Lessons Learnt From SARS - Its Application To HIV And Bird Flu Outbreaks

25 Aug 2005

By Dr Balaji Sadasivan, Senior Minister Of State For Information, Communications And The Arts And Health

Venue: East India Room, Raffles Hotel

Ladies and Gentlemen

Good morning.

SARS, HIV/AIDS and Bird flu are caused by viruses. They are infectious diseases in which there is a public health concern about the spread of the disease from one person to another. We overcame SARS in 2003. I believe that lessons learnt from our SARS experience can be applied in our public health response to the HIV/AIDS epidemic and in our response plans to a Bird Flu outbreak should it occur.

I would like to discuss 5 lessons from the experience with SARS that can be applied in the response to other infectious disease outbreaks.

The first lesson learnt during SARS is the importance of public communication. If public support is needed, then the public health problem must be explained to the public in as accurate a manner as possible without resorting to medical jargon. We have started on this process in our response to HIV/AIDS. HIV/AIDS is a multifaceted disease. Over the last 10 months, we have shared information on different aspects of the disease with the public. In summary, WHO estimates that there are about 4,000 to 5000 infected persons in Singapore but so far only about 2,500 persons have been diagnosed. Last year, there was a record 311 new cases of HIV diagnosed. Ninety-three percent of the cases are men - with two significant risk groups - Gay men and lower-educated single men who have casual sex with sex workers abroad.

The second lesson from SARS is that the public health response must be comprehensive and must be developed using evidence based science. This is an important and difficult challenge in the formulation of programs for HIV/AIDS. In most cases, HIV/AIDS is a sexually transmitted disease and so the spread and control of the disease requires discussion about sexual behavior. Intervention to prevent the spread may require the acknowledgement of sexual behavior that is not approved by segments of society. People's attitudes towards sexual behavior are influenced by deeply held religious and moral beliefs. These beliefs must be respected when developing the response plan.

Our AIDS program has three components. The first component is AIDS prevention education. The second component is the implementation of the four recommendations on AIDS prevention made by the Communicable Disease Centre in Atlanta. We have so far implemented two of them.

The first recommendation is to increase the antenatal HIV testing of mothers to prevent mother to child transmission. Last year, less than 30% of pregnant mothers were tested for HIV. This year it has increased to 98% in our public hospitals.

The second measure recommended is to incorporate HIV testing as a routine part of medical care. Cumbersome HIV specific rules hampered a proper medical approach to the diagnosis and treatment of HIV infection. These rules stigmatized HIV infection in the medical setting. To promote awareness of HIV and make HIV testing a part of routine care, in July this year, we prohibited the stigmatization of the HIV test and directed the medical profession to treat HIV infection in the same manner other infections would be treated. Medical indications and medical professionalism would guide the decision to do HIV testing and HIV infected persons will have a right to a proper standard of diagnosis and treatment just like other patients.

We have two more recommendations to implement. They are the introduction of HIV testing in the non-medical setting such as the use of self-test kits and working with HIV positive persons to reduce the spread of HIV.

The last component of our program is to fight discrimination against HIV positive people. If we can eliminate discrimination against HIV positive persons, more people will test themselves. The disease will then be diagnosed earlier. There will be less spread of the disease, and HIV positive persons will be started on treatment earlier resulting in a better outcome for them.

The third lesson from SARS is that the active support of all segments of society is needed to bring an infectious disease outbreak under control. This was true with SARS and is true for HIV/AIDS. My Ministry has therefore been engaging all groups in our fight against HIV/AIDS, including religious leaders, youth, community groups, workers, women, and MSM. We need the support of the business community, too.

I believe it makes business sense for businesses to develop and implement a HIV/AIDS policy. Businesses cannot avoid having to deal with the problem. Worldwide, there are more than 40 million people suffering from HIV/AIDS. More than 25 million people have the infection in Africa. India and China will be new epicenters of the disease with both countries having about 10 million infected persons each by the end of the decade. In three South East Asian countries - Thailand, Myanmar and Cambodia - more than 2% of the adult population is infected. Malaysia has between 80,000 and 160,000 infected persons. The United States has about a million infected persons.

