Parliament Speech 22 April Closing Speech for the IDA (Amendment) Bill

22 Apr 2008

By Khaw Boon Wan

Venue: Parliament

Mr Speaker, Sir, I thank the members who have spoken in support of the Bill. 

SARS has come and gone.  But SARS or a new virus may appear again.  If the outbreak is similar to SARS, we know now how to combat it effectively.  But nature will always surprise us.  While we hope for the best, we must, within practical limits, prepare for the worst.  

This Bill will help us better prepare for an attack that is worse than SARS.  The two additional powers that we seek, to requisition private sector resources and a new section 17A to prohibit mass gathering in the event of a public health emergency, will expand our capacity and capability considerably.  We know that these are drastic measures and we will use them only when absolutely necessary.   

As noted by Mdm Halimah, these measures will cause major disruptions to the daily lives of Singaporeans and would be a major cost to business. Hence, I agree that they must only be invoked in very grave situations where alternatives are not workable.  The law has therefore built in safeguards to ensure that the powers are exercised appropriately.  We need to strike a balance between individual liberty and the protection of the community at large.  We are not alone in grappling with this problem.  After SARS, many countries have implemented new legislation to enable Government agencies to prevent, control and manage a severe outbreak.  The UK introduced The Civil Contingencies Act in 2004.  Western Australia introduced The Emergency Management Act in 2005.  New Zealand introduced The Epidemic Preparedness Act in 2006.  Others are seriously considering similar legislation.  In drafting this Bill, we have in fact drawn useful provisions from such legislation.  In particular, we have modelled our safeguards against similar provisions found in the foreign legislation.  Ms Sylvia Lim has asked whether Parliament instead of the Minister should make the decision to declare a public health emergency.  Foreign legislations that we have studied do not require the legislature to be convened to decide on whether a public health emergency should be declared.  This is because of the urgency of the situation.  We have taken heed of this and made it a Ministerial executive decision subject to Parliamentary oversight.  We believe that this strikes a good balance between acting speedily to protect public health while ensuring public accountability.

At the same time, we are mindful of the heavy responsibility. How do we recognise and when do we declare a public health emergency?  This calls for sound judgement and decisive action in the absence of complete information.  A delay in sounding an alarm will cost many lives.  Dr Lam Pin Min gave us a good account of what a worst case scenario may be like.  To enhance our ability to make the right call, we need to strengthen our surveillance capabilities.  This is the public health equivalent of intelligence work in anti-terrorism.  We need to investigate relevant signs and signals and pursue them when a plausible trend appears.  Signals will come from clinics, western or eastern.  Hence, I agree with Dr Fatimah Lateef that we should also tap on the TCM practitioners for this purpose of surveillance.  Surveillance data will be treated with the strictest confidentiality.  However, in the larger interests of public health, we need the power of section 7 to examine the affected patients promptly, so that there is no delay and the results would not be skewed by patients who may refuse examination. 

I agree with Mdm Halimah on the importance of regular training of healthcare workers, both in the public and private sectors on how to deal with an emergency.  That is why we have regular exercises to test and fine tune our emergency plans.  We will continue to reach out to the doctors in the private sector. 

My Ministry has to work with all parties in our fight against outbreaks.  A good example is the recent chikungunya outbreak in Little India, where the public, private and people sectors came together and collaborated as one Singapore.  It was a success story which we can be proud of. 

Epidemiological investigation requires a medical examination of an infected person, during which a body sample may be taken.  Prof Thio asked what might constitute “body samples”.  These typically refer to saliva, urine, faeces, swabs of the throat and blood.  I foresee that the most “invasive” sample that will be required would be a blood sample. 

Prof Thio asked what might constitute “reasonable excuse” for rejecting a medical examination.  This will depend on the circumstances.  For example, I think it would be a reasonable excuse for a haemophiliac to refuse to give a blood sample.  However, the claim of a right to privacy would not be a reasonable excuse.  We are dealing here with infectious diseases which may have serious public health implications if uncontrolled.  As I said earlier, some privacy will have to be ceded in return for the collective protection from infection. 

Prof Thio asked what we would do, if a person refuses to be examined. In that case, we will have to quarantine him until we can ascertain that he does not pose a threat to public health. 

Prof Thio asked what practical steps to ensure that affected persons will receive actual notice of the orders under the new section 17A during a public health emergency.  We will make use of the media extensively to disseminate such information.  In addition, where appropriate, we will work with the licensing agencies to inform their licensees of such orders.  On the ground, our officers will also assist in disseminating such information when directing the movement of persons in the restricted zones.

