A Journey To The West

26 Jan 2007

By Mr Khaw Boon Wan, Minister For Health

Venue: Lee Kong Chian Forum at SMU

Last week, I returned from a Buddhist pilgrimage to India.  There were 30 in the group, including a few students from SMU.  The students assured me that they had permission from their lecturers but added that their absence from lectures would be recorded.  I do not quite understand what that means.  We spent a week in the States of Bihar and Uttar Pradesh and visited the main holy sites: Bodhgaya where Buddha achieved enlightenment, Sarnath where he gave his first sermon, Vaishali where his last sermon was heard and Kushinagar where Buddha entered Nirvana. 

I am grateful for the opportunity to meditate under the Bodhi Tree, in the same compound that more than 2500 years ago, Buddha had sat and meditated.  Hundreds of devotees, from Korea to Tibet, prayed and chanted in great earnestness, in a variety of styles, attire and languages.  It was a wonderful sight and experience.

Pioneers of Globalisation

I prepared myself for the trip.  I tracked down "Da Tang Xi Yu Ji" (A Record of the Western Region) which documented in classical Chinese, the travels of Tang Dynasty monk, Xuan Zhuang, who left China for India in the 7th century.  I read the chapters on the various Buddhist sites, including the famous Nalanda University where he was a resident scholar for six years.  

I also read "Hui Chao Wang Wu Tian Zu Guo Zhuan" (A Memoir of the Pilgrimage to the Five Regions of India).  It was also written in classical Chinese, but by a Korean monk, Hui Chao, who visited India during the 8th century.  He is less known than Xuan Zhuang who became a household name after his travels became dramatized in the fiction, A Journey to the West.  Unfortunately for Hui Chao, there is no Korean equivalent of the Monkey God story.  

Xuan Zhuang, Hui Chao and others like Damo, the Indian monk who brought Zen Buddhism to China in the 5th Century, and the records of their journeys, epitomize the intellectual and spiritual intercourse between these two civilizations.  Here were two mature cultures, separated by immense physical, linguistic and cultural barriers. Yet, starting from the early centuries, Buddhism left India, travelled the hazardous tracks and became established as an integral part of Chinese culture.  In Asia, the history of Buddhism is one of contact between cultures.  When Buddhism was alive in India, Chinese culture was in direct contact with Indian culture.  Their interactions, whether in religion, culture, arts, trade or education, made them pioneers of globalization.

Southeast Asia was part of that globalisation flow as not all monks took the land route.  A contemporary of Xuan Zhuang was another monk called I-ching who went by the sea route.  On his return journey from India, he landed in Bhoja, thought by historians to be in Sumatra, where he stayed for several years, translating sutras into Chinese. 

Your organizers have asked me to discuss the theme of globalization.  As you can see from the history of Buddhism, globalisation has early adopters.  It is not a recent phenomenon, although modern transport and communication have drastically intensified and sped it up.  At the fundamental level, it is basic human instinct to want to explore what is over the mountain and to connect with others.  It is a primordial instinct.

Specifically, you have asked me to talk about the globalisation of healthcare.  Fresh from the Indian trip, let me use India to illustrate the impact of globalisation on healthcare in Singapore.

The Rise of India

India is a land of great contrasts: ancient philosophers and religious teachers but also hundreds of thousands of top engineers and scientists who are helping to shape the world.  Backward infrastructure in states like Bihar, but also high-tech parks in Bangalore.  Beautiful poetic Indian classical dance but also great Bollywood dance moves that western pop stars are copying.  

In the globalisation of healthcare, India has, surprisingly, emerged as a significant player.  This is a surprise because its public healthcare infrastructure is under-developed, access to basic medical care is limited and it lags many other countries in life expectancy and infant mortality rates. India also has the world's second largest population of people living with HIV. During this trip, we saw so many polio victims, begging in the streets with severe physical disabilities, a most pitiful sight. 

But amidst these miseries, chaos and severe inadequacies there are shining pockets of ingenuity and enterprise which have overcome the structural constraints through vision, innovation and sheer hard work.  Let me highlight their achievements in three areas.

First: Tele-medicine

New technologies in IT, telecommunications and broadband have disaggregated parts of the healthcare supply chain and opened them up to international competition. Riding on its success in the global outsourcing of back-office support functions such as call centres and accounting work, India has moved up the value chain into tele-medicine. Entrepreneurial Indian doctors, American trained and American Board-certified, have been reporting on X-rays of patients worldwide, providing lab testing services to overseas institutions, and processing medical claims for insurance companies halfway across the globe. Some doctors in India even offer tele-ICU services where ICU patients in America are monitored remotely. They do this over the internet, instantaneously and at excellent service levels.

