SPEECH BY MR EDWIN TONG, SENIOR MINISTER OF STATE, MINISTRY OF LAW AND MINISTRY OF HEALTH, AT THE SINGAPORE PREVENTION AND CARDIAC REHABILITATION SYMPOSIUM 2019, ON 19 OCTOBER 2019

Adjunct Associate Professor Tan Swee Yaw, Chairman of the Organising Committee

Assistant Professor Raymond Wong, Dr Peter Ting and Adjunct Associate Professor David Foo, Co-Chairmen of the Organising Committee

Singapore Heart Foundation Board Members

Distinguished guests

Ladies and Gentlemen

1. Thank you very much for being here. I am happy to join you at the Singapore Prevention and Cardiac Rehabilitation Symposium 2019. This is the third edition of the Symposium and it continues to bring researchers and academics together to exchange ideas and issues and discuss how we can have better cardiac rehabilitation.

Increase in burden of disease from cardiovascular diseases

2. In 2017, cardiovascular diseases contributed to 14.2%¹ of the total burden of early death and disability^2. In 2018, cardiovascular diseases were the highest principal cause of death in Singapore, standing at 29.2%³, almost a third of the death burden in Singapore.

3. Singaporeans are living longer now – our life span has grown longer – but our society is rapidly ageing. It is not just ageing significantly – a proportion of Singaporeans 65 and above will hit 25 per cent in about 10 years’ time – but it is the rate at which it is increasing which is also an issue for us. Today, we have about 420,000 Singaporeans who are 65 and above, but in 2030, we will have about 900,000. The steep and sharp ascent in the curve is something we need to pay attention to. We should also expect to see an increasing incidence of chronic medical conditions associated with ageing, and that inevitably includes cardiovascular diseases. In 2010, slightly more than half of our elderly aged 60 and above were living in ill health due to cardiovascular diseases. That number increased to 62% in 2017⁴. It is not just the number but also the trend and the rate of increase, so we do need to tackle these issues upstream. I heard Prof Tan mention earlier that in rehabilitation after an acute or adverse episode, people tend to rest more, eat better, look after stress, take care of their lifestyle and be more active. But one has to ask ourselves, why does it take an adverse episode for that to happen? Those are some of the issues that we can deal with, and we can bring them upstream and change our lifestyles.

4. Medical advancements and technology like wearables, 5G, Bluetooth, are tools that can help but ultimately, it is the fundamental mindset of the individual that has to change. Our aim is to not just look after the ill, but as far as possible, we want to look after the well. We have taken significant steps in the last couple of years to tackle modifiable risk factors, such as physical inactivity, unhealthy diets, smoking, obesity, hypertension and diabetes. All of these we try to manage through lifestyle changes and regular screening. Regular screening is important and our screening is very cheap and low-cost, and at $5, which includes the first consultation as well if there are any adverse markers.

Greater focus on preventive efforts for better cardiovascular health

5. To encourage Singaporeans to better take care of their lifestyle, the Ministry of Health (MOH), working with the Health Promotion Board (HPB), has been investing in preventive health by making it easier and more accessible to live healthily. In Singapore, our lifestyle is fast-paced and demanding. We not just have to live healthy but it must be convenient to live healthily as well.

6. HPB came up with the National Steps Challenge. It had its fourth instalment at the end of last year and we are looking at how we can do this better. It started in 2015 to encourage Singaporeans to be more physically active. Everyone is on a mobile device and I think it is time we get outdoors and what better way than to use some gadget as well to incentivize, such as getting a shopping discount when you walk ‘X’ number of steps. The initiative leverages the concept of gamification, using behavioural insights and wearable technology to give a gentle nudge to participants to change their lifestyles and be outdoors. I think over time, that would make a difference. HPB also organises regular, island-wide physical activity programmes such as Sundays @ the Park and Sunrise in the City, taking advantage of the fact that we do have a beautiful cityscape and parks to bring our people outdoors, to make exercise programmes more accessible, and to make it generally easier for physical exercise to be embedded into part of our daily lives – to make it usual and normal that we expect to have physical activity as part of our week’s regiment.

7. On top of that, to encourage healthy diets, HPB works closely with the food industry to ensure the availability and accessibility of healthier food choices whether we eat in or eat out. Some people say we look after everything, including what we eat but I think we do need to take those steps as a government, to initiate healthier living choices, to look at the ingredients that go into foods. Sometimes, these are unknown and what we want to do, especially with our recent sugar initiatives is to bring more awareness to the public, to lead with labels so you are aware of the sugar content and the choices you make. We cannot stop you from buying it but ultimately you become aware, and that is the idea. Through two further initiatives, the Healthier Choice Symbol and Healthier Dining Programme, healthier food options are labelled with a visual cue, especially for the elderly who are not able to discern the details in the product labels as well as you and I, giving a visual nudge to help Singaporeans to choose better. Specific to cardiac health, a ban on partially hydrogenated oils, a main source of artificial trans fat will be introduced in 2021. Major supermarkets and manufacturers have pledged to meet the ban one year earlier, by June 2020.

