Ten years ago, Singapore declared War on Diabetes. MOHAMMAD KHAMSYA BIN KHIDZER (King’s College London) examines the logics behind the campaign and finds that one under-appreciated rationale is economic.
When the Singapore Government declared its War on Diabetes in 2016, not all medical professionals were swept along. In her interview with the Oral History Department, epidemiologist and former CEO of National Healthcare Group Polyclinics Shanta Christina Emmanuel noted that the “war” was declared after a scandal at the Singapore General Hospital.[1] Mismanagement of blood samples had led to a Hepatitis C that killed eight.[2] But “suddenly diabetes was the killer”, Dr Emmanuel noted.
Prime Minister Lee Hsien Loong devoted a significant portion of his 2017 Prime Minister’s National Day Rally Speech to the War on Diabetes.[3] While diabetes certainly was and is a serious health problem, contrarian expert perspectives such as that of Dr Emmanuel’s complicates the “war” narrative. While we often think that medical and epidemiological rationale drive the elevation of a disease into a public health crisis, this might not be entirely true. Very often, other factors come into play. This essay foregrounds a less obvious rationale – economics – that animates the emergence of a public health crisis such as the War on Diabetes.
Lee Hsien Loong delivers the Prime Minister’s National Day Rally speech in 2017.
The numbers behind the war machine
Data from the Ministry of Health Singapore website provides an overview of population disease prevalence, as well as how specific diseases contribute to the disability-adjusted life years or DALY[4] metric. If we refer to the disease burden table (figure 1) over a period of 15 years, we see that the prevalence rate for diabetes among adults aged 18-69 is the lowest when compared with hyperlipidemia (high cholesterol), hypertension, daily smoking and obesity. In fact, in the same time frame, the prevalence of hyperlipidemia and hypertension had more than doubled.[5] Certainly, the greater prominence given to diabetes, over and above other diseases was not merely shaped by figures on population prevalence.
Figure 2: From MOH Disease burden (Disease Burden Ministry of Health Singapore):
Was diabetes then chosen because it leads to other health complications? This explanation came up more than once in the War on Diabetes narrative.[6] However, the problem with this reasoning is that it is equally valid for both hypertension[7] and hyperlipidemia[8], both of which are even more prevalent in the Singapore population. Perhaps the answer to why diabetes was singled out can be found in the expected years lived in ill health as a consequence of its incidence, something that was mentioned in the aforementioned 2017 National Day address. This is what DALY measures.
Data from ‘The Burden of Disease in Singapore, 1990-2017’ (henceforth the burden of disease) report published in 2019 shows the DALY – disability-adjusted life year – distribution by causes.[9] DALY measures the burden of disease. One DALY represents a loss of one year of full health. The DALY statistic for a disease or health condition ‘are the sum of years of life lost due to premature mortality (YLLs) and years of healthy life lost due to disability (YLDs) due to prevalent cases of the disease or health condition in a population’.[10] The mortality rate for diabetes in Singapore is not readily available, possibly because diabetes might also be an underlying or co-contributor for mortality, alongside other health conditions. However, DALY figures from the burden of disease report indicate that changes in life expectancy at birth (which are affected by changes in Singaporean mortality rates for specific diseases) are higher for cancers, cardiovascular diseases and substance use disorders than they are for diabetes and kidney diseases.[11]
Figure 2 highlights cardiovascular diseases, cancers, musculoskeletal disorders and mental disorders as the 4 leading contributors to DALY between 1990 and 2017, whereas diabetes and kidney diseases as a category is ranked 7th[12]. Moreover, if we analyze diabetes and kidney disease separately (figure 3), it becomes apparent that the prevalent cases for diabetes went up since 1990 but started to dip around 2013.[13] DALYs due to diabetes, went down in 2008, while DALYs due to chronic kidney disease levelled off around 2015. If we consider the data in its entirety, then, the timing for the war on diabetes and even the choice of diabetes seems rather odd. Diabetes was not even in the top 5 in terms of contributing to DALYs.