Second: Medical Travel 

Globalisation has not only levelled the playing field for developing countries like India, to compete equally for knowledge-intensive work, but it has also changed the way that patients think about healthcare.  In the past, the rich from developing countries like India would go to the West for complex surgeries. Harley's Street of London was a favourite destination.  Now, the tables have turned. Patients from the US and Europe, fed-up with their high healthcare cost or long waiting time, fly to Asia for good, low-cost medical care. Indeed, medical travel is rapidly expanding at about 20-30% a year. It is estimated that more than 1.3 million people travel to Asia for healthcare annually. The outlook is bullish especially as air travel becomes cheaper and more information is available about international medical travel.  These patients simply click and fly.

India has been quick to tap this growing market. Private Indian healthcare provider chains are aggressively marketing themselves, offering first world care at third world prices. The Apollo Hospitals Group from India is now the largest private healthcare provider in Asia. It is actively seeking international accreditation and partnerships with foreign health insurers. India's Fortis Healthcare Group aims to double its hospitals by 2008. At the current rate of growth, healthcare for foreigners will contribute over US$2 billion of additional revenue to India by 2012. 

You would have heard of Indian IT companies such as Wipro and Infosys. They started as small companies and have now grown into global giants synonymous with international outsourcing. Emerging Indian healthcare companies such as Apollo and Fortis may soon join their ranks.

Third: Medical Socialism

I particularly admire Indian medical enterprise for its sense of socialism; it is not all about profits and market share. Social-minded Indian entrepreneurs are leveraging the commercial potential of healthcare to improve basic care for the masses. There are many fine examples.  Dr Reddy's Labs, the second largest pharmaceutical company in India, makes cheaper generic drugs more easily available to the population.  The founder, Dr Reddy, has always targeted the poor for assistance.  He started the Reddy Foundation to equip youths from poor families with useful skills that will allow them to earn a living.

Likewise, the Jiva Institute established the TeleDoc project to bring high-quality but low-cost medicine to poor, rural villages using e-consultations and ayurvedic medicine. 

Dr G Venkataswamy founded the Aravind Eye Care System to make low-cost eye care accessible to the poor.  They now treat over 1.4 million patients each year, two-thirds of them - or almost a million patients - for free. It does this by innovating the surgical practice and inventing low-cost eye implants so that even the poor can afford good eye care and avoid blindness.  In the US where cataract surgery costs at least US$1000, Aravind does it for below US$200.

It is not too difficult to deliver US-style medical care at Indian prices by paying the Indian US-trained doctors and nurses at Indian rates.  But, without significant subsidy, such care remains unaffordable to the masses in India.  The search by doctors, like those in Aravind, for out-of-the-box break-through ideas to treat a disease at a cost which even the poor can afford without subsidy is what will make the dramatic difference to the healthcare scene in Asia. These are what Harvard Professor Clayton Christensen described as disruptive innovations.  They target the bottom 20%, not the top 20%.  I understand that besides Aravind in eye-care, there are pockets of such disruptive innovators focusing on other disease like diabetes and hypertension.

Applications for Singapore

India's experience with the globalisation of healthcare offers us useful lessons.  How should we respond?  How do we compete?

First, we too should take advantage of new opportunities presented by technological advancements to enhance efficiency and lower costs. India and eventually China are opportunities to average down our healthcare costs without compromising standards of care. That is why I am pushing tele-radiology, to stress this point.  

Our polyclinics now send routine X-rays to India for reporting by American Board-certified doctors there. Doctors in India can now discuss the cases with our local doctors over the Internet for free, using Skype. Our patients are happy and benefit from cheaper X-rays, faster X-ray reports. I think the private sector should consider doing this as well. 

We are moving to the next stage of tele-radiology, beyond simple X-rays.  Our polyclinics and hospitals will soon be sending CT scans, MRIs and Ultrasounds for reporting in India. This will further lower our healthcare costs and relieve our over-stretched radiologists to focus on higher value-added work. 

I know some of our radiologists are worried.  They wonder if their jobs will disappear or if their salaries will be lowered to Indian rates.  But globalisation is not a zero-sum game, if the players are nimble and flexible.  Tele-radiology does not necessarily mean a one-way flow of X-rays and scans out of Singapore.  I am aware of a group of radiologists actively negotiating for X-rays from the West to be reported here.  If our standard is high, our Singapore brand can command a cost premium.

Second, we should step up the training of doctors and other professionals and open up for the best to work here.  We need to make Singapore a great place to live, work and play for Singaporeans and talented people from around the world.  There are many very smart healthcare workers in India whom we should try to recruit to augment our talent pool.  In this knowledge intensive sector, talent is the most important success factor. There is a worldwide shortage of healthcare professionals - doctors, nurses and allied health professionals. The 130 doctors we recruit from overseas annually are still not enough. 