Dr Fatimah highlighted the potential public health problems of unhygienic, over-crowded quarters housing foreign workers.  We are equally concerned and are working with other Ministries on this issue.    

Prof Thio has a couple of drafting recommendations on section 8 and I note them for future reference.

Let me now address the comments on HIV.

HIV

Dr Fatimah asked whether the law provides protection against transmission of HIV through non sexual means.  She gave a personal account of a HIV infected patient threatening to infect the healthcare workers if he did not receive immediate attention.  Existing law does confer such protection for staff. For instance, the patient as described by Dr Fatimah may be liable for criminal intimidation under section 503 of the Penal Code.   

I agree with Mdm Halimah that the law alone is not sufficient to deal with the problem of HIV.  As there is no cure for HIV, the only viable solution is prevention.  In HIV prevention, public education remains the key strategy. But the mode of public education has to take into account the nature of our society.  The ABC campaign against HIV: Abstinence, Be faithful and Condom-use cannot be broadcast nation-wide with equal intensity.  Many parents will be upset with such a campaign and we will be accused of promoting promiscuity.  So the general broadcast has a small “c”.  On the other hand, the ABC campaign targeted at high-risk groups will have an enlarged “C” as the main theme.  I agree with Mdm Halimah that we should pay a special attention to vulnerable groups such as the youth and women. Furthermore, we are building capacity for NGOs and healthcare institutions to care and support for people living with HIV/AIDS. We will address stigma and discrimination more aggressively.  We have set aside an additional $10 million to expand on these efforts over the next 2 years.

As for the new provision under section 23 to tighten the control of HIV, let me repeat that it is not our intention to discriminate against or to criminalise HIV infected patients.  What we want to do is to push them to act more responsibly and not to hide behind the ignorance of their HIV status to go on exposing their sexual partners to the risk of HIV infection.  Such behaviour is most unacceptable, particularly in relation to the innocent wives of men who visit prostitutes.

Members have asked what amounts to “reason to believe”, what is high-risk behaviour and who are high-risk individuals.  For example, a man who:

(a) has unprotected sex with prostitutes or other men; or

(b) has unprotected sex with multiple partners; or

(c) shares injection needles with other drug addicts,

would be aware and “have reason to believe” that he has been exposed to a significant risk of contracting HIV. 

Ms Sylvia Lim has suggested that the new section 23(2) include illustrations on what constitutes significant risk of contracting HIV / AIDS.  We think this is not necessary.  Firstly because the examples will not be exhaustive.  Secondly, because our public health education programmes clearly emphasises what activities put a person at risk of contracting HIV / AIDS, and the necessary precautions to be taken to reduce that risk.The new provision does not ban him from sex.  It merely requires him to take any one of the following three measures before he has sex with another person:

i) to inform his partner of the risk and allow his partner to make an informed decision as to whether to accept the risk and have sex with him; or

ii) to undergo regular HIV testing to determine that he is not HIV infected at the time of sexual intercourse; or

iii) to take reasonable precautions to protect the partner, e.g. by using the condom. 

While we encourage such a person to take all three steps to protect his partners, he is legally protected if he takes any one of the three steps. Prof Thio asked what constituted “reasonable precautions” to prevent transmission.  In the current state of medical science, this means the correct and consistent use of condoms each time a person has sex. 

For the purpose of this Bill, a “promiscuous” person who practices safe sex by using condoms every time he engages in sexual activity is not considered at high risk of contracting HIV/AIDS.  Dr Lam asked me to define promiscuity by stating the number of partners.  It is really not possible to put a number to this, but what is clear is that having unprotected sex with people with unknown HIV status simply increases the risk. 

I agree with Mdm Halimah’s observation that in the dynamics of a marital relationship, a husband is unlikely to be truthful about his infidelities and a wife is unlikely to testify against her husband.  Such complexities in human relationships cannot be avoided.  But this new legislation would offer an innocent spouse who is infected the possibility of redress from the reckless behaviour of her husband.

Here, I would add that our experience in working with HIV positive individuals is that the majority do inform their sexual partners voluntarily.  However, that is only after they have discovered they are HIV positive, by which time they would have been engaging in high-risk behaviour for a while.   

