Caught in a lower income trap

MADAM Koh Ting Guat’s bedridden husband needs to be hooked up to an oxygen
machine to help him breathe.

She changes the ventilator tubes once a week, instead of the prescribed every
three days. That way, she reckons, the $5 pack of 50 tubes will last longer.

Such cutting of corners is not out of meanness but a lack of means.

A year ago, they were getting by as a middle-income family. She earns $2,800
a month as a shipping executive and her husband made $1,500 as a salesman.

But life threw them a curveball when he suffered a stroke, leaving him bedridden.

These days, the family makes do on her salary, with little left after paying for
their two sons’ school expenses, her husband’s medical bills, the wages of a Filipino
caregiver, utilities, transport and food.

The family has fallen into that sandwich class of low-middle income Singaporeans
who keep Acting Minister for Community Development, Youth and Sports
Chan Chun Sing awake at night.

In a media interview last week, he said that this group tend to be in jobs that are
vulnerable to being lost in the churn of economic cycles. They also tend to have
little savings to cushion the impact.

He identified them as being in the 11th to 20th percentile in terms of resident
household income, making an average of $2,681 a month. These are headed by a citizen or permanent resident, and with at least one working person.

Another set of figures, measuring individual incomes of Singaporeans, is sobering.

A joint report by the Manpower Ministry and the Department of Statistics
showed that monthly real incomes of Singaporeans at the 20th percentile grew 0.3
per cent over the decade – almost zero per cent a year.

In contrast, those in the middle saw real monthly incomes rise 1.2 per cent a
year over the same period, or 11.3 per cent over the decade.

Who are in this low-middle income group and how can they be helped?

Figures culled from various agencies show them to be mainly made up of large
families with school-going children, with the parents aged between 40 and 50. One
parent may have been recently retrenched, or they may be burdened by
heavy medical bills or in some cases, marital woes have added to their troubles.

Some may benefit from the Workfare Income Supplement Scheme, if they are
aged 35 and above and have gross monthly incomes of $1,700 or less, among other
conditions.

But apart from Ministry of Community Development, Youth and Sports
(MCYS) programmes to help with childcare costs and taking care of elderly parents,
little other help is available as they fall outside social assistance nets.

Government schemes such as Com- Care Transitions and the Work Support
Programme disqualify households with incomes above $1,500.

Those in the 1st to 10th percentile – with average monthly household incomes
of $1,400 – would qualify for benefits such as cash grants and utilities vouchers
under these programmes.

The “at risk” group in the 11th to 20th percentile, Mr Chan pointed out, form a
significant portion of the bottom third of the population. About 377,400 employed
residents aged 15 years and above earn between $2,000 and $2,999, according to labour statistics last year.

And, the minister feels, this group’s meagre savings – not more than a few
thousand dollars usually – mean they are on a dangerous keel in an increasingly uncertain global economy where a recession might be around the corner.

“You think I have savings now? If strike lottery tomorrow, yes,” said Madam
Koh.

She is thinking of taking on a second job to supplement her income. In the
meantime, scrimping and saving is all she can do. She is cutting back even on treatments for her husband.

Acupuncture treatments, for example, have been cut from thrice to twice weekly, saving $100.

“If a downturn really happens, I might have to sell this flat and move in with my
parents in Pasir Ris,” said Madam Koh of their four-room Sengkang flat.

Like many in their bracket, she and herhusband have only secondary education.
Singaporeans in this rung hold jobs such as technicians, security guards and in the service industry.

Top of their wish-lists: financial help from the Government when they hit dire
straits, or utility and transport vouchers, especially if a downturn occurs.

For Mr S. Ahmad, 55, his household is “already in a recession”.

A diabetic, he was a freelance travel agent earning about $1,000 a month until
June last year, when his right foot suddenly became swollen. He has been going for operations and follow-up treatment since. After insurance claims and government subsidies, he still has had to paymore than $10,000 in medical bills.

Now, his 25-year-old son, an optometrist earning about $2,500 monthly, is the
family’s sole breadwinner.

Adding further strain on Mr Ahmad’s finances are a $680 monthly housing loan instalment and another two young children who are still in school.

And as Mr Ahmad did not have the $1,000 advance to pay for a machine to
vacuum the pus from his foot last year, the infection spread upwards to his knee.

More medical treatments, bills and stress followed.

“I just have to borrow money from friends, what can I do?” he said resignedly in an interview in his Pasir Ris flat.

“I’m just living by the day.”

His 53-year-old housewife may resort to making kueh and selling it from home to raise funds, he said.

Another Singaporean trying to make ends meet is Mr Haron Ajit, 51.

He was a logistics supervisor until he suffered a stroke in June. His 21-year-old daughter is now the family’s sole breadwinner,earning about $2,500 from her nursing job. He has two sons – one in Secondary 4 and the other in Primary 1.

Mr Haron said: “We’re financially very tight now because of my condition.”

Apart from help to deal with medical expenses, social workers say some in the
low-middle income group also seek assistance for family problems like divorce, or after they lose their jobs.

