Design and Health World Health Design

Dialogue: Panoramic perspectives

Prof Arthur Lim (Photo credit: Digit Imaging)
The world would not only be a less progressive place if it were not for men like Professor Arthur Lim, it would also be a far less interesting one. Marc Sansom interviews the famous Asian eye surgeon who sees no mirrors, only windows.

Arguably Asia's most celebrated and finest eye surgeon, Prof Lim is acknowledged by his peers as the father of this specialist field of medicine in Southeast Asia, and a mentor and icon to eye surgeons all over the world. Yet, recognition alone of the Singaporean as one of the pioneers of modern ophthalmology would be to also undervalue his contribution – as a prolific author, teacher, artist, sportsman and some might say politician – to the enhancement of a more holistic understanding of humanity.

Prof Lim founded the Singapore Eye Research Institute and the Singapore Eye Foundation, but is perhaps most celebrated in his country of residence for his role as founding medical director of the Singapore National Eye Centre, which through the training of many future generations of leading ophthalmic eye surgeons remains a monument to his vision and relentless pursuit of excellence.

Equally recognised on the world stage, Prof Lim has held numerous international appointments in major world ophthalmic organisations, and famously founded the International Intraocular Implant Training Centre Tianjin in China, which subsequently became the Tianjin Medical University Eye Centre, and for which he was given the Friendship Award by the Chinese government – the highest award that can be bestowed on a foreign national.

Established as a model for eye centres throughout China, the centre has trained more than 2,500 ophthalmologists and restored vision to more than 250,000 blond cataract victims.

Prof Lim has also been published widely on socio-medical issues in principally the areas of mass blindness prevention, medical ethics and healthcare reforms, demonstrating through his writing a unique ability to see beyond his own reflection and develop crusades that would often challenge the authorities.

As Professor Lynette Lim explains in her anthology of his works: “As a proponent of open and transparent discussion, Arthur has always been one to face key issues squarely, even if official displeasure might arise.”

One such issue that concerns Prof Lim today is that the global financial crisis will have a great impact on the development of global medicine and healthcare provision. “The US spends enormous sums of money on health, yet one quarter of its population are not covered by insurance. “When they introduced the National Health Service in the UK, they wanted it to be the best in the world, but it has collapsed under the pressure of demand. The queues get longer and longer.”

Identifying cost as the major factor, he explains: “The price that doctors and specialists charge in the US is unbelievable, and it will continue to go up unless something is done to stop it. Many countries look towards the US as their benchmark, but we should question whether their system of financing health provision is the right system? Maybe the crisis is a good thing if it exposes this issue.” Suggesting that there are systems around the world that might provide a better model, he says: “The systems in Australia and New Zealand offer a different approach, whilst Singapore also has a healthcare model that is used in other countries and has performed quite well.”

Cost control
The Singapore system uses a combination of compulsory savings from payroll deductions through the Central Provident Fund, a nationalised health insurance plan, government subsidies, and price controls to keep costs in check. “Patients have a say” says Prof Lim. “You have your own budget, but if you don’t spend the money, then it is yours. So, if the treatment costs S$1,000, but another provider can do it equally well for $S500, then you have the opportunity to save 50%.”

Controlling costs is a central theme to solving the problems facing healthcare systems around the world, according to Prof Lim. “Much depends on the political thinking of the government. If you believe in a private system of healthcare provision, the advantage is that the control passes to the individual and the burden of government bureaucracy is reduced. The key difference is that for the private doctor, he has to attract the patients in order to operate and earn his money.

“For the public doctor, he will earn the same money even if he does fewer operations, so where is the incentive? To address this in Singapore and in some other countries, the doctors receive a cut of the surgical fee.” On a socio-political level, Prof Lim also recognises how cost control is a new issue for modern society, which in the 19 and 20th centuries only had to concern itself with catering for small numbers of people in the upper echelons of society, rather than providing universal healthcare coverage. “In Indonesia, there are 170 million voters requiring healthcare services, so cost becomes very important.”

Despite being a leading advocate of modern healthcare technology throughout his medical career, Prof Lim also raises concerns about the inappropriate cost of technology. “Some commercial fi rms do not always display honesty in their methods.