Figure 2: From the burden of disease report.
Figure 3: From the burden of disease report.
If not deaths…or the promissory economics of diabetes
So why and how then did diabetes become a top public health concern? A report that preceded the declaration of war in 2016 – the Diabetes Task Force (DTF) report – provides us with a more convincing answer.[14] The report names as overseeing agencies two separate, but not unrelated government entities – the Ministry of Health and the National Medical Research Council – and was authored by a panel of experts from NUS, NTU and A*Star, to name a few institutions. The tone of the DTF report is somewhat less alarmist when compared with the public health narrative. While it presents projections on the prevalence of diabetes similar to the narrative found in the War on Diabetes, these projections are linked to notions of healthcare burden and more importantly, opportunity. The DTF report is therefore as much an economic document, as it is a public health one.
Surveying existing research driven initiatives around the world, the report highlights a research gap that Singapore could fill given its demographic profile and scientific capacity: developing a model of care for diabetes that minimizes healthcare costs and is sensitive to the context of an ageing population. The DTF report describes the following advantage: “…Singapore is uniquely poised to compete effectively in this therapeutic area, by taking advantage of some of the highest complication rates in the world, and a population which represents (in some form or another), up to two thirds of the worlds’ population”.[15] The prevalence of complications and the presumably diverse ethnoracial population that represents a large portion of the world population here are figured as resources. Aside from being a burden to the healthcare system, the presence and prevalence of sick bodies also represent an opportunity for potential economic growth.
This convergence between science, economy and biopolitics has been covered by scholars of Science and Technology Studies (STS). Catherine Waldby for instance, shows how the Singapore state, in trying to develop a national bioeconomy, figures its population as experimentable bodies with value that can then be extracted [16]. Aihwa Ong too highlights the way that value is created by the scientific elite in Singapore through the narrative of genetic diversity and a population that represents much of the world [17]. The underlying assumption here, according to Ong is that therapeutic advancements that have been created based on experimentation on diverse bodies (in terms of ethnorace, genetics and complications) in Singapore are scalable to other populations in Asia and in Asian diasporas [18].
The DTF report goes on to enumerate the value of the diabetes problem at a global and regional scale. The type 2 diabetes market was set to triple in value from US$17.4 billion in 2013 to US$ 45.3 billion in 2022 [19]. The report was also very specific about the area of the market in which Singapore should capitalize: microvascular complications of diabetes. These are essentially complications that arise from high blood sugar, such as retinopathy (vision loss), nephropathy (end stage renal disease or ESRD and chronic kidney disease or CKD) and neuropathy (nerve damage). The report again highlights that the market for diabetes-related CKD/ESRD is expected to grow rapidly, owing to the projected increase in T2D prevalence and the very high cost of treating CKD/ESRD.
