Friday, February 23, 2007

Foreign students in Singapore

A few days ago, the post Thoughts on Foreign Talent appeared on Mr Wang's blog. In the post, he questions the necessity of bringing in large numbers of foreign students from China/India/Vietnam/Malaysia, at taxpayers' expense, into Singapore and some guy in the comment section replies that it is part of the wooing of talent.

Let's pause for a moment, put on our thinking caps and think.

Finished? Okay. Do you think this makes sense? Heck no. Let me explain why. The basic assumption is that the opportunity cost of not bringing in these students will result in them not coming to Singapore in the first place and hence, cause some sort of talent deficit in Singapore. This is clearly wrong because:

1. The overwhelming majority of skilled foreign workers in Singapore are not educated in Singapore. Any deficit in 'talents' can be remedied by just giving out more employment passes.

2. When you poach graduates from China/India/Vietnam/Malaysia who have been educated in their home countries, you are effectively taking the educational subsidies spent by those countries i.e. obtaining a brain gain. On the other hand, when you take an unproven teenager from another country and bear the cost of his/her tertiary education, it becomes more of an increase in head count than a real brain gain. This benefit vanishes if he/she were to move to another country and contribute to the brain drain of Singapore. On the other hand, no such loss is incurred when China-trained engineers move from Singapore to the states.

Thursday, February 22, 2007

Solar power in Singapore

It seems rather strange to me that given the plenty of sunshine (12 hours of it everyday, 365 days a year) that Singapore receives that solar power use is so sparse. Of course, we have to bear in mind that land space in Singapore is rather limited, so it is impossible to have tracts of photovoltaic cell-covered solar farms in Singapore. Still, I do think that Singapore ought to take advantage of its plentiful sunshine. For example, when I was staying with my relatives in Shanghai some years back, I noticed that solar-heated water was used in many of the older apartment blocks. My uncle told me that they have been around since the 1980s and are pretty common.

This is simple technology that really ought to be used in Singapore. An electric water heater has a power rating of 600 to 1000 watts and is a significant component of the average household's electrical bills. One can easily imagine the kind of savings that the average household can have, especially those living in landed estates. Perhaps, these things can be mounted on the roofs of HDB blocks? Maybe. Anyway, I guess not too many people in tropical Singapore like to use hot water to bathe...

Also, photovoltaic technology is something that Singapore does have an advantage given its long-existing microelectronic industry. The science behind photovoltaic cells is very much similar to the science of semiconductors (mostly silicon wafers) - it's all about the control of electron transport in doped semiconductors. Furthermore, the standard of purity for photovoltaic cells is a little more relaxed. You don't need that clean a piece of silicon wafer to manufacture photovoltaic thin films. The problem in adopting photovoltaic technology is largely one of cost. Once a sufficiently cost-effective silicon-based method of manufacturing is found, I predict that solar power generation will take off. It's hard to imagine using more exotic materials for solar power generation given the vast amount of panels that have to be used in mass solar energy generation. If photovoltaic techonology is ever to be adopted en masse, common sense tells us that it has to be silicon wafer-based technology.

Even in Singapore where solar energy cannot be harvested on a large scale, we stand to gain by promoting silicon-based solar power generation given our existing microelectronic capabilities. Seriously, this is something Singapore ought to look into.

Monday, February 19, 2007

Good Engrish

For the duration of the Chinese New Year festivities, I shall take this opportunity to be an English pronunciation pedant.

The word 'abalone' is pronounced 'ae-buh-loh-nee', not 'ae-buh-lone' as many Singaporeans would pronounce it. The word 'lychee' is pronounced 'lee-chee', not 'lai-chee'.

And that's the memo.

Tuesday, February 13, 2007

Compassionately Logical: Part II

This is the second part to Compassionately Logical: Part I.

Regulated kidney trade in Iran

In all developed countries, most living kidney donors are family members or spouses of the recipient. Commercial transactions involving the trade of human kidneys are strictly illegal and there is no compensation of any kind to the donor. Hence, it is extremely rare to find altruistic unrelated kidney donors apart from those with very strong unconventional religious convictions like the Jesus Christians in Australia. Because the pool of potential donors is effectively restricted, there are long lists of ESRF patients waiting for an available kidney. In America, about 3500 people on the waiting list die before receiving a kidney while only 16500 kidney transplants were performed in 2005. In a system which only allows kidneys from cadavers and related living donors, it is quite unlikely that the number of available kidneys will increase significantly to cover the shortfall.