Mr Hindran Maniam, a counsellor at Rotary Family Service Centre in Clementi,said: “They ask for counselling for problems like family violence, taking care of elderly parents, or communication issues with children.”

One middle-income wife, for instance,went for counselling at Fei Yue Family
Service Centre in Yew Tee after she discovered her husband had an affair. She was contemplating divorce, but was held back by fear that it would affect the household income.

Retrenchments are not a problem yet but Ms Florence Lim, the director of Covenant
Family Service Centre in Hougang,expects such cases to surface if the global economy drags Singapore down.

Industry veterans say the best way to help the low-middle income group is to raise
the upper limit for ComCare programmes to about $2,000 to $2,500.

This would open up qualifying for more benefits such as medical assistance,rental and utilities vouchers, and monthly cash grants.

Ms Lim, a social worker for three decades,said: “Why not also look at their net income after Central Provident Fund deductions,rather than gross household income,in deciding eligibility?”

This would widen the pool of those eligible,especially with rising living costs.

The Government could give slightly smaller ComCare subsidies to the low-middle income bracket compared to those at the bottom rung, Ms Rachel Lee, head of Fei Yue Family Service Centre and a social worker for 19 years, mooted.

Getting these workers to upgrade their skills so they can get jobs that are less susceptible to being wiped out by economic cycles was another popular suggestion,
but there are problems with that route.

“These people need money from work. Who’s going to feed their families when they go for training for those few months?” said Ms Lim.

She said CDCs do give a few hundred dollars a month to help these individuals during say the quantum should be higher.

Short-term assistance for about threemonths to help them tide over a difficult situation would also work well, said North East District Mayor Teo Ser Luck.

Mr Teo, whose district has been helping residents who do not qualify for Com-Care through its local scheme, said: “You have to be there when they need you.

That’s what this safety net is about – covering the cracks.”

10 cancer signals

FOR some women, cancer comes hand-in-hand with another syndrome: denial. They may not want to face the reality that they have cancer, or may not want to go through treatment because they think they are doomed to death anyway.

In some cases, denial starts early on at the symptom stage, because they may not even want to consider that it could be cancer at all.

When women neglect to pay attention to cancer symptoms out of denial, fear or ignorance, they could be missing out on a valuable opportunity to detect cancer and treat it early.

Since there are so many different types of cancers that could affect us, the symptoms vary widely between different conditions and different people as well. There are also many instances where cancers do not produce symptoms at all, or symptoms only appear at late stages.

However, we can easily identify about 10 symptoms that should immediately send up warning flags in our minds and prompt us to seek medical advice. These symptoms can be easily mistaken for other conditions or as benign symptoms, but you shouldn't be so quick to shrug them off without proper medical advice.

I will explain each of these 10 symptoms below.

#1: Unexplained weight loss

Say you haven't been exercising more than usual lately, or have not even been exercising at all. Or you haven't gone on a diet and have been eating the amounts that you usually do. Yet you've been steadily losing a significant amount of weight, for instance 4kg or 5kg within a month.

This kind of unexplained weight loss is not necessarily a reason to be happy. It could be a sign of cancer, especially cancer of the colon or other parts of the digestive system.

You should see your doctor and provide as much details as possible about when you began losing weight and how much you have lost. Your doctor will conduct some tests to rule out an overactive thyroid and ask you to undergo CT scans to look at your internal organs.

#2: Bloating

Bloating is something that most women have become used to. We experience bloating at some point or other in our lives, whether due to PMS, water retention, or indigestion.

If you start to experience bloating that is unusual and not related to your menstrual cycle, you should start to pay close attention to what's happening. Are you so bloated that your jeans, trousers or skirts can't fit? Did it appear suddenly and is now occurring regularly over a few weeks?

Is the bloating accompanied by pain or tenderness in the abdomen or pelvis? Do you constantly feel full and unable to eat, even though you haven't eaten much?

All these signs have been known to occur in women with ovarian cancer. If you experience any of the above, it would be wise to see a doctor to check your ovaries because this type of cancer is difficult to detect in the early stages.

If you are able to catch it early, your chances of a better outcome are higher.

#3: Unusual bleeding

Any instance of vaginal bleeding that is out of the ordinary should be cause for concern. As a woman, you should know your body and your monthly cycle well enough to be familiar with when you should bleed, how much bleeding you experience, and how you feel.

Basically, you should not ignore any bleeding that is abnormal from what you normally have. If you have very regular cycles, but suddenly experience bleeding or spotting between periods, then it is abnormal.

If you usually have light flows, but suddenly have heavy and painful periods, then you should also have it checked out.

Other symptoms that may accompany unusual bleeding are unpleasant odours or discharge, bleeding after intercourse or blood in the urine. All these types of unusual bleeding should be checked out because they could be signs of cervical or uterine cancers.

Bleeding may also originate from the gastrointestinal tract or parts of the urinary system, such as the bladder or kidney.

If you discover blood in your urine or your stool, it could be due to a number of things, such as haemorrhoids, or blood from the vagina. But it could also be a sign of bladder, kidney or colorectal cancer, so you should see a doctor to rule these out.

