SPEECH BY DR JANIL PUTHUCHEARY, SENIOR MINISTER OF STATE, MINISTRY OF HEALTH, AT THE 20TH SINGAPORE INTERNATIONAL STROKE CONFERENCE, 4 OCTOBER 2024

1. Good morning, everyone. At the Ministry of Health (MOH), stroke is an area of focus, because cerebrovascular diseases are among the leading causes of death and disability among adults in Singapore.

2. Age is only one of the risk factors for stroke. In Singapore, we see that stroke episodes have risen in tandem with our ageing population. In 2011, there were over 6,100 episodes. By 2021, ten years later, this number had increased to 9,600 episodes. If we don’t act, there will be an increasing impact of stroke on our ageing population. Ageing is inevitable, but we can take control of our lifestyle to manage risks of stroke. This is crucial as approximately four in five strokes are preventable and nearly one in four strokes occur in people aged below 60 years.

3. This year’s National Stroke Awareness Campaign by the Stroke Services Improvement (SSI) team, set up by MOH, highlights actions that are important for stroke prevention. Be Smoke-free, stop cigarettes, take Meals that are healthy, eat better, engage in an Active lifestyle, move more, attend Regular health screening, see the professionals, Take prescribed medications as recommended.

4. These efforts complement existing national health initiatives, such as Healthier SG, which has enrolled more than a million residents aged 40 and above. Eligible citizens receive fully subsidised health screenings for stroke risk factors like hypertension, hyperlipidaemia and diabetes. We don’t see disease on its own. Each of the preventative screening programmes and interventions around hypertension, hyperlipidaemia and diabetes. They are important for that condition, but they are also important for a variety of conditions, including stroke. These chronic conditions can be attributed to lifestyle habits, such as unhealthy diets, smoking, low physical activity levels. Enrolled patients and enrolled residents under Healthier SG before they become patients, collaborate with family doctors on personalised health plans, including lifestyle changes to prevent or manage chronic conditions.

5. However, putting a health plan into action can be a challenge. It’s one thing to sit down in the office, have a great discussion. Everybody commits to doing all the right things. We are all human. Getting it done consistently and applying over a period of time, is a challenge. Recognising this, support for a healthier lifestyle extends beyond the clinic. The Health Promotion Board (HPB), for example, offers physical activity programmes island-wide for all age groups. These programmes support residents to engage in at least 150, or hopefully more, up to 300 minutes of moderate intensity aerobic physical exercise and two days of muscle and bone-strengthening exercise per week. To further expand on current offerings, HPB is enhancing the Healthy365 app to list programmes offered by community partners such as SportSG, People’s Association, and Active Ageing Centres. All of these provide residents with a broader selection of physical activities within the community. Is this a stroke prevention programme? It is not called stroke on the label. But this is part of a healthier lifestyle, this is part of our interventions around a broad variety of lifestyle factors, broad of range of diseases. If done well, done properly, it will improve the risk for stroke of the population and individuals who participated.

6. Our dietary habits are just as important in reducing our risk of stroke. Excessive sodium intake for example, is a significant risk factor for hypertension. Hypertension can lead to stroke. MOH and HPB have embarked on a sodium reduction strategy since 2022. This approach includes collaborating with the food and culinary sector to encourage the use of less salt or lower-sodium alternatives. We intend to extend the Nutri-Grade labelling – you will be familiar with this. When you go and buy your drinks and you will see “A”, “B”, “C”, “D” and you know that the “A” is healthier and the “D” is less healthy. That concept of Nutri-Grade labelling – making sure that the information is available to the consumer at the point of purchase, but also influencing how the manufacturers and retailers behave is important for what we have done around sugar. We are going to extend this Nutri-Grade labelling approach and advertising prohibition measures to key contributors of sodium.

7. Staying smoke free can help reduce one’s risk for stroke as well. HPB runs preventive education campaigns, I Quit programme, to help smokers quit. Our efforts have shown encouraging results: the smoking prevalence of adults in Singapore aged 18 to 74 has fallen from 13.1% in 2013, to 8.8% last year¹. We are making progress and we have to keep pushing through. So those of you who smoke, or know people who smoke, please continue to pass on this important message. This is something easily addressable that we can do to improve the health of that individual. We must continue to repeat that message even as we continue to make progress.

8. When healthy lifestyle changes alone are not enough to manage these risk factors, medication becomes necessary to manage hypertension, hyperlipidaemia and diabetes. If you have these chronic diseases, it is actually very important to manage them well. Not just for your own sake, but because they then contribute to a risk of other diseases. If you have contracted hypertension, hyperlipidaemia and diabetes, part of managing it well means medication for some of the patients. However, nearly half of our stroke survivors² do not take their medication as prescribed after their hospital discharge. This means you have had an assessment. You have been determined to need medication. A treatment plan has been settled on but then half of the patients in that situation don’t follow through on taking medications as prescribed. What does this mean? It means that you think that you are being treated, the doctors think that you are being treated, but actually your risks are not being correctly managed. You continue to expose yourself to risks as a result of hypertension, hyperlipidaemia and diabetes. So we have to encourage patients to take prescribed medications. We have to keep on working on the issues of non-compliance. Healthcare professionals have to also play their part. It is not enough to just provide a prescription or come up with a treatment plan. As a community of practice, we have to engage with patients, engage with the population, and understand what are the reasons for non-compliance, how can we continue to find more solutions to help this idea of compliance with prescribed medications. The healthcare clusters are playing a part in this. one of the efforts is to co-locate community health posts at the Active Ageing Centres, to support the seniors with medication management.