In contrast, in Iran, there is no waiting list for kidneys. This is because most transplanted kidneys are taken from living donors, the majority of whom are unrelated to the recipient. Iran has a regulated system in which people can trade their kidneys - the recipient and the regulatory agency compensate the donor for his/her kidneys. According to this article,
"There are no private agencies or middlemen involved in the process of organ donation in Iran and all volunteer donors present themselves to the National Association for the Support of ESRD Patients. The sale of organs is legally and ideologically forbidden, but the concept of compensated donation is accepted."
In Iran, the middleman is a non-profit charitable organization, called the Dialysis and Transplant Patients Association (DATPA), which refers the donor to state hospitals where experts screen the donor physically and psychologically to ensure that the health and welfare of the donor is not compromised by the operation. It arranges for potential sellers to meet potential buyers. The donor receives a sum of US$1200 from the DATPA as well as health insurance coverage from the government for donating his/her kidney. The donor also receives a monetary 'gift' from the recipient, the quantum of which is agreed on by the two transacting parties. For more details, please see this article on the Iranian model of paid and regulated living-unrelated kidney donation.

For emphasis, I like to repeat this: there is no middleman, no risk of getting hepatitis from the transplanted kidney or surgical complications (unlike in India where the medical screening is dodgy), no coercion, etc. The donors are counselled about the risk and assessed for suitability in terms of physical and psychological health. I should also mention that both the donor and the recipient have to Iranian nationals. For foreign patients, the donor has to have the same nationality as the recipient.

As for concerns that the scheme might exploit the poor, I quote from the article:
"All transplant candidates who are poor receive renal transplantation. The elimination of renal transplant waiting lists means that all patients with ESRD, either rich or poor, have equal access to renal transplant facilities; otherwise, many poor patients would remain on the renal transplant waiting list. The main reason for this equal access is the active role of charitable organizations that pay for many expenses of renal transplantation that the poor patients cannot afford. One of the arguments against paid kidney donation is that the kidney donors are almost poor and illiterate, whereas the majority of recipients are educated and wealthy. We previously conducted a study on 500 renal transplant recipients and their living-unrelated donors to determine which socioeconomic classes are receiving transplants more from paid kidney donors (16). All of these donors and recipients were grouped according to their level of education, which showed no significant differences. In this study, 6.0% of living-unrelated donors were illiterate, 24.4% had elementary school education, 63.3% had a high school education, and 6.3% had university training. Corresponding levels in their 500 recipients were 18.0, 20.0, 50.8, and 11.2%, respectively. Then they were grouped according to whether they were poor, rich, or middle class. The results showed that 84% of paid kidney donors were poor and 16% were middle class, and of their recipients, 50.4% were poor, 36.2% were middle class, and 13.4% were rich. So >50% of kidneys from paid donors were transplanted into patients from poor socioeconomic class. This finding is a clue against commercialism in the Iranian model renal transplant program."
Of course, the Iranian model is not without its problems. Again, I quote:
"Because the amount of governmental donor award (approximately $1200 USD) is not enough to satisfy the majority of kidney donors, recipients provide rewarding gifts to donors. If the recipient is poor, then the rewarding gift is provided by charitable organizations. This also results in directed paid kidney donation, meaning that the transplant candidate and the volunteering kidney donor meet each other in a DATPA meeting for arrangement of rewarded gifting to be paid to the donor after transplantation. Providing sufficient financial incentives and some social benefits to each living-unrelated donor by the government will eliminate rewarding gifts and will make the Iranian model a nondirected paid kidney donation program whereby the donors and the recipients will not see and know each other at least before transplantation. All transactions for financial incentives will be carried out by organ procurement organizations (OPO). The OPO will receive all governmental donor award budgets as well as all charitable donations. The donor will donate a kidney to the OPO and will receive all defined financial incentives from the OPO. Because of lack of administrative expertise in health authorities, this approach has not yet been tested in the Iranian kidney donation model.

