Politicians call it a “war on diabetes”. With one in five Singaporeans projected to have diabetes (that's 1 million people) by 2050, the Government of Singapore responded earlier this year with welcome urgency. One can understand why. Today, diabetes costs Singapore S$1 billion. By 2050, that figure will likely have risen to S$2·5 billion. Painful past failures—the “war on cancer” and the “war on drugs”—have not deterred Singapore's public health leaders. They worry they face an unsustainable future. Amy Khor, a senior minister whose portfolios span health and the environment, emphasised two threats to Singapore's prospects—newly emerging infections (Zika struck in August, raising anxieties about the health security of this small city state) and non-communicable diseases. An epidemic of overweight and obesity seems uncontainable. The government has focused on three strategies. First, to understand obesity and overweight in young adults. Obesity rates have increased four-fold during the past 20 years in young men (to 20%) and two-fold in young women (to 11%). Second, to promote health at work. The Singaporeans call their plan TWSH—Total Workplace Safety and Health—and they take it far more seriously than most countries take occupational health. And third, to investigate lifestyle behaviours in pre-school children and how those behaviours transition into adolescence and adulthood. This strategy sounds sensible and science based. Yet it is being fashioned amid sharply competing ideologies of public health—what public health is, what it is not, and what it is there to do.

Although public health has long been part of Singapore's short national history, its formal organisation is new and fragile. Singapore has one School of Public Health, established only 5 years ago thanks to a generous donation by Singaporean philanthropist Saw Swee Hock. A gathering of public health researchers and practitioners to take stock of the nation's health in a global context takes place once every 4 years. The inaugural meeting was in 2012. When those responsible for a country's future feel their nation is in danger, as Singapore's leaders do, they may invite experts to offer wise advice. Two such experts—Richard Coker (who leads the London School of Hygiene & Tropical Medicine's Communicable Diseases Policy Research Group) and Sarah Harper (who directs the Oxford Institute of Population Ageing)—gave their best advice at Singapore's second International Public Health Conference, held last month. Their messages to Singapore's Government were strikingly contrasting. Sarah Harper looks at public health through the lens of demographic transition. Life expectancies are rising (or, put another way, people are “not dying on time”). Families are choosing to have fewer children. Societies are living with larger numbers of older people and smaller wealth-creating workforces. It took 150 years for European nations to pass through this transition. In Asia, it is happening in just one generation. So what should be the objective of public health? “The goal of public health”, Harper argued, “is to help people take more responsibility for their health”.

Richard Coker presented a very different vision. Globalisation, inequality, migration, ecological shifts—these are the challenges facing public health today. An isolated citizen is not able to confront these massive societal forces alone. Only governments can do so. It is politicians who have to address the deep tensions adversely shaping health. Xenophobia, racism, stigma, discrimination, social exclusion, poverty, loss of trust, destroyed habitats. Public health must be political, abroad as well as at home. Coker drew attention to the financial contributions made by nations unaffected by Ebola—even small nations, such as Norway—to ensure that future epidemics would be detected and dealt with more robustly. All nations have a stake in global health security. Singapore should be part of that international commitment. Currently, it is not. So what is a Singaporean policy maker to make of these competing ideologies of public health? Should they prefer a policy of personal responsibility (in the context of an ageing society)? Or should they look to government to make public health a higher priority (and protect Singapore's citizens against the next Zika)? That choice wasn't resolved in Singapore last month. But with accumulating risks to health now posing a threat not only to the country's economy but also to its existence, Singapore's famed efficiency in health spending may have to be reassessed. This discomforting lesson is one that is amplified across much of the world today.

Copyright © 2016 Richard Horton

Copyright © 2016 Richard Horton

Copyright © 2016 Richard Horton

Copyright © 2016 Richard Horton