For many years, I was using a very good instrument at a very good price, between S$8000-S$10,000. “But one day they presented a new machine costing four times the price at S$40,000, yet the changes were made principally in the packaging and the marketing and only a small technical modification that would not have cost more than S$2,000.”

On a more systemic level though, the key to keeping costs down and at the same time being more sustainable, says Prof Lim, is flexibility. A long sworn advocate of community hospitals and nursing homes, he argues that the current trend towards large, expensive general hospitals is creating the potential for medical dinosaurs. Referencing the famous American writer and futurist, Alvin Toffler’ thoughts on the development of the knowledge society, he says: “Toffler wrote about three waves of society. The first wave followed the agrarian revolution, where farming stimulated mass food production. This was followed by the industrial revolution, within which to be competitive, you needed economies of scale, which led to factories, schools, hospitals all being developed on a huge scale.

“But now we live in the post-industrial era where knowledge is important and change is very fast. In the knowledge society, the talents do not wish to group in large organisations where everybody is the same.” Toffl er envisages the third wave society as being affectional, emotional and diverse, not just cognitive, characterised by subcultures and smaller, more fluid organizations able to quickly adapt to change. It is a vision that Prof Lim suggests should be applied to healthcare.

“In a meeting with the Ministry of Health discussing proposals for new large, general hospitals costing up to £3 billion, I quoted Toffler, and raised the prospect that in 20 years time when these hospital projects were completed, we may not need them anymore. Just as has happened in Europe, the UK and the US, the super-hospital which caters for many people will not survive. It will be obsolete.”

The community principle is very important, Prof Lim explains, not just for improving the effectiveness of care but for reducing costs too, particularly in the developing world where the impact of the economic situation could hit hardest. “Many countries in the west are very critical of China and the ‘barefoot doctor’. But many countries will suffer great poverty from the fi nancial crisis, and how will we cater for their poor?”

China’s struggles after the war under Chairman Mao to provide healthcare coverage for its vast rural population led to the much debated development of the barefoot doctor, who typically was a healthcare worker with minimal training who had access to the most remote populations.

“The principle of the ‘barefoot doctor’ was to elect someone from within the village who could be trained in medical care” Prof Lim explains. Reflecting on the patriarchal approach of modern medicine, he adds: “The failure we often make is telling people what to do, but if the village chooses a medical representative from within their community whom they respect, then it will work.”

Innovation and novel approaches, such as the ‘barefoot doctors’, arise from challenges to our everyday perspective. Prof Lim jokes that this is particularly important for eye surgeons. “Architects are lucky as they are exposed to many things in their work. But, an eye doctor? All he does is look into eyes and nothing else! The trouble with doctors is their choice of profession!

“For some strange reason, in all countries, all the top brains choose medicine. But in the practice of medicine, you memorise a lot of things, so that once you become an eye surgeon, you do not need a brain anymore. I make a point of spending at least one or two hours a day doing something that has nothing to do with the eye.”

As his anthologist, Prof Lynette Lim proclaims that Prof Lim is acclaimed almost as much for his art and his art collection as he is for his ophthalmic talents. And with many published works and stories to tell, he is a reminder that there is no substitute for knowledge, wisdom and experience in an unpredictable world.

Marc Sansom is editorial director of the International Academy for Design & Health

Prof Arthur Lim Siew Ming

Research Areas
Prevention of Blindness; Cataract; Glaucoma

Teaching Areas
Live surgery demonstration and national & international courses
Academic / professional qualifications
1956  MBBS, National University of Singapore
1962  FCRS Moorfi elds Eye Hospital, London
1999  MD (Hon) National University of Singapore

National institutional appointments
Clinical Professor, Dept of Ophthalmology, National University of Singapore
Founding Medical Director, Singapore National Eye Centre
Founding Chairman, Singapore Eye Research Institute

International institutional appointments
Visiting Professor and Honorary Director, Tianjin Medical University Eye Centre, People’s Republic of China
Honorary Director, Xiamen Eye Centre, People’s Republic of China
Honorary Professor, The Chinese University of Hong Kong, People’s Republic of China

Prof Lim has also received numerous national and international awards and honours, surgical fellowships, held numerous senior administrative positions within national and international institutions, and been published in major publications and peer-reviewed journals.

Photo credits: Digit Imaging

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