Unfortunately, the financial incentives to kidney donors in the Iranian model neither has enough life-changing potential nor has enough long-term compensatory effect, resulting in long-term dissatisfaction of some donors. However, providing adequate financial incentives to kidney donors and awarding some social benefits to them will eliminate almost all long-term dissatisfaction. Some opponents have sensationalized that the majority of Iranian paid kidney donors have been poor and have remained poor after kidney donation. As mentioned, in the Iranian model of paid kidney donation, not only the majority of donors (84%) but also the majority of transplant recipients (50.4%) also are from poor socioeconomic class. This national program is not adopted to upgrade the socioeconomic class of kidney donors and is very different from commercial transplants that are carried out in other countries."
Kidney transplant in Singapore

In Singapore, like most developed countries in which only deceased and living-related donors are allowed, there is a long waiting list and the average waiting time for kidney is roughly 7 years, despite the 'opt-out' system (as legislated in The Human Organ Transplant Act or HOTA) currently in place. We should also bear in mind that, as mentioned before, the longer the patient spends on dialysis, the lower the effectiveness of the renal transplant. The Ministry of Health acknowledges here that donor availability is a problem. Actually, what it is implicitly saying is that we don't have enough living donors.

Possible paid kidney transplant system in Singapore

I could envisage a system in Singapore similar (but not identical) to the Iran model in which living-unrelated kidney donors are paid for donating their kidneys. No point in reinventing the wheel. Such a system would have the following features:
  1. A national regulatory body which screens potential donors physically and psychologically to assess their suitability for donating their kidneys. Potential donors are counselled about the risks.
  2. Donors are paid a fixed sum by the government, say $20000, as compensation for the risk and loss of personal time. The exact quantum can be worked out later. This money would come from the patient or from charitable organizations. If the patient cannot afford the full amount, then we can have in place some kind of financial assistance to help him/her pay. The idea is that everyone pays the same amount for a kidney so that the wealthy have no advantage over the poor. There is no need for the recipient to know whom the donor is.
  3. Priority in receiving the transplant is determined by the regulator body based on medical condition.
  4. The donor receives free health insurance coverage/additional medical benefits from the government in recognition of his contribution. The national regulatory body should maintain a high level of post-operative care and the health of the donor is to be monitored over 10 years. Again, the duration of post-surgery monitoring is not set in stone.
  5. The patient and the donor have to be Singaporeans.
I believe if we have such a system in place, donor availability will increase tremendously and the waiting list in Singapore will be eliminated.

Monday, February 12, 2007

Compassionately Logical: Part I

There are a couple of lively debates over organ trading, as suggested by an Assoc. Prof. Lee Wei Ling from the National Neuroscience Institute in a letter to the Straits Times forum, at the Kway Teow Man and nofearSingapore, where the majority of opinions have been against the sale of human organs. There seems to be some sort of instinctive revulsion towards the idea of trading human organs. The idea of regulated organ trade is fairly interesting and since I know next to nothing about the issue, so I decided to dig a little deeper. It turns out that there has been a flurry of discussion over the regulated trade of human organs.

Organ tranplant is a fairly complex issue so I decided to just look into kidney transplant since there seems to be much more information on it in general; also, there is some information on the regulated kidney trade in Iran which has been going on for some years. The following articles are quite informative, especially no. 7 to 10 which describe how the 'trade' in kidney transplants is managed in Iran.
  1. Iran's market in human organs which was published on Nov 16 in the US print edition of The Economist. Sorry, it is available online only to subscribers of and I don't want to violate copyrights on this website.
  2. Organ transplant? which was also published in the same issue of The Economist.
  3. Call to allow body organ selling, published in BBC online.
  4. Experts warn against organ trade, published in BBC online.
  5. What is a kidney worth? published in The Christian Science Monitor.
  6. Kidney market, anyone? by Tan Hui Leng, published on Nov 24 in Today.
  7. An organ is no different from a life-saving drug by Assoc. Prof. Lee Wei Ling, published on Feb 6 in the Straits Times forum. You can find the letter in the post by the Kway Teow Man.
  8. Renal transplantation from living related and unrelated donors by I.Fazel ,MD, FACS.
  9. Iranian Model of Paid and Regulated Living-Unrelated Kidney Donation, by Ahad J. Ghods, and Shekoufeh Savaj, published in Clin J Am Soc Nephrol 1: 1136-1145, 2006.
  10. About kidney transplants in Iran, by Firooz Fassihi M.D.
  11. Iran's desperate kidney traders, by Nima Sarvestani, published in BBC online.
  12. Iran kidney sale, published in BBC online.
  13. Organ sales 'thriving' in China, published in BBC online.
  14. Flesh trade, by Stephen J. Dubner and Steven D. Levitt, published in the N.Y.Times.
  15. Living kidney donor FAQ from the University of Maryland Medical Center.
  16. Living donor kidney donation from the University of Pittsburgh Medical Center.
  17. Living with one kidney from the National Kidney Foundation, Inc in the United States of America.
  18. Kidney transplant from Medline Plus.

