Some Lessons in Singapore

I stopped in Singapore while transitioning between Indonesia and Viet Nam. There were a couple of HHS investments I needed to see.

First of all, Singapore took me by surprise. It is beautiful. You would think you were in southern California—climate, quality of infrastructure, construction, etc. It is well run and on a roll of success. I’ve heard this for years, but seeing was believing, for me.

A conversation I had with the Health Minister Khaw Boon Wan had several interesting aspects to it. In some ways Minister Khaw is typical of the policies that have made Singapore a success. He grew up in Malaysia but accepted a grant from the Singaporean Government to study in Australia. The grant had what he described as an 8 year bond. It was an obligation to work in Singapore for that period after they paid for his education. Singapore became his home.

Health Minister Khaw Boon Wan of Singapore

Because the country is so small and has few natural resources, they have mined talent internationally. The Minister is an example of their investments paying off.

I want to mention three topics we discussed that I will be thinking more about. The first is the importance of a population continuing to grow.

The Singaporean Government identified many years ago that their population growth rates were beginning to fall. Intuitively they understand that if a nation’s population growth falls below replacement, it will, under normal circumstances, create serious problems in the future. They have been working to increase their birth rate now for nearly 20 years, with little success.

I asked the Minister what Singapore had learned from the millions they have spent researching and trying different policies. He said they had done mountains of demographic research and tried many different incentives including direct tax subsidies amounting to as much as $20,000 for couples producing a child. They have produced disappointing results. Direct financial subsidies he said are, “like pushing a string.”

Interestingly enough, many other nations provide the subsidies but the results seem to have far more to do with other factors. Australia pays $2,500 (his estimate) and has seen a resurgence in birth rate. He thinks there is simply a different attitude among nations with lots of space. He pointed to super cities like Hong Kong and Tokyo and that they have low birth rates.

The Singaporeans have concluded a series of sociologic changes have clearly contributed to their dilemma. Woman desiring careers, couples deferring the age of marriage, and a de-emphasis on marriage were other points he raised. Our conversation came on a day I had just received a brief on a CDC report indicating that in 2006, 38.5% of all births in the United States were to unmarried mothers. The Minister’s main point was that married couples have more children and foster them more successfully than unmarried parents.

Singapore is pursuing policies that work to develop three things: supportive employers, supporting families, and Government policies that are family-friendly. I took that to mean encouraging marriage. They are also working to increase the percentage of births from successful in vitro fertilization. They have found some European countries, such as Denmark, have as many as 6-7% of births from this method. Singapore has only 1% of their births from successful in vitro fertilization. Even science can play a role, he pointed out.

When I was Governor, I started a Marriage Commission to encourage the practice of marriage and to strengthen existing marriages. It was the first in the country and it was criticized by some. Others have since followed and it has become more common for governments to recognize what a hugely important issue this is.

I have spent time looking at the long-term problems faced by cultures that have limited family size. Japan is deeply worried about its population trend. China has also begun to deal with the impact of their “one child” policy.

In the United States, our population figures are just slightly over replacement. Frankly, if it weren’t for the increase of immigrants, we would be in the same spot as many European countries, facing negative growth.

If you think that sounds like a positive thing, I would recommend two things. First read Will and Arial Durant’s book, The Lessons of History. After studying every major civilization in a 5000 year period they concluded societies that fail to grow, fail to survive. The second thing I would recommend is looking at the Medicare program to which our nation is obligated. Today there are four workers to pay the health care benefits of each senior. In 20 years, because of lower birth rates, there will be two workers for every person on Medicare. Add social security to that mix and a declining birthrate becomes a rather serious problem.

Demographics are destiny.

Comments

Mike - I have done some work overseas in the area of medical tourism. Singapore consistently comes up in the literature as a destination. When I started my work it was unheard of that insurers in the U.S. would contract with overseas hospitals but now you have Blue's such as in South Carolina doing just that. Would the government ever think of off-shoring health care programs such as Medicare to give people choice and reduce costs? Thanks, Anthony Cirillo, FACHE

Posted by: Anthony Cirillo | April 22, 2008 at 11:33 AM

Sorry sir, but you're going to have to rethink your mindset on what constitutes sustainable population in the US. More is not better; we're well past the break-even point in per capita unit basic social services costs. What will have to change is the concept of retirement entitlements. Federal and State governments will also have to push and prod our population into responsible behavior of fiscal, social, physical and mental health practices.

Could you please comment on the PLoS Medicine article published today on life expectancy trends in the US?

Posted by: Oracle | April 22, 2008 at 01:24 PM

Dr. Leavitt,

There is a diary on the Flu Wiki about impact on Social Security and future populations when so many young could die in a pandemic (source: http://www.newfluwiki2.com/showDiary.do?diaryId=2053)

While I agree with you, how do we balance food and population growth? Hopefully the US will grow as fast, or faster from current families than immigration or the growing illegal immigration.

Regards,
Kobie

Posted by: Kobie | April 23, 2008 at 03:02 PM

Belieing Singapore's success story exist dynamics which rarely come to light in the United States.

While the country shares the same capitalist ethics as does the U.S.- i.e.,valuing higher education, hard work and investment, there are some important differences between the two societies.

Singapore is a one party state. Though it holds elections, it can hardly be called a democracy. Also, it freely traffics in blatant discriminatory practices as per some of its immigrant population. Household "servants" which constitute a significant bulk of those immigrants are treated as second class citizens, and are afforded few rights. The related horror stories are freely available for anyone who has the desire to do the research.

Singapore has an "open market"- but is not an "open society." The country's political- and to some extent- its cultural life- is highly orchestrated. Political opposition to the controlling party requires bravery. Fear of police and government reprisal helps keep the people in their place. Slight infractions consequence harsh punishment and social ostracization. Singapore has executed more people through its legal system over the past few years than just about any country in the world.

So what does this have to say about "health?" In such a rich country with a regulated economy and culture, it seems good physical health can thrive- but freedom of expression itself is sacrificed.

Is that a price Singaporeans are willing to pay? You'd have to ask them, and ultimately it is their business.

Spiritual health is the issue now at hand. In spiritual terms, Singapore cannot rightfully be termed a healthy society. Rather, the atmosphere is oppressive, and the character of the people, repressed. I think many, many foreign travelers who visit the country would agree. The fact it is clean and even "beautiful" to the eye amounts to as much superficiality as it lends itself to positive substance.

Tauting Singapore's health system- and then by extension lauding its society as a whole- does not necessarily follow.

Posted by: John Merah | April 25, 2008 at 03:57 AM

What an interesting post. I am surprised to hear that 38.5% of births in the U.S. are to unmarried mothers! It makes sense that the number of births are declining in various countries; more women are becoming career focused and do not want children or even to get married. Is it really a surprise they our current generation has more problems with kids? Moms don't have time to raise their kids properly anymore. Many women think staying home and raising their children is old fashioned. Thanks for sharing information with readers of how demographics such as birth rates impact our society.

Posted by: Patricia Beck | July 22, 2008 at 01:17 AM