Tuesday, 12 August 2008

OPQ 21 July 2008: Sudden Deaths of National Servicemen

I filed this question primarily because of a burning sense of inequity, at how NS is compulsory for all, and yet certain tests that are acknowledged as being "useful" are essentially the reserve of the privileged few only. I know full well that when I was at the age of enlisting for NS, my family would not have been able to afford these "useful" tests for me.

While it does seem that the SAF's tests are at least adequate for testing NS enlistees on a mass scale, and certainly the numbers appear to bear out its approach which is comforting, it remains a little difficult to shake off this sense of inequity. This is especially so if doctors are sending their own children for these additional tests. The Italian study I referred to also suggests that medical opinion may evolve further on this issue.

(Outcome of investigations)

16. Ms Indranee Rajah asked the Minister for Defence (a) what is the outcome of his Ministry's investigations into the sudden deaths of Recruit Andrew Cheah Wei Siong and Second Lieutenant Clifton Lam Jia Hao; and (b) whether the investigations indicate the need for any consequential action to be taken by the SAF, such as more stringent or different pre-enlistment medical screening.

17. Mr Siew Kum Hong asked the Minister for Defence (a) how many cases of sudden cardiac deaths have occurred in the Singapore Armed Forces since 1965; (b) of these, how many have occurred amongst Full-time National Servicemen (NSFs) and how many may have potentially been detected through the use of exercise ECGs or echocardiograms; and (c) whether the Ministry intends to introduce additional screening for NSFs such as exercise ECGs or echocardiograms.

The Minister for Defence (Mr Teo Chee Hean): Mr Speaker, Sir, as Question Nos 16 and 17 by Ms Indranee Rajah and Mr Siew Kum Hong are closely related, may I have your permission to address them together?

Mr Speaker: Yes.

Mr Teo Chee Hean: Mr Speaker, Sir, I would like to express my heartfelt condolences to the families of the late 2LT Clifton Lam Jia Hao and the late REC Andrew Cheah Wei Siong.

MINDEF treats every death of a serviceman with utmost seriousness. For each case, we conduct a thorough investigation to determine the cause and also to enable us to take all necessary preventive measures in the future. MINDEF has convened two separate inquiries to investigate the deaths of the two servicemen. As the investigation process has yet to be completed, it would not be appropriate for me to comment on their outcomes at this point in time.

Ms Indranee Rajah asked about the need for any consequential actions to be adopted by the SAF. Sir, the SAF did not wait for the outcome of the investigations but, in fact, took immediate action by imposing a three-day time-out for all physical and endurance training to review their systems, processes and procedures. The review provided an opportunity for units to confirm that the systems are good and sound, and that proper processes and procedures are in place and are being followed. The time-out allowed both commanders and soldiers themselves to refocus on safety.

Ms Indranee Rajah and Mr Siew Kum Hong asked about medical screening in the SAF. I should first say that it would be premature to draw conclusions about whether medical conditions that might have been detected in pre-enlistment medical screening were factors in the incidents, as the investigation process has not yet been concluded. Nevertheless, since there has been quite a lot of interest in the medical screening processes of the SAF, let me take the opportunity to describe these processes.

The SAF carries out medical screening of our servicemen carefully. Medical screening takes place at several key junctures: before enlistment, before attending specialised courses, before strenuous training or deployment and, periodically, after the age of 25.

The screening is comprehensive. There are 14 medical speciality areas, including eyesight, hearing, cardiovascular, muscular-skeletal conditions. Let me take the screening for cardiac conditions as an example. A 12-lead resting electrocardiogram (ECG) screening is conducted for all pre-enlistees, and the SAF has 28 different protocols to address the different cardiac conditions based on these ECG findings. If abnormalities are found, the pre-enlistees will be sent for additional testing, which may include the stress ECG test or the 2D echo-cardiogram and referral to a cardiologist.

The 12-lead resting ECG screening was introduced in November 2000 on the recommendation by the SAF's panel of medical experts. The panel of medical experts concluded that the findings of a study published in 1998 on the screening of competitive athletes in Italy were appropriate for the SAF and ought to be adopted by the SAF. The comprehensive study showed that resting ECG was a reliable tool for screening for Hypertrophic Cardiomyopathy (HCM), which is one of the more common causes of sudden cardiac death among young adults. HCM is a disease of the heart muscle in which a portion of the muscle is thickened.

