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Asthma in Singapore: Past, Present and Future.

The story of asthma in Singapore over the past 50 years mirrors the history of Singapore as it progressed from a third world to a first world country.1 In 1965, infectious diseases such as tuberculosis, diphtheria and cholera were the main challenges to public health as a consequence of poor sanitation, overcrowding and malnutrition. Asthma was not a priority. Patients often used traditional remedies ranging from herbs (Chinese, Jamu or Ayurvedic) to animal products to “cure” asthma. In 1971, a very unfortunate incident occurred. A 28year -old asthmatic died of arsenic poisoning from taking ‘Sin lak’ pills, a Chinese herbal remedy for asthma. Between 1972 to 1973, two astute clinicians, Drs Tay and Seah reported an outbreak of arsenic poisoning when they observed patients with skin hyperkeratosis and areas of hyperpigmentation associated with neurological involvement and skin malignancies, occurring in asthmatics taking ‘Sin Lak’.2 ‘Sin Lak’ was subsequently banned in Singapore, a measure that undoubtedly saved many lives. In that era, treatments for asthma were very diverse and included some that are no longer recommended. Private practitioners made home visits and tried to help patients with prescriptions of oral salbutamol, theophylline and steroids. Injections of subcutaneous adrenaline and intravenous aminophylline were commonly used for asthma attacks in hospitals. Inhaled corticosteroids, currently recognised as the most effective treatment for long-term control of asthma, became available in the late 1960s but were not widely accepted as the drug of choice, chiefly due to cost reasons. Asthma-related deaths were common then. Coordination transformed this landscape. The 1980s and 1990s saw the amalgamation of dispensaries and clinics into polyclinics, which provided mass vaccination, programmes to promote health and standardised availability of drugs. Inhaled corticosteroids became more widely used and asthma mortality and admission rates fell correspondingly.3 In 2001, the Singapore National Asthma Programme (SNAP) was launched to improve asthma control in the primary care by promoting treatment with inhaled corticosteroids