Tan Tock Seng Hospital Doctors' Night 2004

10 Nov 2004

By Dr Balaji Sadasivan, Senior Minister of State for Information, Communications and the Arts and Health

Venue: Raffles Town Club

Speech By Senior Minister Of State, Ministry Of Information, Communications And The Arts And Ministry Of Health At The 6th TTSH Oration At The Tan Tock Seng Hospital Doctors' Night 2004 On Wednesday, 10 Nov 2004 At Raffles Town Club At 7.25 P.M.

The AIDS epidemic in Singapore

I am honored to be here to address you. Tan Tock Seng Hospital is probably Singapore's most famous and most respected hospital in the world. This is an achievement that you have earned for yourselves. All eyes were on you during SARS. You proved to the world that SARS could be managed in a hospital without spread to Health Care Workers. And in the process Tan Tock Seng Hospital became the standard against which other hospitals in Singapore and around the world compared themselves with. You have much to be proud of and I am proud to be here. Some of you know that I spent many years learning, training and working in Tan Tock Seng Hospital. I left a bit of my heart in the hospital and I carry a bit of TTSH in my heart; And so although I had no direct part in your achievements, nevertheless, I share your pride in what you did last year.

Tan Tock Seng Hospital did not always have this pride in itself. When the hospital was being rebuilt, there was talk about changing the name of the hospital to a more English sounding name. I for one did not like that idea. Tan Tock Seng, our benefactor, to me represents the best of our Singapore heritage. Tan Tock Seng was a Singapore success story. Coming to Singapore to sell fresh produce and chickens to ships in the newly established British trading post, he was Singapore's first rags to riches story. A story of the rewards of hard work and enterprise - a story still relevant today.

In the 19th century, the rich were taken care of at their homes by physicians. The poor and discarded, yes, there were discarded people. Sailors who fell ill were discarded at the port and left to fend for themselves. The poor and discarded sick had no where to go. Tan Tock Seng in a philanthropic act paid for a building to house and care for these persons. This is probably Singapore's first major act of philanthropy - a gesture still relevant today. Today, Singapore has become rich and prosperous but there are still a few who have difficulty keeping up. We as a society must have the same generosity as Tan Tock Seng to help the poor and ensure that no one is left behind as Singapore moves forward.

Tan Tock Seng built the hospital for people of all races. This gesture resonates with our pledge to be one united people regardless of race, language or religion. At a time when slavery was the norm in a large part of America, and Englishmen made a name for themselves as slave traders and drug peddlers, Tan Tock Seng had a humanistic vision far ahead of his time.

Medical people are sometimes myopic and do not see the greatness in achievements that are non-medical. Hence, the suggestion to change the name of the hospital. But now, the name Tan Tock Seng will forever be associated with medical excellence when last year, you showed that you are equal or better than the best in the world. But last year is history and you have new challenges to meet. But if the only way to judge the future is by looking at the past, I am confident you will measure up to the new challenges.

I am here to tell you what you already know and have heard, but sometimes it has to be said again and again. Rene Laennec, the Regius Professor of Medicine in France during the Napoleonic era said "do not fear to repeat what has already been said. Men need the truth dinned into their ears many times and from all sides. The first rumor makes them prick up their ears, the second registers and the third enters." And so I have decided to repeat a message that you have heard before:

We are facing an alarming AIDS epidemic in Singapore. This should not surprise us since much of the world faces the same crisis. In 2003, an estimated 4.8 million people became newly infected with HIV. This is more than in any one year before. Today some 38 million people are living with HIV which killed 2.9 million in 2003. Over 20 million have died since the first case of AIDS was identified in 1981, which is less than 25 years ago. The epidemic remains extremely dynamic. We are a global city and Singaporeans travel around the world. When global efforts to control AIDS have failed dismally, we should not be surprised that we now face the same problem that the world has been grappling with. In Asia, the HIV infection remains largely concentrated in MSM, and sex workers and their clients. This is the case in Singapore too.

For those hearing the term MSM for the first time, let me explain what it means. It does not mean Minister's Staff Meeting although that is also called MSM. MSM is now the politically correct term in AIDS circles to mean gays or homosexuals. It stands for Men having Sex with Men. Even the UN Secretary General, Mr. Kofi Anan uses this term. Personally, I find the term a bit graphic and prefer gay which at least has a happy connotation associated with it.

Most Singaporeans often read about AIDS in other countries. They may come across reports that in Sub-Saharan counties like Swaziland and Botswana, more than one-third of pregnant women delivering are HIV positive, or that there are about 5 million HIV cases in India, or that there will be 10 million infected cases in China by 2010. The Aids problem in Singapore is not as dramatic as these reports but nevertheless just as dangerous because it has quietly crept into our society over the last two decades without much fanfare.

Most doctors are only peripherally involved in the management of AIDS and follow its development as spectators. I remember that as a young Medical Officer at Tan Tock Seng Hospital in 1981, I first read about the new disease that was affecting young healthy homosexuals in California. The following year, the term "AIDS" was coined. In 1985, just before I left for the United States, the first case was reported in Singapore. The rate of new cases diagnosed that year was 0.8 new cases per million population. When I returned in 1990, there were about 17 cases reported that year, giving a rate of 6 new cases per million population. Doctors were afraid of treating AIDS patients. I remember a young gay singer with AIDS who had a brain lesion which did not respond to treatment. He was referred for a brain Biopsy. We could not do the operation at Tan Tock Seng Hospital and so we did the case at CDC. I believe it was the first neurosurgery case done at CDC. I remember another AIDS patient, who developed paraplegia. Investigations were normal and we could not explain his paralysis. When he died, we got a consent to do a limited autopsy to discover the cause of his paralysis. However, the pathologists were reluctant to do the autopsy. After speaking to the late Prof Chao Tzee Cheng and getting his permission, I did the autopsy at CDC. The spinal cord showed inflammation from vacuolating myelitis. I think it was the first AIDS autopsy at CDC.

