7th Singapore Stroke Conference

22 Oct 2005

By Dr Balaji Sadasivan, Senior Minister of State, Ministry Of Information, Communications and the Arts and Health

Dr NV Ramani,

Chairman - 7th Singapore Stroke Conference Organising Committee

Distinguished guests

Ladies and gentlemen,

In 1995, prominent Parisian journalist Jean-Dominique Bauby suffered a major stroke in his brain-stem. He went into a coma for 20 days. When he awoke, he found himself paralyzed except for his left eyelid.  Eye movements and blinking a code became his sole means of communication. Despite this, Bauby managed to write a book called The Diving Bell and the Butterfly, a memoir about his life chained to an unresponsive body, and the power of his unfettered mind soaring to places and experiences his physical body can no longer travel to. The book became an instant best-seller in France. Tragically, Mr Bauby died 2 days after his book was published in 1997.

I tell this story of Mr Bauby not just because his book represents a triumphant victory of mind over body, but also as a reminder of the ravages stroke can inflict on previously healthy and energetic people.

Every year, thousands of Singaporeans succumb to stroke. About 10% to 15% die within the 1st year. Of the survivors, only a few, perhaps 10% to 30%, are able to recover fully and return to their previous level of independent functioning. And even that may take many months.

The cost of stroke is tremendous. Hospital stays for stroke averages about 7,500 dollars. This rises to about 15,000 dollars for an intracerebral haemorrhage, and almost 29,000 dollars for subarachnoid haemorrhage. Costs continue to mount after hospital discharge. Patients may need medication and rehabilitation, nursing care, and home assist devices such as wheelchairs. Relatives and family may also have to take time out to look after the patient, resulting in loss of income. To the society, the biggest costs lie in the loss of productivity in the stroke patient, who, before his illness, was an economically productive and integrated member of society.

Stroke is currently the 4th leading cause of death after cancer, heart disease and pneumonia, and is also joint 4th with pneumonia for number of hospital admissions, after accidents, heart disease and cancer.

The problem of stroke is bound to worsen in Singapore. Our population is ageing rapidly due to an increase in life expectancy combined with a declining birth-rate. By 2030, 18% of our population will be above 65, compared to 8% in 2003. With the aging of our population, the number of Singaporeans suffering a stroke will rise.

This is the bad news. However, there is a silver lining. We now know the many factors that can increase the risks of a stroke. Many of these factors are preventable. Scientific evidence suggests that stroke risk can be reduced by actively managing major vascular risk factors such as hypertension, diabetes and hyperlipidaemia. Combined with lifestyle changes including weight reduction, regular exercise and a diet rich in fruits and vegetables, stroke risk can be significantly reduced.

I note with approval therefore that the main theme of this year's meeting is "Stroke Prevention". We can spend vast amounts of money managing strokes, with expensive investigations, medications and surgical procedures. These treatments however, do not produce a cure, but can only reduce complications and improve the quality of life and independence. The brain, while to some extent still plastic, is almost never the same after a stroke.

During my time as a practising neurosurgeon, it distressed me that there were so many stroke patients who were not aware of their stroke risk factors, or if they were aware, failed to visit their family physicians regularly for optimal control of their risk factors. If they had taken the appropriate measures, they could have significantly reduced their risk of stroke.

I urge all Singaporeans to visit their doctor regularly for screening for these well-known risk factors for stroke, and to follow their medical advice closely. I also ask the medical community to be vigilant in identifying these factors in their patients, and in actively working with their patients to combat them. I have no doubt that the medical profession is a ready and willing partner in our joint quest to fight strokes.

A total ban on cigarette smoking has been proposed recently. The Ministry is fully aware of the dangers of cigarette smoking, including its role as a risk factor for strokes. We have embarked on aggressive public education programs to drive home the message of the harmful effects of smoking, and urge the public, especially the young, not to take it up. Smoking cessation programs are widely available for those who wish to give up smoking. Import duties have made smoking a more expensive habit. Restriction of sales to those above a certain age reduces its availability to the young. In recent months, we have also reduced the number of available areas for smoking in public and air-conditioned places.

Banning may increase the illegal trade and smuggling of cigarettes, as happened to alcohol during the Prohibition in the US. The income of some Singaporeans may be reduced. Tourists may shy away from coming to Singapore. Hence, a total ban on cigarettes in Singapore is a measure which we will have to consider very carefully.

Meanwhile, we will continue our anti-smoking efforts. It is our aim to reduce the number of new smokers acquiring the habit to zero, and to decrease the number of existing smokers. In time, it may not even be necessary to have a smoking ban.

I ask that all doctors contribute to this national effort against smoking. Remember to ask every one of your patients: "do you smoke?", and if the answer is "yes", urge them to quit or reduce smoking as soon as possible. Numerous studies have shown that physician intervention has a positive impact on quitting rates, and your contribution would greatly enhance our anti-smoking efforts.

Despite our best efforts at primary prevention, some people will still develop a stroke. Once a stroke has occurred, the risk of another occurring is about 10% a year. There are effective interventions that can reduce this recurrence. Secondary prevention interventions involve medications for some, and surgery or interventional neuroradiological procedures in others. Recently, researchers have explored new techniques to limit brain injury and prevent the brain from sustaining further damage. These emergent technologies will have to be given acutely, and may even have to be administered in the Emergency Department. Many of these new interventions offer hope that the cruel disabilities associated with strokes can soon be averted or ameliorated. I am happy to see that many of these exciting developments will be discussed in tomorrow's symposia.

I must congratulate the Organising Committee of this, the 7th Singapore Stroke Conference, for putting together a comprehensive program for the weekend. I am happy to note the strong emphasis on evidence-based medicine; this is entirely the right way forward.

So, my many thanks once again for this kind invitation and I am pleased to declare the "7th Singapore Stroke Conference" officially open.

Thank you.