Singapore is a global city and an international travel hub. We have to be prepared for the onslaught of AIDS in Asia. That is why, although our HIV prevalence rate is low relative to other countries, the rate being about a quarter of that of the US, we are pro-actively taking measures to control the disease. We are especially concerned because the number of new HIV cases in Singapore is increasing geometrically. It would be prudent for businesses to take note that no country can insulate itself from HIV/AIDS. The logical solution therefore is to be prepared and to develop solutions that minimize the consequences. My Ministry will be happy to work with businesses to help them be prepared.

There are two important areas where businesses can make a major difference. The first area is in AIDS education. Many of you in today's audience run big organizations and have many employees. If your organization has an AIDS education program, all members of your organization can be taught about AIDS prevention. As the prevalence of AIDS is increasing, companies will have to learn how to deal with the HIV positive worker. Part of the solution requires education of the co-workers about working with HIV positive persons. This will go a long way towards reducing the fear and discrimination that people have towards HIV positive persons.

The second area that businesses can make a difference is to have a code of practice that does not disadvantage the HIV positive person. This will encourage the HIV positive person to get diagnosed early and start treatment early. HIV positive persons can lead productive lives. With an enlightened policy, companies can maximize the productivity of their HIV positive employees.

Last week, my staff and I had a meeting with Ms Euleen Goh, CEO of Standard Chartered Bank and her staff. They gave us a presentation about the HIV/AIDS program that they have in their organization. It is an exemplary program. I urge all business organizations to develop similar programs if they have not already done so. This requires commitment from the leadership at the top. I hope that as top business leaders, you will spare some time to personally show commitment and leadership in this fight against AIDS. Your example will make a difference.

My Ministry would like to propose an AIDS-Alliance with the business community. This will be an alliance that will eventually consist of businesses, employees, health workers and the community. Together we can work towards two goals: preventing the spread of HIV/AIDS and reducing the fear and stigmatization of HIV positive persons. I have Mr. Koh Peng Keng with me here this morning. He leads the Ministry's effort in this battle against HIV/AIDS. I hope the businesses represented here will join this alliance. The first step you can take in the battle against HIV/AIDS today is to give Mr Koh your business card so that we can contact you.

Be prepared. This is the fourth lesson I think we can learn from our SARS experience. Over many years, we had invested in training epidemiologists, infectious disease specialists and in building health and research infrastructure. During SARS, this preparation helped. We had epidemiologists who worked out the pattern of spread of SARS and clinicians who developed treatment and practice protocols. Research staff from the Genome Institute sequenced the virus and from this work, test kits were developed. Defense research workers developed the thermal scanners which were used by many airports around the world.

We are applying this lesson in our bird flu outbreak response preparations. WHO has been working with Singapore and regional countries on bird flu preparedness. We have our response plans ready and will implement them, if needed.

This brings me to the fifth lesson learnt from our SARS experience. We must deal with any infectious disease outbreak with an open mind and modify our responses as we learn more about the disease. The SARS infection had unique features. An infected person was not infectious until he was febrile. So the strategy of temperature taking and quarantine was developed and the strategy worked. Many viral infections do not behave in this manner and are usually infectious before the onset of symptoms. At the onset of the SARS outbreak, we feared that if the infection spreads into the community, we would lose control of the outbreak. But later, we realized that the infection was actually being perpetuated by the hospitals and that the outbreak would peter out in the community.

Although our bird flu preparedness plan is influenced by our SARS experience, the next pandemic will have its own unique features. We should not assume that it will behave in a particular manner and that our planned measures will always work. Rather, we should be open to changing our response as the features of the bird flu outbreak or any other pandemic become apparent.

Our attitude to HIV/AIDS control should be the same. Some of our control measures may not always be successful. We should keep an open mind and be willing to change our plans as we go along. We should consider all feedback and ideas seriously. We don't have all the solutions. But if we work with the community and businesses as our partners, I am certain we will succeed in bringing HIV/AIDSs under control.

Thank you.