With all due respect to Assoc. Prof. Lee, I will like to state that she did a rather poor job of selling the case for regulated human organ trade. Then again, the thrust of her letter was not that why we should have a regulated human organ trade but how we should approach the issue ("compassionately logical" in her own words).

What is a kidney?

It's more than an ingredient in kway chap, lah. According to the Wikipedia article on the kidneys,

In anatomy, the kidneys are bean-shaped excretory organs in vertebrates. Part of the urinary system, the kidneys filter wastes (such as urea) from the blood and excrete them, along with water, as urine. The medical field that studies the kidneys and diseases affecting the kidney is called nephrology, from the Ancient Greek name for kidney; the adjective meaning "kidney-related" is renal, from Latin.

In humans, the kidneys are located in the posterior part of the abdomen. There is one on each side of the spine; the right kidney sits just below the liver, the left below the diaphragm and adjacent to the spleen. Above each kidney is an adrenal gland (also called the suprarenal gland). The asymmetry within the abdominal cavity caused by the liver results in the right kidney being slightly lower than the left one.


In order not to bore people with the technical detail, our kidneys are our body's built-in sewage treatment plants which clean our blood, remove its waste and send it off as urine. In our daily lives, we produce a fairly large amount of metabolic waste and they are removed from our blood by our kidneys. Generally, the greater your muscle mass and the more protein you eat, the harder your kidneys have to work to remove the nitrogeneous waste.

Most humans have two kidneys (although it should be noted that 1 in 750 individuals is born with only one) which give us a high level of redundancy. Furthermore, modern humans generally have a far more sedentary lifestyle and consume less protein compared to our hunter-gatherer ancestors, which increases the level of redundancy. It must be noted that healthy kidneys can handle a very high level of nitrogeneous waste over prolonged periods; drug-free bodybuilders have a far higher level of muscle mass, exercise more and consume much more protein but don't have a higher incidence of renal failure than the general population. Also, there are no restrictions on healthy individuals with only one kidney from doing vigorous physical sports although they are usually advised not to take part in contact sports like rugby, football, boxing, etc since there is a chance that the kidney might get physically injured. They are more vulnerable to physical injury to the kidney since the one kidney usually grows bigger to deal with its increased workload.

On the other hand, if we are on medication - a benefit of modern civilization - our kidneys have to work harder to remove it from our blood and that is a problem that our hunter-gatherer ancestors didn't have. Having two kidneys in this case is an advantage in case you ingest something you're not suppose to. For example, in the rare case, some individuals can get renal failure from just ingesting aspirin.

Renal failure

There are many causes of renal failure. I am not a medical doctor and have the vaguest knowledge of nephrology. But in general, from what I know, renal failure can result from problems in your blood circulation (like getting hypotension), damage to your kidneys (like ingesting some kind of toxins or medication that you are allergic to) and/or problems with your urinary tract (e.g. kidney stones). If you are interested, see

There are several stages of renal failure, which progresses with the level of loss of function of your kidneys and increasing use of hemodialysis (aka dialysis). End-Stage Renal Failure (ESRF) is the term doctors use to mean that the kidneys are gone-case. At that stage, the patient has to be hooked up to a dialysis machine until he/she has a renal transplant. Hemodialysis is only a stop-gap measure and is also expensive. Very expensive if you have to keep having it non-stop. Once the patient has ESRF, he/she is put on a waiting list for renal transplant until he/she finds a suitable donor or dies. There are others who do not have ESRF but can receive a renal transplant provided that they have a willing donor (who is usually a family member). It should be noted that not everyone with ESRF gets to be on the waiting list. There are age limits and some health restrictions. Basically, the qualifying condition is that the transplant procedure will not endanger you and getting the transplant will significantly improve your chances of survival. The medical authorities do not see any point in giving a kidney to a 90 year-old individual with ESRF and terminal lung cancer.

