will all be wise and discerning and will scorn any health product with "fraudulent advertisement", insisting instead on good quality evidence. Of course, that day may never come. In the meantime, angry doc is glad that we have such a law.

Still, he cannot but feel that he is applying double standards to how we legislate on health-seeking behaviour in looking at the case of the Health Products Act and that of the proposed amendments to the Infectious Diseases Act.


Friday, October 05, 2007

Them 4

Who would have thought that the solution to our HIV/AIDS problem was so simple?

(emphasis mine)

When passion gets the better of reason
An ignorance-no-excuse law may yet discourage some from taking HIV tests
Tan Hui Leng

THE law may compel you to do certain things, but can it endow you with reason in the heat of passion?

The Ministry of Health (MOH) certainly hopes so, as it proposes an amendment to the Infectious Diseases Act that makes it an offence for any HIV-positive person to have sex — regardless of whether he knows of his status, as long as he has reason to believe that he has been exposed to the risk of contracting the virus. He is not liable, however, if he has informed his partner who voluntarily agrees to undertake the risk, or if he has practised safe sex or tested negative before the act.

If this legislation is pushed through, Singapore will be the first country with such laws in place.

Yet another punitive approach for the "fine" city? Not so, said the ministry. Rather, this new provision is to make people take personal responsibility and get tested regularly if they are in "high-risk groups".

Speaking to reporters on the sidelines of an event last week, Health Minister Khaw Boon Wan, talking about who would fall into the high-risk groups, explained: "A high-risk one is really simple: 'Do you visit prostitutes?' — that you must know, right? And if you do, then at least, you must do regular testing."

But is it really that simple?

Conservatives may not like this. Parents may not like this. But the truth is: In an increasingly sexually-open society, one can be sexually-active but not necessarily promiscuous. It will not be difficult to find many who have had several, or even many, sexual partners in a number of serious relationships in a lifetime.

If a woman has had sexual intercourse with five boyfriends, would she be considered high-risk? Should she have reason to believe she might have contracted HIV? She certainly might not think so. But if she had contracted HIV in such a manner, would she be liable?

Just as a drunkard tends not to admit he has had too much, a high-risk person would not want to classify himself as such.

Where is the line between safe and high-risk? Such subjectivity can be highly controversial in a court of law.

What is more, it will not be easy to investigate each case. Indeed, even with current legislation, under which it is an offence for an HIV-positive person to have sex without the voluntary consent of his partner, just two people have been found to have run afoul of the law — one was not charged but fined, another left the country before he could be prosecuted.

As a report in the London-based New Scientist magazine said recently, even genetic sequencing may not reveal the HIV source. Given the uncertainty of it all, surely what one should do is to get tested anyway, whether one is high or low-risk.

But why should anyone do so? Especially if one is young (and feels invincible and immortal), especially if one appears healthy and has no symptoms, and especially if one already chooses to live life in a certain way.

In fact, we should be wary that the new laws may end up as a disincentive to getting tested for HIV. After all, whether or not I know of my infection, if I choose to have sex and not be upfront with my partner, I would still have broken the law. Without the test result, I could well carry on with my life — and perhaps never be caught. But what if I decide, one day, to go for a test, and it comes up positive? Will that spark off contact tracing, and will I be hauled to court to answer for the sexual encounters I had before the test?

One wonders, too, what is 10 years' in jail to someone already slapped with a death sentence, or a $50,000 fine to one who has lost almost everything?

A scenario posed by a spokesman for Aids activist group Action for Aids also merits serious consideration: Will the proposed amendments lead to more frequent anonymous and casual encounters, where there is no exchange of identities or contact information between the partners?

Rather than jump into legislation, the Government should continue its efforts on public education and expand its message beyond "abstain, be faithful and use a condom". When announcing the new provision last week, MOH's director of medical services Professor K Satku lamented that some are still not having safe sex or going for regular HIV tests despite public education efforts.

It is a pity the ministry holds that view. Where Aids campaigns are concerned, Singapore remains conservative and could certainly be more creative in exploring its choice of messages and strategies.