Bladder, kidney or colon cancer can also trigger symptoms like changes in bowel and bladder habits. You should be concerned if you develop unusual bowel and bladder movements, such as continual constipation, diarrhoea or stomach aches. More frequent urination, or pain during urination or during a bowel movement, are also worrying signs.

Finally, if you cough up blood more than once, you should also get medical advice.

#4: Breast changes

The breasts hold a lot of clues for women. We've been told countless times that we need to know our breasts intimately and examine them once a month for lumps and other changes within the breasts, on the surface of the skin, as well as on and around the nipples.

Redness and thickening of the skin on the breasts should be looked at immediately as this could indicate inflammatory breast cancer, which is a very rare but aggressive form of breast cancer. A rash, flaking of the skin, or itchiness that persists over weeks should also be examined.

Changes to the skin surface may also include swelling, dimples, puckerings or rough spots.
Observe your nipples as well and look for changes in appearance that are not normal. If your nipples suddenly start producing discharge (if you aren't breastfeeding), become flattened, or turn in or out (contrary to what it usually is), it is best to see your doctor or gynaecologist.

#5: Skin changes

Changes in your skin texture, warts, moles or pigmentation, are well-known signs of skin cancer.
Melanoma is a common type of skin cancer and has symptoms like spots on your skin that have unusual changes in colour, size, shape or border. If certain spots on your skin appear to be funny-looking or different from your usual skin pigmentation, get it checked out.

Look out for moles or warts that change, such as growing excessively, sprouting hair, or changing colour or shape. Be wary if you suddenly develop bleeding on your skin or excessive scaling too.

Observe the changes for one or two weeks, and if they persist, see your family doctor or a skin specialist.

#6: Difficulty swallowing and constant indigestion

Have you found it difficult to swallow your food lately? If you feel as if food is always caught in your throat when you eat, take note of this, as it could be a symptom of oesophageal or throat cancer.

Repetitive indigestion, not linked to pregnancy or any other apparent reason, is also a red flag. If you constantly feel nauseous, discomfort or a burning feeling in your upper abdomen, or vomit blood, you could be showing early signs of oesophageal, stomach or throat cancer.

#7: Persistent pain, fever or cough

These are three of the most vague and common symptoms that accompany many illnesses. It is extremely difficult to pinpoint them to cancer or any particular condition, but they are also not to be ignored or neglected.

Unexplained pain, in any part of the body, may point to some cancers. If it persists over a period of time, and cannot be attributed to any obvious physical wounds or conditions, then you should see your doctor and describe it in as much detail as possible.

Take note of when the pain arises, what kind of pain it is, and what exacerbates it.

A fever is often a sign of an infection, like influenza or some other viral or bacterial infection, but it can also point to certain types of cancer. The American Cancer Society says that fever is one of the symptoms that occur with early blood cancers such as leukaemia or lymphoma.

Of course, you do not have to run to your doctor in fear every time you have a fever. The point is that unexplained and prolonged fever needs to be examined, not ignored.

A very prolonged cough (one that lasts more than three or four weeks) that is unrelated to a cold or influenza, should also be noted. If lung cancer is suspected, especially if you are a smoker, your doctor should examine your throat, check your lung functioning and ask for X-rays.

#8: Swollen lymph nodes

Your lymph nodes are found in the sides of your neck, under your armpits, and around the groin area. Usually, they may become mildly swollen if you have an infection, and will subside once the infection has been treated or healed.

However, if the lymph nodes get progressively larger for more than a month, or develop lumps that do not go away, and are not related to a treatable infection, then the concern may be that it is linked to cancer, such as blood and lymphatic cancers.

#9: Mouth changes and sores

If you smoke or used to, you should look out for signs of oral cancer. Symptoms include white patches in the mucosa of the mouth, white spots on the tongue, or sores on the lips or in the mouth.

Other sores on the skin and genital area that won't heal, or cause excessive bruising or bleeding, should also be examined by a doctor.

#10: Fatigue and weakness

Finally, we come to the last potential symptom of cancer that is most commonly ignored - fatigue. Obviously, fatigue is such an everyday symptom of so many conditions that we cannot jump to the conclusion that it must be caused by cancer.

However, fatigue caused by cancer will probably be unlike the usual tiredness that you experience after a long day at work. It may plague you even when you have had sufficient rest or have not exerted yourself. It will be prolonged, unabated by rest, and may be accompanied by unexplained weakness.

You will realise that the 10 signs and symptoms described above are very subtle and vague indications of a problem. It is not easy to distinguish symptoms of cancer, and you should not work yourself up into a panic just because you suddenly have a mole on your arm or you are feeling a little tired.

Just keep in mind that if these symptoms persist, or appear without due cause, then it is a good idea to discuss your concerns with your doctor. It could be nothing, but it could also save your life.

Datuk Dr Nor Ashikin Mokhtar is a consultant obstetrician & gynaecologist (FRCOG, UK). The information provided is for educational and communication purposes only and it should not be construed as personal medical advice.