In this week’s world of genomics, we explore Asia’s “Lion City”, Singapore. This small island country is home to a diverse population, famous for being a renowned global financial and technological hub. Singapore has made significant contributions to the field of genetics and genomics: Notable achievements include the creation of the world’s most extensive Asian genetic databank, with whole genome sequences of over 5,000 Singaporeans, a population that had not been comprehensively studied previously.
The Population of Singapore
Singapore is a sovereign island country in Southeast Asia, sharing maritime borders with Malaysia and Indonesia. In 1819, Singapore was a trading post for the British Empire, until it was occupied by Japan during the second world war. Singapore was subsequently returned to British control in 1945. A decade later, Singapore reclaimed independence as a self-governed city-state under the People’s Action Party.
Geographically, Singapore is located at the tip of the Malay peninsula, consisting of the main island and 64 smaller islands offshore. It boasts 4 official languages: English, Malay, Mandarin and Tamil. Singapore has a diverse ethnic make-up of Chinese, Malay and Indian populations and is the most religiously diverse nation in the world, according to a 2014 survey by the Pew Research Centre.
Geographic and demographic information
- Land area: 718 km²
- Gross domestic product (GDP):
- Total: $340 billion USD
- Per capita: $59,797.75 USD
- Population size: 2021 estimate: 5.45 million people
- Birth rate: In 2020, the crude birth rate was 8.584 births per 1000 people
- Death rate: In 2020, the crude death rate was 4.8 per 1,000 people
- Infant mortality rate: In 2020, it was 1.8 deaths per 1,000 live births
- Life expectancy: In 2020, the average life expectancy was 81 years for males and 85.5 years for females.
- Ethnicities: Singapore is a multicultural country. The largest ethnic groups in Singapore are Chinese 74.3%, 13.5% Malay, 9.0% Indian and 3.2% others.
Having achieved universal health coverage, Singapore’s healthcare system has been ranked amongst the best healthcare systems in the world. In 2020, the Bloomber Health-Efficiency Index ranked Singapore 1st in the world for the most efficient healthcare. Healthcare is based on a multi-payer financing framework, wherein citizens have a shared responsibility through funding via taxes and other insurance schemes.
The healthcare system in Singapore today was first introduced as the National Health Plan in 1983. At the core of this system is the Medisave scheme. Later on, in the 1990s, other healthcare programmes were introduced including Medifund and Medishield which together with Medisave, are known as the 3Ms. In 2002, Singapore introduced Eldershield, a long-term insurance scheme targeted at severe disabilities that come about in elderly patients.
Medisave is a national savings scheme, wherein individuals put aside a portion of their income into Medisave accounts to meet any future out-of-pocket medical payments. Medishield is an affordable medical insurance scheme that helps Medisave account holders meet the cost of treatment for serious or chronic illnesses. Medifund is a fund set up by the government as a safety net to meet the needs of individuals who cannot afford to pay for medical care.
While the healthcare system is excellent, there are still challenges. Singapore faces issues with a shortage of doctors and nurses, and like many developed countries, Singapore has an ageing population, putting a strain on resources such as hospital beds.
Cancer is the leading cause of death in Singapore, accounting for 28.6% deaths in 2020. The most common type of cancer in men is lung cancer, and in women, breast cancer. It has been reported that the likelihood of developing cancer is 1 in every 4 to 5 Singaporeans by the age of 75. The next most common causes of death are Ischaemic heart diseases (at 20.5% in 2020) and pneumonia (at 18.5% in 2020)
Mental health is still widely stigmatized in Singapore. Approximately 14% of Singaporeans have experienced a mental health condition in their lifetime, with 75% of them never seeking professional help. An 18% increase in suicide prevention calls (in 2020) has also been recorded by the Samitarians as a result of the COVID-19 pandemic.
Successful public health strategies include the introduction of targeted health measures to specific demographics. There are also plans to increase access to mental health services and to provide subsidies to lower-income Singaporeans and citizens with chronic conditions.
Singapore’s effective COVID-19 response was focused mainly on mitigation rather than containment, following their experience in adopting preventative measures for the SARS epidemic in 2003. Mitigation aimed to limit the movement of the population and encourage social distancing, whereas containment focused on contact tracing and quarantine measures. To date, Singapore has had 1.76M cases with 1,539 deaths, which is significantly better when compared to countries of a similar size like Denmark, with 3.25M cases and 6,758 deaths.
