AsianScientist (May 25, 2016) – With some 600,000 children affected by pre-emptive school closures and thousands placed under home quarantine orders, the 2003 severe acute respiratory syndrome (SARS) outbreak was one of the worst epidemics that Singapore has faced in living memory. And yet for two whole weeks after the first case was detected, it was a fear that had no name, as doctors struggled to tame the highly contagious but completely unknown infectious agent.
“Facing an epidemic is bad enough,” says Tan Chorh Chuan, president and professor of medicine at the National University of Singapore (NUS), and Singapore’s director of medical services at the time.
“But having an epidemic of a completely novel virus adds tremendous complexity and difficulty to the situation as nobody knows the mode of transmission or infectiousness of the new agent. If you don’t know these things, it’s very hard to think about effective ways of containing it and managing patients.”
All this meant, he says, that the degree of uncertainty and fear in Singapore was very high—and not just among the public, but among health workers as well, especially when it became clear that many of the infections were spread in a hospital setting.
Steering Singapore through SARS
As frontline health workers began succumbing to the disease, the fear continued to grow. Nonetheless, not a single doctor or nurse abandoned his or her post, recalls Professor Tan, and several even went far beyond the call of duty.
One such doctor was vascular surgeon Alexandre Chao, the son of respected forensic pathologist Chao Tzee Cheng. Upon hearing about the SARS outbreak, the younger Chao rushed back to Singapore from a family holiday abroad to replace colleagues who had been infected and could no longer perform surgeries. Tragically, he too became infected and passed away, leaving behind his wife and two young daughters.
“Seeing people I know pass away, Alex among them, was the hardest part of the SARS crisis for me,” Professor Tan reveals, striking a sombre note. But, he admits to being “deeply impressed and appreciative of the fact that our health professionals lived up to their calling; delivering care under very difficult circumstances, living with the fear and uncertainty but remaining driven by the interests of patients and the public.”
Professor Tan himself had to make extremely difficult decisions almost on a daily basis. Perhaps the toughest was the temporary re-designation of Tan Tock Seng Hospital (TTSH) from general to SARS-specific care. The call was made very early on.
“Tan Tock Seng is one of the largest hospitals and at the time had the busiest emergency department,” explains Professor Tan.
“To recommend to close the hospital down to normal operations on the basis of just thirty suspected SARS cases was a very big decision, as it meant taking out quite a bit of capacity of the health delivery system.”
In retrospect, it was the right decision, he believes, because it allowed TTSH’s staff to focus fully on learning how to manage SARS; their confidence and expertise spread through the rest of the healthcare system.
“For example, after Tan Tock Seng Hospital ensured that the personal protective equipment protocol was rigorously adhered to, there were no further cases of healthcare workers who became infected from SARS from looking after patients,” he says.
Professor Tan received the Public Service Star in 2003 in recognition of his contributions to the management of SARS, and the Public Administration Medal (Gold) Medal in 2004 for his work in the Ministry of Health.
Professor Tan first heard his calling to the medical profession as a schoolboy at St. Joseph’s Institution (SJI), when, as a member of the St. John Ambulance Brigade, he helped resuscitate a footballer who had collapsed during a match.
However, as the seventh of nine children, Professor Tan needed a scholarship to pay for medical school.
“It was pretty competitive,” he relates, in his trademark, understated style. “I was thrilled to be accepted [by the University of Singapore], and even more so to receive a scholarship that allowed me to stay in King Edward VII hall for the five years of my studies.”
Staying at a hall of residence proved to be a formative experience, both in terms of his introduction to medicine as well as his holistic development. In particular, Professor Tan remembers the words of Khoo Oon Teik, professor of medicine and master of the hall, to the medical students just days after they registered. Professor Khoo impressed on them the need to be humble as they were entering a profession with many truly distinguished members, and an institution whose history stretches back to 1905.
Inspired by dedicated and passionate mentors such as Evan Lee and Woo Keng Thye, as well as Professor Khoo, who set up the National Kidney Foundation, Professor Tan trained as a nephrologist after his graduation from medical school.
Intrigued by the workings of the kidney, he decided to pursue research alongside his clinical practice, completing his research training at the Institute of Molecular Medicine (IMM), Oxford University for a PhD conferred by NUS in 1993, to become one of the first home-grown clinician-scientists in Singapore.
Charting a course for career and country
At the time of his graduation, however, Singapore was placing greater emphasis on chemicals, electronics and engineering research—fields seen as the three main drivers of economic growth.
Undeterred, Professor Tan continued doing biomedical research while seeing patients, eventually winning the Singapore Youth Award in 1996 for his work on the regulation of erythropoietin, a hormone that controls red blood cell production.
But his hopes for the scientific enterprise in Singapore extended far beyond his own career. Led by fellow SJI alumnus Philip Yeo, and working with John Wong and Kong Hwai Loong, Professor Tan was instrumental in conceptualising and setting up Singapore’s biomedical sciences (BMS) initiative. Launched in June 2000, the BMS initiative saw a substantial increase in government investment with the aim of making the biomedical sector the fourth pillar of Singapore’s economy.
The BMS’s challenges included growing basic science strengths from a low base and developing excellent clinical research capabilities, while fending off naysayers who thought its ambitions unrealistic.
“Today, as we look at the considerable science talent and capability base that we have, it’s hard to recall those early days,” Professor Tan muses.
“I don’t feel that there were any substantial shortcomings in the approaches taken, although it might have been good to put a stronger focus on building our translational and clinical research expertise and capabilities earlier on in the process.”
An interdisciplinary approach to the challenges ahead
Indeed, the main thrust over the course of his tenure as president of NUS has been the need for multidisciplinary research, especially collaboration between clinical research and basic science. Convinced of the importance of such research, Professor Tan played a key role in setting up the Duke-NUS Medical School to train the next generation of clinician-scientists.
“When I first came back from my research training , there was just a handful of MD-PhD’s and a few clinicians involved in research. Today, we have a much larger number of well-trained, active and productive clinician-scientists, at least ten times more than before,” Professor Tan enthuses.
In this there are shades of Oxford’s IMM, where during Professor Tan’s time one-third of the researchers were also practicing clinicians. Quite naturally, he says, IMM’s basic science work became related to clinical problems and patient populations.
“That rich interaction was very positive in helping to shape the research questions,” he says.
Beyond clinical research, Professor Tan believes greater collaboration between basic medical research and the social sciences is necessary.
“It’s clear that most of the health challenges that we face will not be solved by science and technology alone,” he stresses. “They also require social science research to understand the behaviourial and social aspects that influence them.”
Professor Tan gives the example of chronic non-communicable diseases such as diabetes, which require the active participation of patients and the community if they are to be adequately managed. This is where social science and behaviourial science research can help.
Indeed, Professor Tan’s ability to synthesise the medical sciences with the social and behavioural, in a time of blinding crisis, is a big reason why he has already established a rich legacy in Singapore.
“Today, Singapore is immensely better prepared for an infectious disease epidemic,” Professor Tan says. “The policies, approaches and protocols are in place, and there are many individuals who have deep experience in the implementation of control measures.”
In other words, even if the next enemy has no history or name, Singapore should feel confident in its ability to fight it off.
This feature is part of a series of 25 profiles, first published as Singapore’s Scientific Pioneers. Click here to read the rest of the articles in this series.
Copyright: Asian Scientist Magazine; Photo: Cyril Ng.
Disclaimer: This article does not necessarily reflect the views of AsianScientist or its staff.