"Live Long, Live Well, With
Peace of Mind"
Live Long
Last week, I spent some
time in the Japanese island of Okinawa. It has a population of 1.4
million, largely concentrated in the capital city of Naha. But it
also has a significant rural sector population spread over 40 small
towns and villages. I visited one such village called Ogimi
(“大宜味村”). It has 3,500 villagers. Accompanied by the village
Mayor, I participated in the village life and absorbed the
villagers’ attitude towards life and death. They have much to teach
us.
The Ogimi village has a
reputation as “the village of long life”. It has the highest number
of centenarians, adjusted for population, in Japan and most
probably, in the world. Out of a village of 3,500, 1,050 are above
65 and 100 above 90. Among them, 16 are above 100: 1 man and 15
women. I have not spoken to so many centenarians on the same day.
Okinawa has 740
centenarians, making it the highest ranking prefecture in Japan for
longevity. In comparison, Singapore has over 500 centenarians but
out of a much larger population of 4.5 million. What is
particularly impressive about Okinawa and Ogimi is that 80% of their
elderly live independently, requiring no hospital or nursing home
care. They manage quite nicely on their own, with support from
family and community and in close communication with those around
them.
Secret of
Longevity
I visited Ogimi not to
seek the secret of longevity. But a local University academic who
has studied this subject and observed the villagers for years
briefed me on his research findings. I suppose there is no harm in
sharing his conclusions. As genetic factors are beyond our control,
his briefing focussed on non-genetic factors, of which there are
many. But he singled out three important factors which help explain
the villagers’ longevity.
First, their traditional
diet: they eat more pork, more tofu (bean curd), more dark green
vegetables and more seaweed than other Japanese. And their salt
(sodium) intake is low, about half of Japan’s national average and
many times lower than the Western countries.
Second, they are
physically active. They exercise a lot and keep active all their
lives. They work for as long as there is work available. It is
common to see some of the villagers continue to work into their 70s
and 80s, even in laborious work such as farming and weaving. I
visited Toshiko Taira who runs a cottage industry of about 20
workers, weaving banana fibres into art pieces, textile materials
and expensive kimono threads. She is 87, with excellent hearing and
dexterity. She tried to teach me how to tie the fibres into a
continuous thread, without revealing any knot. While I am proud of
my eyesight, it was no match compared to hers and I failed in my
task. She has the status of a Living National Treasure in “kijoka
bashofu” (banana fibre weaving) and is well respected among
Japanese. Even when work is not available, they are committed to an
active social life, in senior citizens’ clubs, village events and
volunteer activities. They meet friends often and very few isolate
themselves at home.
Third, their active
daily life in turn benefits their sleep at night. They sleep easily
and while they do not sleep long, they sleep soundly with little
interruptions.
Live Well
So this is the Ogimi
secret to longevity: a healthy diet, an active life and good quality
sleep. I had several longevity meals and I also joined the
villagers in their activities, of which there were many: folk
dancing, singing, socialising or simply helping one another. The
elderly are fiercely independent and are proud of their
independence. The oldest woman is 106 and lives with her daughter
who is 80. Although recently wheel-chair bound, that does not stop
her from coming to the community centre to observe the village
dancing and simply to socialise.
Given their diet and
regular activity, the prevalence of diabetes and cardiovascular
diseases is way below their national average. Osteoporosis is also
less of a problem, with the incidence of hip fractures at half of
the US rate. Unlike most elderly villagers in other parts of the
world, the old folks in Ogimi walk with straight backs. I did not
meet any hunch-backed residents. This is not the result of
medications or health supplements, but sheer simple and healthy diet
with plenty of vegetables and physical activities.
We talked about the
younger generation. They lamented the erosion of traditional
village lifestyles and worried a lot about the bad influence of fast
food. They prefer their “slow food” tradition - prepared from fresh
ingredients and cooked slowly to carefully remove the animal fat.
They also practise “hara hachi bu”: eating moderately and only to
80% full. The other 20%, they believe, will only go to enrich the
doctors. We did not meet any who were obese.
Ogimi is, of course, not
entirely a bed of roses. Among the 16 centenarians, 3 are
bed-ridden, including the oldest man who, at 108, also suffers from
dementia. I visited several nursing homes where the bed-ridden
elderly were being served. Just like in some of our nursing homes
here, many of the elderly seemed unaware of what was going on around
them. The difference is that their residents are one generation
older. We met many grand parents in their 80’s but still fit,
looking after the bed-ridden great-grand parents. The parents who
form the third generation are however missing, having to work in the
cities. The children who could form the fourth generation are few
in number, if any, as Japan is facing a rapidly declining birth
rate. As a result, village schools are progressively being closed
and existing schools are struggling with very low enrolment and tiny
class size.
Good Death
Okinawa reflects the
extreme end of a society dealing with advanced ageing. But the rest
of Japan is heading in that direction. In Tokyo, I had a
substantial discussion with the Health Ministry on a range of ageing
issues, including the morbid topic of where people died. They noted
that soon after WWII, 85% of Japanese died at home, with the
remaining 15% in hospitals. They lamented that the reverse is now
true. This is despite regular surveys pointing to the elderly
patients’ preference to die at home.
The Japanese are not
unique. Last month, NHS London released its review report on
“Healthcare for London: A Framework for Action”. It devoted a
section to end-of-life care and lamented the lack of discussion in
society about “what constitutes a “good death””. It observed that
“most people are dying in hospital when they would rather die at
home”. It added that repeated surveys of the general public have
shown that the first preference for most people would be to die at
home. In practice, only 20% of deaths in London occurred at home,
with 66% occurring in hospitals.