Prof Thio had asked what constitutes informing a partner of the risk of contracting HIV, and raised the possibility of conflicting evidence.  Let me return to the spirit of this provision.  The intention is that a person who knows that he is HIV positive, or that he had been exposed to a significant risk of contracting HIV, to act responsibly and inform his sexual partner of the risk of contracting HIV from him.  How such information will be communicated between partners will be different in every relationship and in every sexual encounter.  We can expect some will be more truthful and direct while others may try and hide the extent of their indiscretions.  We do not intend to prescribe a consent form to be signed or some standard words to be uttered.  In a prosecution, the courts will look at the unique circumstances of the case, and decide whether there had been sufficient disclosure of the risk.

As for the possibility of conflicting evidence, this is to be expected.  Sometimes, complainants may embellish their evidence for reasons of jealously or anger.  Witnesses may be uncooperative because of embarrassment or because they have feelings for the accused person.  We will be sensitive to all these dynamics when investigating a complaint.  If, after careful investigation and evaluation, we conclude that there is an offence, our findings will be submitted to the Attorney-General who will again assess if there is evidence to support a prosecution.  If the Attorney-General decides that there is, we will then leave it to the courts to weigh the evidence given by the accused, his complainant and other witnesses, and decide on the case. 

Mdm Halimah suggested that we investigate every new HIV case for possible breach of the new section 23.  However, there must be victims who are prepared to testify against their sexual partners, before an investigation is likely to uncover anything.   

But, we do follow up on every new case of HIV infection for contact tracing.  This way, every known sexual partner who has been put at risk will be traced for counselling and HIV screening.

Dr Lam asked about the “window period” and the validity period of HIV negative tests.  Current evidence suggests that up to 97% of the newly infected patients have a window period of 3 months, although the majority would have detectable antibodies within 2-8 weeks after infection.  The standard practise by the doctors today is to advise anyone who has a negative test within 3 months of last exposure to the risk of HIV infection to be retested more than 3 months after that exposure, to ascertain that indeed he does not have AIDS or HIV Infection.  In order not to be liable for an offence, the person must have a negative result outside the window period.  The negative result would be valid so long as the individual does not have a new exposure to the risk of infection.  As for whether section 23 of the Bill will apply to both males and females, the answer is “yes”. 

Prof Thio queried why the Act does not require a known HIV infected person to take reasonable precautions to protect his partner, whereas this new provision will seem to apply to those who are at-risk but are not aware of their HIV status.  As clarified earlier, under the new provision, if an at-risk individual informs his partner of the risk of contracting HIV infection from him, his partner may still consent to unprotected sex with him.  Once a person has been informed of the risk, we leave it to the person to decide whether to accept the risk, and to take whatever precautions to reduce the risk of transmission.  I am not saying that we are unconcerned about HIV transmission where the risk is known.  Our public education efforts have always been to encourage those who choose to engage in casual sex to use condoms to avoid HIV infection.  However, we do not think it appropriate to legislate how people should have sex.  In this connection, I thank Prof Thio for her comment on our definition of “sexual activity”.  It is a fair comment, but I think the present definition should sufficiently capture the range of activities which present a risk of HIV transmission. 

Prof Thio also asked how a high-risk person who donates blood while awaiting his HIV test results, and who therefore does not know he may be HIV positive, will be treated by the law.  If he does not disclose his high-risk history, and he is subsequently found to be HIV-positive, then he would be committing an offence for making a false declaration. 

I have noted Dr Fatimah’s comment that the extended imprisonment term for HIV related offences may exceed the life expectancy of some.  But I believe it is necessary to raise the maximum penalty so that it is commensurate with the severity of these offences.  We should not look upon the offence lightly just because the offender may have a shortened lifespan.  That said, the courts will have the final say on the penalty meted out in each case.  

Mdm Halimah asked for more anonymous test sites to get more people to voluntarily go for HIV testing.  We can take a look at this suggestion.  However, from the point of view of patient care, HIV testing is but the first step.  A patient needs to be properly followed up for treatment and counselling.  Therefore, we encourage at-risk individuals to come forward to be tested in a normal clinic setting, so that the appropriate clinical management, counselling and contact tracing can be carried out.  Nearly 100 medical clinics offer HIV testing using rapid HIV test kits that can produce results in about 20 minutes.   

We will do our best to combat HIV.  But the government alone cannot stop the transmission of HIV in Singapore.  We need at-risks individuals to practise safer sex, and regularly test themselves.  That is the spirit of the new legislation.

Conclusion

Mr Speaker Sir, I thank the House once again for their support of the Bill and beg that the Bill be moved.