8. Smoking is a significant risk factor for cardiovascular diseases. To reduce smoking prevalence, we will progressively raise the minimum legal age for smoking from 18 to 21 years old in 2021, and standardise all tobacco products’ packaging from July 2020. To help smokers quit the habit, the HealthySG Taskforce will be piloting new support models with subsidised interventions at our public health institutions starting from March next year. These include fully subsidised nicotine replacement therapy to complement existing cessation counselling for smokers receiving treatment at our public health institutions. We recognise that it is not just a question of making you stop and thereafter say that we have succeeded. There needs to be a follow-through programme. There needs to be a consistency in the programme to not just encourage cessation but see that cessation is sustainable in the long-term. We hope to reach out to at least 10,000 smokers over the next two years and help them quit the habit and to sustain the cessation.

Importance of cardiac rehabilitation

9. For patients with cardiovascular diseases, we must look towards appropriate cardiac rehabilitation as well to improve our heart’s health. Cardiac rehabilitation helps patients to recover better from their heart condition and improves long-term cardiac health. It includes risk factor control and monitoring, patient education and individualised exercise training.

10. The first cardiac rehabilitation programme started 15 years ago in 2004 and today, cardiac rehabilitation programmes are offered at all acute hospitals in Singapore. Beyond having them in hospitals and a hospital setting, it is also important for patients to have better access to care in their community. In this respect, I am heartened that the Singapore Heart Foundation’s three Heart Wellness Centres are running community-based programmes to aid, assist and better support cardiac rehabilitation in the community, including nutrition counselling, regular health and educational talks after patients complete their early rehabilitation in the acute hospitals. So we start early rehabilitation in the acute hospitals, give them the basics, teach them, let them understand, but many of them can be done in the community. I personally believe that a lot more treatment and rehabilitation are in the long term more sustainable if they are found in the community, where you do not dislocate the patients from the normal course of living, from their families and from where they live. I think over time, this course of looking at the community as a stronger base of support will be more sustainable. The centres also offer peer support and motivation to help patients along, as well as their families, and I think the family, as the most immediate and most important support system, cannot be ignored. These programmes help them to adjust to life and adopt healthier lifestyles after being discharged.

Leveraging technology to improve cardiac rehabilitation and redesigning model of care

11. In addition to having a robust suite of programmes and services, we also aim to leverage technology, which is ever-changing. All of these can make cardiac rehabilitation a lot more accessible and convenient, and for healthcare delivery, especially, to be more efficient without compromising on patient safety. Aligned with this year’s theme, “Contemporary Cardiac Rehabilitation”, we hope to utilise technology to improve the rehabilitation process and for outcomes for cardiac patients to be more consistent, sustainable and to ensure timely care and better health outcomes. That is the overriding objective of any good rehabilitation programme.

12. A pilot study⁵ conducted by the National Heart Centre Singapore between 2012 and 2013 showed how we could apply technology on cardiac implantable electronic devices such as pacemakers or pager-sized defibrillators, to allow remote monitoring of cardiac patients with life threatening cardiac arrhythmia. Whenever the device detects abnormal cardiac rhythm or device malfunctioning, it will transmit the data to a remote monitoring system, which would subsequently alert the doctors via fax, email or SMS, and patients would be promptly called back to check and have intervention carried out. Such remote monitoring gives patients the flexibility of home monitoring, while ensuring that patient safety is not compromised. I think home monitoring is particularly important because it allows the patients to get back quickly to the environment they are comfortable in, the community they are happy to be around and to get back into some semblance of normality in their life, but at the same time, ensuring that the monitoring and degree of care are not compromised. This kind of measure could also potentially reduce healthcare providers’ workload at the hospital setting or at community hospitals, and to healthcare cost to patients in the longer term.

13. Another good example is the application of artificial intelligence on the data tracked by wearable gadgets such as electrocardiogram (ECG) wearables. These devices track ECG rhythm around the clock and allows continuous ECG data transmission from anywhere in the world with a connected smartphone. Physicians can remotely log in securely into the database and report findings to the patient from another connected device. All of these changes the paradigm and landscape and our usual, slightly outdated, understanding of how we can deliver patient care. At the same time, patients can take ownership of their own health and I think ultimately, that is important – how do we empower patients through these wearables and technology; how do we empower patients to take ownership of their own health and own lifestyle. Patients can also monitor their own cardiac rhythm through an app-enabled smartphone that allows continuous personal visualisation of the ECG⁶.

14. There is much potential in using technology to deliver better healthcare and health outcomes, not just in the short term but to ensure it is sustainable. I certainly hope that the debates that we have and exchange of ideas will better enable all of us to share ideas and best practices, and discuss opportunities to collaborate with our friends from overseas on how we can improve ourselves in Singapore. I thank all of you for that interest because it is these kind of sessions, working collaboratively, that we can then as a country, lift our healthcare system and lift our healthcare services to patients.

Closing

15. In closing, I would like to thank the Singapore Heart Foundation for all of your efforts to continually raise awareness of heart health, both among the public and healthcare community. On this note, I wish all of you a very enjoyable session and good health. Thank you very much.

[1] Source: The Global Burden of Disease (GBD) Study 2017.
[2] Measured in disability-adjusted life years, or DALYs
[3] https://www.moh.gov.sg/resources-statistics/singapore-health-facts/principal-causes-of-death
[4] Source: The Global Burden of Disease (GBD) Study 2017.
[5] A recent study featured in the Singapore Medical Journal. http://www.smj.org.sg/article/remote-monitoring-patients-cardiac-implantable-electronic-devices-southeast-asian-single
[6] https://www.businessinsider.com/fireeye-stock-price-spikes-after-hiring-goldman-sachs-sale-effort-2019-10