For a start, the MOH could do more to demystify the Aids patient, who is hitherto unseen and unheard. It is no wonder people think of Aids as a death sentence — you disappear from public view and are as good as dead even before the illness claims your life. More information on how HIV can be treated, and how one can continue to lead a constructive life even after contracting the virus, will help remove some of the irrational fear that may be stopping people from going for tests.

Getting the individual to take responsibility for his actions may be a righteous move. But in dealing with a problem that has its roots in emotionality and irrationality, punitive measures don't always work.

angry doc must say this is a rather well-written article.

angry doc doesn't think threatening people for not revealing that they have visited prostitutes with a fine or jail term is the solution to our HIV/AIDS problem. It will not, as the article pointed out, encourage people to go for testing.

Not that he has a solution, of course. To begin with he doesn't even know who are the people who are already known to be HIV-positive, or when, where, how, and from whom they contracted the disease.

Does anyone?

Does anyone care?

Or are we just happy to have a law that lets us put those people who are 'high risk' into jail?


Tuesday, October 02, 2007

"For what it's worth"


Monday, October 01, 2007

How NOT to argue for Alternative Medicine 8

Another letter supporting TCM using the typical 'cow dung' arguments:

More local hospitals should conduct clinical trials for TCM drugs and treatments

I REFER to the article, 'TCM drug for stroke to undergo clinical trials' (ST, Sept 27).

I support that move and I like to see more local hospitals conduct clinical trials for TCM drugs and treatments.

TCM warrants the serious attention of the medical community. The body of knowledge has survived over thousands of years and is still being practised today. That is testimony to its efficacy and potential.

TCM, however, is a fragmented body where medical prescriptions can be inconsistent, as compared to Western medical treatments.

For example, a cancer patient will be prescribed similar treatment plans if he goes to 10 different oncologists. It could be surgery, radiation therapy, chemotherapy or a combination.

The intensity of therapies and dosages of drugs may differ but the core plan would generally be the same.

If the same cancer patient goes to 10 TCM practitioners, he could get 10 treatment plans; herbal drugs of different kinds, acupuncture of different traditions and even qigong of different schools. It can be confusing and overwhelming.

The evidence-based approach of Western medicine should be applied to TCM. Clinical trials are necessary. Doctors and patients can then have real numbers to work with, in deciding on a treatment plan. There is also a need for a certification body for TCM practitioners, using the protocol of modern medical education. This way, patients can be more confident in TCM physicians. There is also less probability for patients to be swindled by phony physicians.

Western medical treatment can often be too focused and aggressive. The principle is that there is some bad thing in your body so you fall sick. That's why we need to destroy the bad thing. But elimination of the original problem often creates another problem. Chemotherapy is an example where blood cells are destroyed indiscriminately and internal organs are loaded with great stress.

The TCM principle is that an imbalance in the body and a disharmony with the environment make a person sick. The key is to restore balance and harmony.

The treatment may be milder and more holistic. It is also reputed to be useful for palliative care.

Singapore is positioning itself to be a regional medical hub. While we focus on the wave of the future like biomed, let's not neglect the innovations of the past, like TCM.

Felix Ang Kok Hou

Mr Ang sets up a strawman in his criticism of Western medicine - Western medicine is not just about destroying bad things in your body, it is also about homeostasis and 'balance'. Just ask any endocrinologist.

(And anyone who thinks Western medicine is not 'holistic' just needs to do a Geriatric Medicine posting...)

But the difference between Western medicine and TCM is not just one of principles, but also of science and efficacy; chemotherapy for cancer may cause many side-effects to the patient being treated, but it is also better understood and more efficacious than anything TCM has offered.

Mr Ang is correct to say that TCM needs to be studied with an evidence-based approach, but the last three paragraphs of his letter betray a fundamental error in his reasoning: if a mode of therapy traditionally used in TCM is proven to work through clinical trials, it will prove that that mode of therapy works for that condition; it does not, however, prove that the principles behind TCM are true.

As with the case of acupuncture, this type of flawed reasoning is not only unscientific, it also wastes resources which could better go towards improving our understanding of the true mechanisms of action behind TCM therapies.

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