Dr Philippe Halbout, CEO, International Osteoporosis Foundation
Dr Manju Chandran, Chairperson, Asia Pacific Consortium on Osteoporosis
Ladies and Gentlemen
1. Thank you for inviting me to this small but important gathering. I noticed that today, we have more of an international audience, so I thought I would share what Singapore is thinking of doing, in terms of prevention of severe diseases, which will also include and affect osteoporosis.
Impact of Osteoporosis
2. The Asia Pacific is home to more than a third of the world's population aged 65 years and above. This number is projected to triple by 2050 to reach 1.3 billion, and that is just for those aged 65 years and above. For Singapore, it is estimated that by 2030, one in four of our population will be of this age group. Today, it is about one in six.
3. Throughout Asia Pacific, and certainly in Singapore, there is a discernible change in lifestyle. People are becoming more sedentary – less time on sports, a lot more time on devices, and many have stopped going to the supermarket, and instead have everything delivered to them. With urbanisation in Asia Pacific, this sedentary lifestyle will be even more common.
4. As a result, in Singapore, we have noticed that the disease burden is not just increasing in line with ageing. The disease burden, and the prevalence of chronic diseases whether diabetes, hypertension or hyperlipidemia, is increasing faster than what ageing can explain. As this happens, as you would expect, the prevalence of osteoporosis is likely to increase beyond what age can explain, and with it, an exponential increase in fragility fractures.
5. In 2018, there were more than 1.1 million hip fractures in China, Hong Kong, India, Japan, Malaysia, Singapore, South Korea, Taiwan and Thailand, and this led to an estimated direct cost of US$7.5 billion. By 2050, the number of hip fractures in these countries and regions is projected to more than double, to about 2.5 million cases each year, resulting in projected direct cost of US$13 billion.
6. In Singapore, Dr Manju and her colleagues have shown that the incidence of osteoporotic fractures is projected to increase by about 60%, from more than 15,200 in 2017, to more than 24,000 in 2035. This will translate into higher economic and personal burden.
Prevention and Management of Osteoporosis
7. These are staggering and worrying increases. I have attended many of such gatherings, and today we hear the story of osteoporosis. In many gatherings of other specialists, you hear a similar picture of many other diseases. As I mentioned, it is not just an issue of ageing, but it is also an issue of deteriorating health because of the lifestyle people are leading now.
8. Let me outline what Singapore is going to do about it. As COVID-19 stabilises, I realised there is a bigger problem of a rising and uncontrollable disease burden that Singapore and Asia Pacific are going to face.
9. But the lessons of COVID-19 can be applied to this big and inexorable tsunami that is coming our way. During COVID-19, everything that we did which were effective was preventive in nature – hygiene, wearing of masks, social distancing and very importantly, vaccination. That was how we rode through the COVID-19 pandemic. Likewise, we need preventive care to able to ride through this huge tsunami of a major disease burden coming our way.
10. We have put together a major national strategy called “Healthier SG”. This is a major change in our philosophy and the way we deliver healthcare. In essence, it is a universal preventive care delivery system for everybody. Some of my doctor colleagues say this is the biggest reform in the last 50 years.
11. Essentially what we are doing is that we are going to mobilise all our family physicians. We are going to equip them with health protocols and health plans, and map out the most common chronic diseases that they will see. Osteoporosis is not there yet, but I think it should come in time.
12. Once they are equipped with the processes and protocols that the Ministry of Health (MOH) endorses, the next thing is to beef up community support. In preventive care, treatment is not in the hospital; treatment and preventive steps are done at home and in the community. These are simple things – eat well, less sugar, less salt, exercise and physical activity for everyone at a suitable level, have friends and have a social life. These would keep many people healthy, especially the seniors.
13. Incidentally, this is probably one of the key reasons why amongst men aged above 65 years who have a hip fracture, 25% die within a year. I think a lot has to do with the fact that once they are immobile, they are cut off socially, and this is when their health really deteriorates.
14. We will launch an enrolment process which we will start in the second half of next year, where we want Singaporeans above a certain age to enrol with a doctor, so that you start a dedicated relationship between a patient and his doctor, and the doctor will guide him through his life, to live healthily.
15. Behind all these, we need to make sure that the IT systems share data seamlessly across healthcare settings. We need to hire a lot more manpower, and there is tough international competition out there for nurses, pharmacists and allied healthcare professionals, but in Singapore, we can capture a good part of healthcare talent in the region.
16. The future job responsibilities of allied health professionals and nurses will change because as we move healthcare out of the hospitals to the community, healthcare and preventive care, including health screenings, will likely be supervised and conducted by nurses and allied health professionals.
17. Lastly, on financing. In Singapore, we always make sure our public services are of high quality, but people co-pay. But there are a few very basic things in Singapore that do not require co-payment. For example, you can walk into public parks for free, our public libraries are free, and primary school education is practically free, with just the need to pay some miscellaneous fees. We are going to add a fourth item – preventive care – which will be free. Nationally recommended vaccinations and screenings and preventive care consultations will be fully funded. This is a lesson that we have learnt from COVID-19.
18. This is essentially what we are doing. It will shift the centre of gravity of healthcare away from hospitals, into the community. How would this affect osteoporosis? I think it will in a major way. In interacting with many groups of specialists, everyone talks about preventive care, because by the time of treatment, it is often too late, and we have to go upstream. When we boil it down to the things that are effective in preventive care, it converges.
19. I have spoken with cardiologists and diabetes and hypertension specialists, and their preventive care is less salt, less sugar, good sleep and exercise. When I spoke to specialists in neurodegenerative diseases, expecting a different answer, they told me the best way to prevent these diseases is less salt, less sugar, a healthy body, a healthy mind, exercise and having friends. Likewise, as we were chatting about osteoporosis, I think if we can control the chronic diseases, we do reduce the risk of osteoporosis.
20. So that is what we are doing in a big way – build up community resources and the preventive care system in Singapore. When we have done that successfully, we would have built two healthcare systems. We tend to associate the healthcare system with the acute care system, but there is a second important system which is the population health system, and namely the preventive care delivery system.
21. If we can build up both and run in parallel, I think we are ready to build up a third one – aged care system where the aged live and age in the community. We have a great asset in terms of our public housing estates, where close to 90% of the Singapore population live in public housing estates which were built for racial harmony. We created wonderful common spaces for different communities to interact. These are valuable assets which we can activate and leverage for the aged to live healthily in the community with friends, love and relationship. That is actually the biggest social determinant for them to stay healthy.
22. A lot for work lies ahead. I cannot say that we are doing it specifically for osteoporosis, but I think if we are successful, it will come a long way in preventing many diseases, including osteoporosis. Thank you very much.