The economic rationale behind this national science initiative relies heavily on the potential successes of the biomedical industry, particularly in developing solutions for the problem of diabetes in Asian bodies. Kausik Sunder Rajan terms this fusion between the biosciences and economics ‘biocapital’ [20], an iteration of capitalism that relies on linking notions of value with bioscientific promissory narratives and imagined futures such as those presented in the DTF report. Ironically, this system banks on the continued growth of type 2 diabetes within the Asian continent and in Asian diasporic populations; only in such a future can Singapore capitalize on a ‘market-in-waiting’, to paraphrase sociologists Stefan Timmermans and Mara Buchbinder.[21]
Undone science and beyond
So, what makes a public health crisis? Is it deaths? Is it the burden of disease on the public health system and economy? Is it the promise of value for the national economy? Diabetes as a population health problem did not necessarily exist out there to be discovered.[22] Facts that are seen as immutable and ‘hard’ scientific truths are ‘yoked together’ with other technologies, practices, ideas, expertise, actors and institutions to enable a coherent, stable and importantly, convincing narrative of crisis.[23]
The way in which a public health issue is framed has very real implications on the modes of intervention. For one, it sets very clear boundaries on the type of research that needs to be mobilized to tackle the problem[24] An ethnoracial (Asian and its constitutive categories) framing of public health tends to require individualized, behavioral solutions that includes adjustments to ‘ethnic’ diet and taste. Likewise, an economically driven public health program that banks on biomedical innovation focuses on the development of treatments such as drugs or other consumables with massive markets.[25][26] These obscure social determinants of health that structure health harming behaviors and risk: employment status, access to recreational time and space, food environment, built environment, and poverty to name a few.[27][28]
Paying attention to social determinants of health would require a recalibration of the public health and bioscientific machinery to address the aforementioned factors. Such a move is not only potentially politically charged, but may not present the ‘dual-use’ scenario that come with the coupling of a diabetic, diverse population with potential economic value. It could be argued then that the economizing of diabetes fosters a gap in knowledge regarding the broader causes of diabetes, thereby foreclosing research related to that gap. In his piece on the sociology of ignorance or agnotology, David Hess discusses ‘undone science’[29], a concept proposed by Scott Frickel and colleagues[30] to understand how neoliberal governments and corporations influence research agendas to benefit powerful actors and institutions, rather than the public. In the context of Singapore, undone science minimizes attention on the social determinants of health in the war on diabetes.
This essay has tried to bring unmade and undone knowledges to the fore, and spark conversations regarding the broad implications of policy on medical categories, definitions and of course, the very subjects of public health. Public health measures don’t just reflect medical and epidemiological concerns. They also offer insight into priorities and interests that shape governance, policies, and importantly, the relationship between politics, science and medicine. Next time you, the reader, encounters a public health message in Singapore or wherever, take a beat and ask ‘why (insert disease)?’ The point of asking this is not to discount the gravity of the public health issue in question. Quite the contrary. Casting a critical lens on why certain diseases are prioritized over others could help us see resulting imbalances in the way the disease is researched, discussed, and dealt with.
– Mohammad Khamsya Bin Khidzer is Lecturer in Medicine, Health and Society at King’s College London. This essay is based on a chapter for a book manuscript being prepared by the author.
Notes
[1] From the oral history interview of Dr Emmanuel, Shanta Christina (Accession No. 004513, Track No. 9), Oral History Centre, National Archives of Singapore
[2] Salma Khalik, “SGH’s Lapses Led to Hepatitis C Outbreak Earlier This Year: Independent Review Committee,” The Straits Times, January 19, 2016.
[3] “National Day Rally 2017,” August 20, 2017, YouTube, https://www.youtube.com/watch?v=oz46MbfBZvI&t=2555s.
[4] The burden of disease is calculated using DALY, or disability-adjusted life year. One DALY represents a loss of one year of full health. The DALY statistic for a disease or health condition ‘are the sum of years of life lost due to premature mortality (YLLs) and years of healthy life lost due to disability (YLDs) due to prevalent cases of the disease or health condition in a population’. (Disability-Adjusted Life Years World Health Organization). The mortality rate for diabetes in Singapore is not readily available, possibly because diabetes might also be an underlying or co-contributor for mortality, alongside other health conditions. However, DALY figures from the Singapore Burden of Disease report indicate that changes in life expectancy at birth (which are affected by changes in Singaporean mortality rates for specific diseases) are higher for cancers, cardiovascular diseases and substance use disorders than they are for diabetes and kidney diseases.
[5] “Disease Burden,” Ministry of Health, May 31 2019, https://www.moh.gov.sg/resources-statistics/singapore-health-facts/disease-burden.
[6] Salma Khalik, “Study: Cost of Diabetes to Singapore to Soar beyond $2.5b,” The Straits Times, April 13, 2016.
[7] “Hypertension,” World Health Organization, March 16, 2023, https://www.who.int/news-room/fact-sheets/detail/hypertension.