Kidney transplant

There's a relevant Wikipedia article here. I am not going to reproduce the article here in any form but will mention a few points that I think are rather salient.
  1. Basically, there are two types of kidney donors - living and cadavers. In any case, donors and recipients are screened for compatibility before the operation. Studies seem to indicate that "overall, recipients of kidneys from live donors do exceedingly well in comparison to deceased donors".
  2. Transplant patients should be under 69 and have no other other conditions apart from kidney disease. Obviously, the recipient and the donor have to be evaluated to ensure that they are fit for surgery.
  3. "Some studies seem to suggest that the longer a patient is on dialysis before the transplant, the less time the kidney will last. It is not clear why this occurs, but it underscores the need for rapid referral to a transplant program. Ideally, a kidney transplant should take place before the patient starts on dialysis (pre-emptive.)"
  4. "Recent studies have indicated that kidney transplantation is a life-extending procedure. The typical patient will live 10-15 years longer with a kidney transplant than if they stay on dialysis. The years of life gained is greater for younger patients, but even 75 year-olds (the oldest group for which there is data) gain an average of 4 years of life with a kidney transplant. People generally have more energy, a less restricted diet, and fewer complications with a kidney transplant than if they stay on dialysis."
  5. Acute rejection occurs in 10% to 25% of people after transplant during the first 60 days. Rejection does not mean loss of the organ, but may require additional treatment.
  6. Recipients have to take immunosuppressants for the rest of their lives to prevent rejection, unless the kidney is from a genetic twin (or clone if you've watched the movie The Island).
From the University of Maryland Medical Center's FAQ, I quote:
Death from kidney donation is extremely rare (about 3 in 10,000). Donating a kidney does not change your life expectancy nor does it increase your chance of kidney failure. The health effects of kidney donation have been and continue to be carefully studied by several research groups in the United States. This research has shown that kidney donation does not appear to put donors at any increased risk for future health problems.
Illegal kidney trade in India

Illegal kidney trade is a thriving unregulated business in India. Kidney transplants from living donors are illegal if they involve any kind of commercial transactions but not much has been done by the authorities. Kidneys are mostly obtained from poor people, who are usually impoverished rural villagers and paid a sum of money, and then transplanted into rich recipients. The transaction usually involves a middleman and the entire business is carried out with the connivance of doctors in India. There is minimal or no post-operative care for the donors and some of them seem to suffer from health problems following the operation but there has been no actual study on the extent of the problem. Most of the recipients are actually locals although India is regarded as an international centre for kidney trade. Many foreigners in need of renal transplant go to India to get their kidneys.

There are several factors contributing to the growth of the illegal kidney business in India. Firstly, dialysis is expensive and the country does not have enough dialysis facilities. It is much cheaper to get a kidney transplant than go on dialysis. Secondly, enforcement is weak and the punishment for selling an organ is rather light; it is punishable by up to seven years in prison and provides a fine of Rupees 10,000, about 300 U.S. dollars. Also, there is a loophole in the law that allows donors not related to the patient to donate in extreme circumstances on "compassionate" grounds. Thirdly, there is a ready supply of of willing sellers from the impoverished rural areas. Fourthly, the supply of kidneys from cadavers is too low and the country lacks the medical expertise to perform cadaveric kidney transplants. There is no law regulating the harvesting of kidneys from brain-dead patients which further restricts the supply of kidneys from deceased donors. Fifthly, kidney transplants have a higher rate of success given the availability of more effective immunosuppressants in recent years.

For further information, see:
  1. Nepal's trade of doom.
  2. India Kidney trade.
  3. India: A Pound of Flesh. Selling kidneys to survive.