Sir, the introduction of this 12-lead resting ECG screening is an example of how the SAF keeps up with the best and most appropriate screening practices. The SAF is guided by an independent panel consisting of top medical consultants and specialists in Singapore that sits regularly to review the entire medical screening regime. In a recent review concluded last September, the SAF medical screening protocols were found to be comprehensive, robust and in line with good clinical practice. In fact, the SAF's routine screening for heart disease in pre-enlistees is equivalent to the standards recommended by the European Society of Cardiology and International Olympic Committee, and higher than the standards recommended by the American Heart Association. The SAF's screening protocols are also more comprehensive than those used by many other established armed forces.

Mr Siew Kum Hong asked for figures on sudden cardiac deaths (SCD) in the SAF since 1965, and how many of these were Full-time National Servicemen (NSFs). Sir, I am unable to give the figures since 1965, but I am able to provide the figures from 1995. Specific data on SCD for the years before 1995 was not systematically collected, as SCD itself, in young adults then, was not a well understood phenomenon in the medical community. The figures for 1995 to 2008 show that there were a total of 23 SCD cases in the SAF. Seven of them were of Full-time National Servicemen (NSFs), three of which occurred during training.

Mr Siew also asked whether any of these could have been detected by exercise ECGs or echocardiograms, and whether the SAF was going to introduce additional screening such as these. Of the seven NSFs who died from SCD both during training and not during training, six were due to conditions that were most unlikely to be picked up by exercise ECGs or echocardiograms. This is what the doctors have told me. The remaining one had a condition that could have been detected by exercise ECGs or echocardiograms. This death occurred in 1999, a year before the SAF began conducting ECG screening for pre-enlistees. His condition could have been picked up by the 12-lead resting ECG that was introduced in 2000, and this pick-up would have led to him being referred to a cardiologist and subjected to an exercise ECG or echocardiogram.

Sir, MINDEF will continue to review our medical screening procedures, and amend the protocols or adopt new procedures should the SAF's panel of medical experts advise that it is appropriate to do so.

Mr Siew Kum Hong: Sir, I would like to thank the Minister for his comprehensive reply, which I think would have given Singaporeans some comfort. Nevertheless, I have three supplementary questions for the Minister.

Firstly, the Minister has said separately that additional screening in the form of the exercise ECGs or echocardiograms is "helpful". If that is the case, then why is this "helpful" screening not made available to NSFs who serve the nation by performing National Service and so the nation should serve them by taking all the measures that are helpful, instead of leaving it only for those who can afford to pay for these additional testing.

My second question, Sir, is that the Minister has said that MINDEF has a panel of leading doctors who say that the existing tests are sufficient but a cardiologist in private practice has publicly stated that many of his colleagues who agree with this publicly, nevertheless, send their own children for additional screening. Can the Minister then confirm whether this panel of leading doctors send their own children who are required to serve NS for additional tests?

My third question, Sir, is that a recently published study by the Institute of Sports Medicine in Florence, Italy, tested over 30,000 people including 23,500 men, using both resting ECG and exercise ECG. The resting ECG test found a previously undetected heart anomaly in 1.2 % of those screened. This rose to 4.9% for the exercise ECG. In light of this study, does the Ministry still stand by its decision not to introduce additional screening for NSFs?

Mr Teo Chee Hean: Sir, I think that if the individuals or parents want to go for additional medical screening and tests, that is entirely their right to do so and they may do so if they wish to. But whether they do so or not, I think that they and their parents should be assured that when they come for National Service at the pre-enlistment stage, the SAF will give them a comprehensive medical screening whether they have gone for one themselves or not. So that is our commitment, and that is important. The medical screening protocols are audited and recommended by the SAF medical panel of specialists. There are about 50 of them covering 14 medical specialities and areas. I can only go by what they recommend to us and if there are doctors, individuals who feel that there are practices supported by good evidence and research which will be helpful for SAF servicemen, we will be happy to receive such research reports and reviews supported by good evidence. The medical panel will be happy to consider them and if they are appropriate for application in the SAF, we will be happy to do so. I would invite Mr Siew or doctors in public or private practice or individuals who have such information, who feel that it is relevant to us, to please do so and send it to us. But I do assure the public and parents that the SAF medical panel itself does comprehensive literature searches, they are experts in their field, and they do look out for the best practices available. The example I gave was that of a study that was concluded in 1998. The panel looked at it very quickly after the study was completed, found that it was a study which was useful and valid to us, and we brought it into effect by the year 2000. And we will be happy to receive any other studies or information which the panel may, by some chance, have missed.