Improving outcomes for stroke survivors

9.  Aside from these preventative measures, much has been done to ensure that patients can receive timely stroke care. You will know this – restoring blood flow to the brain as quickly as possible can significantly reduce long-term disability in stroke survivors. These are several steps in addressing this time gap between the stroke happening and the restoring of blood flow to the brain. One of the first steps is recognising that a stroke has occurred, so educating the public is going to be very important. How do you know when a stroke has occurred or may have occurred? At the national level, the annual National Stroke Awareness campaign by the SSI helps to raise the public’s awareness on spotting the early signs of stroke through the ‘Think F.A.S.T’ campaign and encouraging them to call 995 immediately if they think a stroke is coming. That is at the national level.

10. But at the institutional level, our public healthcare institutions have also enhanced collaborations between the different hospital teams to streamline the workflows and expedite the delivery of care. Now, many hospital teams are involved in looking after patients, to get them from the doorway onto the bed, have that needle in their vein and to start receiving the medication. Now, to coordinate across many teams, many disciplines – that type of coordination work is something that is the heart and soul of our healthcare institutions think about improving their work processes and improving outcomes for their patients. A notable example is the Singapore General Hospital (SGH) and National Neuroscience Institute (NNI) stroke team’s initiative to optimise the Endovascular Thrombectomy (EVT) decision workflow. Through this work, they have reduced the what they called the ‘door to groin’ time – “door: because the patient walks in through the door, “groin” because that’s the vein or artery that they use, the vessel is cannulated in the groin – so the ‘door to groin’ time was reduced from 130 to 82 minutes. Over 200 patients benefit from EVT at SGH³ every year. It makes a difference – getting that time down. The team has shared their best practices with other hospitals, extending the benefit to more stroke patients nationwide. As a result, these efforts were recognised with the Best Practice Medal (Care Redesign) at the National Health Innovation and Productivity Medals 2024.

11. These efforts are present in all our institutions and it is important for us to share best practices. People will do so through the academic processes, publishing their results, but operationally, as a community of practice, we also have to learn from each other and continue to improve. With more timely recognition of stroke, the proportion of ischaemic stroke cases in Singapore receiving thrombolytic agents (tPA) increased from 3.8% in 2011 to 6.2% in 2021⁴. Not all cases are going to be suitable for tPA or EVT, but delayed hospital arrival should not be the limiting factor. The gap between ‘door to groin’ should not be the limiting factor. By raising awareness, we can continue to ensure that more patients receive timely, potentially life-saving interventions.

Enabling stroke survivors and caregivers in the community

12. All of these timely treatments, interventions in stroke patients will save lives, and improve the chances of recovery. The real challenge for stroke survivors begins post-discharge from the hospital as they continue rehabilitation in the community. Up to 60% of stroke survivors face long-term disabilities that affect walking, talking, swallowing, cognitive functions. These physical and mental challenges impact not only the stroke survivors’ independence but also their families as spouses and adult children often become caregivers.

13. To address this, NNI, in partnership with Temasek Foundation, is piloting the Temasek Foundation Re-Integration for Stroke Community Endeavour (RISE) programme to enhance post-stroke care, prevent recurrent strokes and improve the support in the community. This three-year initiative aims to support up to 1,000 patients with mild to moderate stroke, and their caregivers, facilitating community reintegration and improving their overall well-being.

14. RISE will consolidate and enhance existing resources and partnerships in post-stroke care, to provide comprehensive support throughout the rehabilitation process, and focusing on three key areas. First, it will improve care coordination and support for stroke survivors after they leave the hospital, such as following up with patients to screen for common stroke-related issues such as spasticity, incontinence and dementia, providing patient-specific advice on medication compliance, healthy lifestyle changes, and guided individualised care plans. Second, RISE will implement a structured training programme for stroke caregivers. Last, it will introduce the Stroke Empowerment Programme to help survivors take charge of their recovery journey so as to improve their function and quality of life. Three broad thrusts – one focused on the clinical issues of the patient, one focussed on the caregivers and the people around the patient, and one on the education of the survivor so that they can then continue to play a significant role of taking charge of their recovery – all aiming to improve the function of the survivor, the quality of life for the survivor, as well as for the caregivers.

Closing

15. In closing, today, I extend my heartfelt gratitude to the stroke community. You have worked tirelessly for the benefit of the patients and in advancing patient care. I urge you to use this conference as a platform to share best practices, learn from one another, forge new collaborations that will further advance stroke care. Thank you for your dedication and commitment to improving the lives of those affected by stroke, and I wish you all a very fruitful conference. Thank you.

[1] National Population Health Survey

[2] Modifiable Factors Associated with Non-Adherence to Secondary Ischaemic Stroke Prevention Strategies - PubMed (nih.gov)

[3] The National Healthcare Innovation and Productivity Medals 2024 Fact Sheet, Centre for Healthcare Innovation; page 2

[4] Singapore Stroke Registry Annual Report 2021