Since 2003, we have increased the number of recognised foreign medical schools six-fold to 120.  There is scope to further expand the list.  From India, we now recognize two of their top medical schools: All-India Institute of Medical Sciences and the Christian Medical College.  The SMC will soon add three more top Indian medical schools to our schedule.   

Thousands of well-trained and highly competent specialists from Asia are currently working in the UK.  EU rules coming into force are now giving advantages to EU citizens.  Many Asian professionals may now consider coming back to Asia.  This is an opportunity for Singapore to draw them in and expand our healthcare sector. My Ministry is easing the registration criteria to attract more clinicians with good qualifications and experience. Foreign-trained doctors from recognized medical schools have just got their supervisory durations reduced - by 1 year for specialists and 2 years for non-specialists. Those with at least 5 years of relevant clinical experience after acquiring their Specialty or Family Medicine qualification are now allowed to practice from the outset in a private setting.  Doctors with insufficient clinical experience will need to be supervised for at least a year in an approved institution.  Their supervisory framework will also be enhanced by using 360-degree assessment. 

Besides doctors, we also need to increase our number of nurses and allied health professionals. In the last few years, nurses from China, Myanmar and Philippines have come and provided good care to Singaporeans. We will continue to retain good foreign nurses by offering them citizenship or PR status. We also cannot take our Singaporeans for granted. I hear there is a "mini Tan Tock Seng" of physiotherapists in London. We will do more to expand the allied health profession.

We should also invest in more facilities.  Besides the new general hospital in Yishun, the private sector ought to expand too. I see a need for at least one or two more major private hospitals in the short term. We are working with the URA to release the land for them to do so.  We should be able to announce details in the next few months.

Third, we should continue to innovate, learn from the best and get better. We should be a trusted provider, by ensuring high standard of care with transparency of bills and outcome. In healthcare, trust is an important element.  Is the blood supply safe?  Are the doctors ethical?

Look at Bihar.  It is stuck with a poor reputation.  A recent Economist article described it as "India's most dysfunctional state".  Political leaders are alleged to be corrupt and in cahoots with criminals.  As it turned out, there are visible signs of development.  Roads are being widened, hotels being expanded.  The holy sites were well kept and quite clean. Gaya airport we flew into has a new terminal building.  Bihar has a new Governor and he is clearly making progress.  

The reality there is better than what has been portrayed in the press.  That is a reminder to us: public image is sticky and takes a long time to wash.  So never acquire a bad image; and if you have a good image, work hard to preserve and enhance it.  

In this regard, let me share with you that the SMU has acquired a good brand and image.  Your students have been described as confident, articulate, cool.  Keep it up. 

Indeed, SMU is a good illustration of how to compete in a globalised world.  You did not blindly copy the NUS or the NTU.  You draw in some very talented local academics and practitioners, and also attract talented people from around the world.  You draw on the strength of the Wharton School of the University of Pennsylvania.  You take in some of the brightest students from our top JCs and also from the Polytechnics.  You do not just look at the academic qualifications of applicants but also the X-factor.  Much credit should go to Mr Ho Kwon Ping, whom I know put a lot of his heart into this project. 

The result speaks for itself.  SMU students are snapped up even before they graduate. 

Conclusion

During the Indian trip, we spent half-a-day at the ruins of the Nalanda University.  This was the site of a monastery where Buddha and his top disciples stayed for many years.  A university was later founded in the fifth century and developed into a global centre of Buddhist education where the top monks and trainees from China, Japan and Korea gathered to learn from the Indian monks and from one another.   

Then in the 12th century, the Moghul invaders destroyed and literally buried it.  If not for Xuan Zhuang's Record and the excavation works in the 19th century, it would have remained buried in the jungle.  

Why did Nalanda become destroyed?  A short reply is that it was destroyed by the invaders.  But actually Nalanda had already gone into decline prior to the invasion.  Living on past glory, the Nalanda leadership had gone complacent and was in fact in moral decline.  Bogus teachings displaced serious Buddhist practice.  Learned monks could recite the sutras but few put them into serious practice.  The conditions were ripe for destruction.  The invaders were merely the agents of execution.  

As always, our greatest enemy is ourselves.  This is true for religions, it is so for universities, societies or a country.  When leadership is morally corrupt, decline is inevitable.

On the other hand, an enduring society is one which is cohesive, where the able consciously help the less able and the leadership remains forward looking, dynamic and fresh.  Above all, the establishment must maintain high moral standard and character and be good role models for all.  

You will soon graduate to serve the world.  By all means, go and make your millions.  But never forget the less fortunate in our midst.  That is why I admire Dr Venkataswamy and the Aravind System, for their innovations are not profit-driven but for a higher ideal. The same is true for all of you. What ethical spirit and cause that you bring to bear, will make a difference to the richness of your life, as well as those around you.  It must be more than serving yourselves.   

Thank you.

---------