[8] “Prevention and Treatment of High Cholesterol (Hyperlipidaemia),” American Heart Association, last modified February 19 2024, https://www.heart.org/en/health-topics/cholesterol/prevention-and-treatment-of-high-cholesterol-hyperlipidemia
[9] University of Washington, and Ministry of Health Singapore, Rep. “The Burden of Disease in Singapore, 1990–2017: An Overview of the Global Burden of Disease Study 2017 Results,” Institute for Health Metrics and Evaluation, Seattle, Washington, 2019.
[10] “Global health estimates: Leading causes of DALYs,” World Health Organization, https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/global-health-estimates-leading-causes-of-dalys
[11] University of Washington, and Ministry of Health Singapore, Rep. “The Burden of Disease in Singapore, 1990–2017: An Overview of the Global Burden of Disease Study 2017 Results,” Institute for Health Metrics and Evaluation, Seattle, Washington, 2019: 57-8.
[12] Ibid: 23
[13] Ibid: 30
[14] Thomas Coffman, James Best, Yap Seng Chong, Melvin Yeow, Weiping Han, Christiani Jeya Henry, Ralph Graichen, et al., Rep. “Diabetes Taskforce Report,” National Medical Research Council, Singapore, 2015.
[15] Ibid: 3
[16] Catherine Waldby, “Singapore Biopolis: Bare Life in the City-state,” East Asian Science, Technology and Society: An International Journal 3, no. 2-3 (2009).
[17] Aihwa Ong, “Why Singapore Trumps Iceland: Gathering Genes in the Wild,” Journal of Cultural Economy 8, no. 3 (2015).
[18] Aihwa Ong, Fungible life: Experiment in the Asian City of Life (Duke University Press, 2016).
[19] Thomas Coffman, James Best, Yap Seng Chong, Melvin Yeow, Weiping Han, Christiani Jeya Henry, Ralph Graichen, et al., Rep. “Diabetes Taskforce Report,” National Medical Research Council, Singapore, 2015: 3.
[20] Kaushik Sunder Rajan, Biocapital: The Constitution of Postgenomic Life (Duke University Press, 2006).
[21] Stefan Timmermans and Mara Buchbinder, “Patients-in-waiting: Living Between Sickness and Health in the Genomics era,” Journal of Health and Social Behavior 51, no. 4 (2010).
[22] Bruno Latour. “Give me a laboratory and I will raise the world,” in Science Observed: Perspectives on the Social Study of Science, ed. Karin D. Knorr Cetina and Michael Mulkay (Sage Publications,1983): 147.
[23] Andrew Abbott, The System of Professions: An Essay on the Division of Expert Labor (University of Chicago press, 2014): 868
[24]Irving Kenneth Zola. “Medicine as an Institution of Social Control.” The Sociological Review 20, no. 4 (1972).
[25] Joseph Dumit, Drugs for Life: How Pharmaceutical Companies Define our Health (Duke University Press, 2012).
[26] Jeremy A. Greene, Prescribing by Numbers: Drugs and the Definition of Disease (JHU Press, 2007).
[27] Claire R. Williams and Barbara Buttfield. “Beyond Individualized Approaches to Diabetes Type 2,” Sociology Compass 10, no. 6 (2016).
[28] Nicole R. Den Braver, Jeroen Lakerveld, Femke Rutters, L. J. Schoonmade, Johannes Brug, and J. W. J. Beulens. “Built Environmental Characteristics and Diabetes: A Systematic Review and Meta-analysis,” BMC Medicine 16, no. 1 (2018).
[29] David J. Hess, “The Sociology of Ignorance and Post‐truth Politics,” Sociological Forum 35, no. 1 (2020).
[30] Scott Frickel, Sahra Gibbon, Jeff Howard, Joanna Kempner, Gwen Ottinger, and David J. Hess, “Undone science: Charting Social Movement and Civil Society Challenges to Research Agenda Setting,” Science, Technology, & Human Values 35, no. 4 (2010).
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