Genomic medicine capabilities
Singapore has rapidly increased its involvement in genetics and genomics research since the 2010s, being the first to complete the world’s largest multi-ethnic Asian genetic databank. This study was achieved in 2019 through collaborative efforts from A*STAR’s Genome Institute of Singapore, NUHS, PRISM, NUS, and others. The joint project involved whole genome sequencing of around 5,000 Singaporeans, with the ultimate objective of providing valuable insights into the unique genetic diversity of Asian populations. Study findings have revealed 98.3 million genetic variants across Singaporean genomes, most of which have not been previously reported in databases that have focused on Western populations. Professor Yong Loo Yin stated that this study would not only help scientists understand the genetic basis of diseases in Asian populations, but also enable accurate diagnosis of inherited diseases, empower chronic diseases research, and facilitate preventive medicine approaches and targeted therapies.
Genetic counselling and testing are becoming more widely available in Singapore. In 2019, the SingHealth Duke-NUS Genomic Medicine Centre (SDGMC) was launched to provide specialised genetics care and expedite genomics research. This was done with the aim of advancing care for patients and families with genetic diseases in Singapore. The establishment of this centre is said to have allowed the seamless integration of genomics care into Singaporean healthcare clinics, providing crucial genomics perspectives, personalised treatment for patients with genetic diseases, better risk assessments and intervention for at-risk family members.
Institutions such as the Genome Institute of Singapore, NUS, NTU Singapore and Precision Health Research (PRECISE) have also made significant strides in genetics and genomics research. The integration of research with government efforts to make national precision medicine a strategy has been planned to be achieved by 2027.
- National Precision Medicine (NPM) strategy: Singapore’s NPM strategy is a 10-year research roadmap to accelerate biomedical research and improve health outcomes. This strategy is sectioned into 3 phases. Phase I established a Singaporean reference database containing 10,000 genomes. Phase II involves the SG100k project and will embed genetics into clinics and capture economic value. Phase III will establish population-scale genomics and implement precision medicine by 2027.
- SG100k: Part of the NPM strategy, Precision Health Research is partnering up with genomics firm Illumina to sequence and analyse the genomes of about 100,000 participants in Singapore. This will benefit local sequencing companies in Singapore, the ministry of health, and healthcare, in Singapore.
- WGS of 5000 Singaporeans: Collaborative efforts from A*STAR’s Genome Institute of Singapore, NUHS, PRISM, NUS, etc. gathered the whole genome sequencing of around 5,000 Singaporeans.
- Singapore Genome Variation Project: Conducted by the NUS, this project characterized the extent of common variation in the human genome across at least 1 million single nucleotide polymorphisms (SNPs) in DNA samples from Chinese, Malays and Indians in Singapore. The data generated has been uploaded to the public database of genetic variation.
Notable organisations and companies
- Genomics Institute of Singapore: Created in 2000, the GIS is a national initiative with a vision that seeks to use genomic sciences to achieve improvements in human health. They have been involved in research on disease gene discovery, population, evolutionary genomics and statistical genetics.
- Precision Health Research, Singapore (PRECISE): This SME is involved in coordinating the government’s effort to implement Phase II of Singapore’s 10-year NPM strategy.
- Single Cell Omics Centre (SCOC): A collaboration between GIS and A*STAR, SCOC is the first research centre in Asia exclusively dedicated to single-cell genomic applications.
- Centre of Genome Diagnostics: This organisation was established to co-develop genomic technologies for nucleic acid-based therapeutics and diagnostics markets.
- Assistant Professor Xue Shifeng: With her team, she discovered a new way to decipher unsolved Mendelian diseases by studying the inheritance of a protein known as SMCHD1, which is coded by the SMCHD1 gene.
- Chan Lai Fung: Chairman of the Agency for Science, Technology and Research. Responsible for GIS, Centre of Genome Diagnostics and more.
- Professor Ivy Ng: Group CEO of SingHealth since January 2012, Professor Ng helped to launch the SingHealth Duke-NUS Genomic Medicine Centre, which helps provide citizens with genomic care and personalised treatments.
The future genomics landscape
Although their implementation of genomic medicine and research output lags behind countries such as the USA and the UK, Singapore has slowly but surely made efforts to ensure genomic medicine becomes more widely accessible to the public. The increasing number of initiatives related to genetics and genomics, such as the SDGMC and NPM strategy, are a testament to this. Phase III of the NPM strategy is expected to span from 2024 to 2027 and this will further help implement precision medicine on a large scale by linking the genomic sequencing of up to 1 million people with clinical and lifestyle data.
As research and progress made toward the genomics field grow, Singapore’s contribution will progressively be recognised, making it one of the leading countries in providing citizens with accessible genomic medicine.
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