We have not done such a
survey in Singapore, but I will be surprised if Singaporeans are any
different from the Japanese or the Londoners. After a full and
meaningful life, I certainly wish to die at home, among my loved
ones, in familiar and peaceful surroundings.
We have done a study of
where Singaporeans died, mostly (55%) in acute hospitals. 28% died
at home but I suspect many more would prefer that too.
Meeting
Preference
Why is the modern
healthcare system failing in meeting the preference of the dying? I
think this is a subject worthy of a study. I believe we should try
to facilitate dying at home for the terminally ill if this is their
preference. The London report recommends creating a register to
elicit and record patients’ preferences on where to die. Perhaps we
should study this aspect too.
While dying in hospitals
is natural for fatalities due to accidents, heart attacks and other
unforeseen events, the terminally ill have time to prepare for their
final moments and express their preferences. The families and the
healthcare workers should strive to meet their final wishes. My
Ministry will study this subject in greater detail and identify the
obstacles and gaps. If need be, we shall change the rules and
processes that currently hinder dying at home.
But there have been
cases of the terminally ill living out their final phase of life at
home. Let me mention one. Mr Samsudin bin Mohammad Ismail was
terminally ill with kidney cancer. He decided that he would want to
die at home. His family members prepared themselves by going
through care-giver training. Supported by palliative home care
provided by Dover Park Hospice, his loved ones were able to render
quality care to him at home. Mr Samsudin lived out his final months
in dignity and with fortitude. He passed away peacefully two months
ago, surrounded by familiar surroundings and warmed by familiar
faces.
Home hospice care was
critical in meeting Mr Samsudin’s final aspiration. However, for
many elderly Singaporeans, hospices still carry a stigma. Perhaps,
this is a legacy of the “death houses” at Sago Lane which in the
1950s were where the destitute and the sick went to die. It was a
pitiful way to go – alone, in fear, and more often than not, in
squalor.
Rendering Peace
of Mind
Our hospice movement has
come a long way since. It affirms life and regards dying as a
normal process. It neither hastens nor postpones death. It
provides personalised services so that patients and families can
attain the necessary preparation for a death that is satisfactory to
them. We have much to thank the pioneers for their untiring
efforts. Let me single out two outstanding individuals: Dr Seet Ai
Mee and Prof Cynthia Goh. They were and remain passionate about the
cause and have inspired many to join the movement. Many are in the
audience today. Thank you for your dedication and hard work in
service of this worthy cause. My Ministry will work with you to
make hospice and home palliative care an important part of our
healthcare delivery system.
First, we will support
and grow palliative medicine as an attractive and effective medical
sub-specialty.
Second, we will extend
palliative care and its benefits beyond oncology to other
terminal-stage chronic conditions, such as chronic obstructive lung
disease (COLD) and heart failure.
Third, we will ramp up
other manpower to support the growing demand. This is a labour and
skill-intensive service. We need to train many more nurses,
counsellors, medical social workers and therapists. We need to
support them with long term career paths and meaningful salary
schemes to attract and retain them.
Fourth, we will do more
to educate the public on hospice and end-of-life care. Death remains
a taboo subject and most people avoid talking about it. There was a
time when death was an integral part of family life. People died at
home, surrounded by their loved ones. Family members experienced
death together, mourned together and comforted one another. My
grandmother died of old age at home. She had never been
hospitalised and hospital was the last place she would want to be to
draw her last breath. My mother died of ovarian cancer at home; we
were all with her to bid our final farewell. She had been in and
out of hospital for her surgery and chemotherapy and when the end
was near, we knew that she would want to die at home. In a way,
modern healthcare has made dying a lonelier process as more people
die in hospitals. Their loved ones have less opportunity to be with
them and often miss their last moments of life.
Let’s Talk About Death
While death is a
difficult subject to discuss among adults, it is even more difficult
to broach with youngsters. Unfortunately, some children do not get
to live long. In such case, all the more we hope that they can live
well for the time that they live and that they can die free of pain,
discomfort and in peace. If we are to help them deal with death, we
must let them know that it is alright to talk about it. Talk does
not solve all problems but without talk, we are even more limited in
our ability to help them cope. In any case, not talking about it
does not mean we are not communicating. Children are great
observers; they read our facial expression and our body language.
Helping the young
terminally ill therefore requires special skills and sensitivity.
Often the patient’s condition deteriorates over several years,
placing enormous strain on the family. While family members
willingly invest their love, energy and devotion into the care of
the child, they can and do become exhausted. Meanwhile, the healthy
siblings can feel left out. With proper training and support, we
can help the patients cope with their final phase of life.
Let me share with you
the brave story of Adam Kamaruddin, a 7-year old leukaemia patient.
After multiple rounds of chemotherapy and having exhausted the
limits of medical science, Adam’s last wish was to die at home. The
KK Paediatric Palliative Care team cared for Adam at his home, while
supporting and guiding his family through the difficult period.
Last year, Adam passed away peacefully at home. His last wish was
fulfilled.
End-of-life issues are
deeply emotional. But at the Ogimi village, I did not find the
villagers squeamish when talking about it. They laughed and joked
about it. They realise that treating death as taboo does a
disservice to both the dying and the living, adding to loneliness,
anxiety and stress for all. They are grateful for a healthy life
and pray for a good, dignified and discreet death, a “pokkuri”
moment.
It takes humility to
acknowledge that medical science, however advanced, has its limits.
For the most vulnerable group of patients at the close of their
lives, for whom curable treatment is no longer an option -- their
last moments matter. We must use the art and science of medicine to
help them and their families find comfort and meaning in the last
phase of their lives.
“Live long, live well
and with peace of mind”. This is my Ministry’s motto. Working
together, we can help most Singaporeans realise this goal. I wish
you a fruitful congress. Thank you.
A healthy life and a good, dignified
and discreet death
All rights reserved