I left Tan Tock Seng Hospital at the end of 1993. The number of new cases that year was 64 giving a rate of 22 new cases per million population. When I returned to public service as Minister of State in the Ministry of Health in 2001, the number of new cases that year was 237 giving a rate of 71 new cases per million population. This year CDC expects the number of new cases to exceed 300 which will give a rate of about 100 new cases per million population. The number of new cases diagnosed appears to double every 3 to 4 years. At this rate of increase, we can expect more than a thousand new cases to be diagnosed in the year 2010. What is more, this is only the tip of the iceberg. According to WHO, there are about four thousand people in Singapore with HIV. We have only diagnosed less than half of them. If we do not act, by 2010, we may have more than 15,000 HIV persons in Singapore. Then, sometime in the next decade, Tan Tock Seng may very well become the AIDS hospital. There is a difference between AIDS and SARS. SARS hit you without warning. With AIDS, you can foresee the crisis. CDC is part of TTSH. If all of you put your minds together, you can come up with the solutions needed to stop this epidemic, in the same way that you conquered and stopped the spread of SARS.

We are fortunate that at the present time, the explosion in HIV infection is occurring in two distinct groups of men. HIV has not entered the mainstream population in a big way. The two groups are MSM i.e. the gays, and heterosexual men having casual sex in other countries.

Of the two, the gays are the bigger concern. CDC briefed me on the AIDS situation in Singapore. CDC believes that there is a real explosion of the disease among gays. CDC doctors told me that the gays are themselves concerned by the increase in AIDS among gays. Last year, there were 54 gays who were diagnoses with AIDS. By October, this year, 77 cases have been diagnosed. There has been a high incidence of sero-conversion among gays diagnosed this year. This indicates that the infections are recent. This recent explosion of cases is due to the promiscuous and unsafe lifestyle advocated and practiced by some gays. Men who have sex with men are at extremely high risk because of the variety of their sexual practices, the large number of sexual partners with whom they engage with in these sexual practices, and the high percentage of homosexual men who are already HIV- positive.

Recently "Her World" had a feature story with a title that went "I slept with a hundred men and one of them could be your husband." It was a story of a gay who had sex with a hundred men, some of whom were married men. I asked doctors who are involved in contact tracing if this type of reckless promiscuous behavior occurs and they said "Yes". This means our AIDS prevention message is not getting through to the gay population.

Action for Aids is a Non Governmental Organization or NGO that does AIDS prevention education in Singapore. CDC has left much of the gay community education effort to this NGO. I went into their web site to see how educational it was. In Capital letters, there was the statement "NOT EVERYONE WHO HAS SEX CONTACT WITH AN INFECTED PERSON WILL GET INFECTED." The statement is true but the statement misleads and promotes the spread of the infection by giving assurance when alarm would be more appropriate. The proper statement should be "YOU HAVE A HIGH CHANCE OF GETTING AIDS IF YOU HAVE UNPROTECTED SEX WITH AN INFECTED PERSON". Without clear messaging, we may actually make things worse by promoting unsafe sex.

I next went into www.fridae.com. It was started by a Singaporean and there was some hype about this site in the media. I was shocked by what I read. A "sexpert" called Alvin Tan, I presume "sexpert" means a sex expert, was advocating a promiscuous and reckless lifestyle. In an interview with the Far Eastern Economic Review, the CEO of the web-site said "Change at the grass roots is outpacing change at the policy level. But things are moving in the right direction." However from a public health perspective, the lifestyle advocated in the website which is a life-style of reckless regard to sexual health and safety is dangerous. Those who follow such a lifestyle will run the risk of getting AIDS. There were also many advertisements for saunas. Why so many saunas? We are not Russians or Finns.

Randy Shilts, a gay journalist wrote a book called "And the band played on". He eventually died of AIDS. As a journalist, he covered San Francisco during the early days of AIDS and he describes the events in San Francisco in his book. San Francisco had many bath-houses where rampant reckless sexual activity occurred despite the danger of AIDS. This was one reason why so many in San Francisco died of AIDS. He was attacked by many in the gay community in the US for his honest and accurate description of the promiscuous behavior of some gays which was a contributing factor to the AIDS epidemic in the US. In response to the AIDS epidemic, the San Francisco Health Department eventually banned bathhouses in the city, a health measure that helped stem the epidemic in San Francisco. CDC must ensure that saunas in Singapore do not become San Francisco style bath-houses.

Recently, Taipei police raided an all male party and tested 27 people arrested at the party. Fifteen or 55% of them tested positive. We do not know how high the incidence of HIV is in our gay population. If we do not have champions to spread the anti-AIDS message among the gay, a high percentage of them will get infected and many will eventually die. Action for Aids needs to review its messaging so that it is simple, it is effective and it promotes safety. CDC should look for more community partners in its fight against AIDS.

The second group who are HIV positive are males who have casual sex outside Singapore. Fortunately, 70% do not have a Singaporean spouse. Many are poorly educated. Spreading the prevention message to them is difficult. Perhaps a different approach will be needed. If CDC can screen high risk Singaporeans at our borders when they return, we may be able to protect Singapore women from catching AIDS from these men.

When I visited CDC, I wanted to give them a hypothetical case to ponder on. You may have read about the German who knew he had HIV but nevertheless went to Thailand and infected hundreds of women. He refused to give consent to the Thais to test him. The Thais deported him. We do not know who this German is. I wanted to ask CDC, what they would do if this German came to Singapore.

Before I gave them the question, they gave me a hypothetical case which they wanted me to ponder over. I want to share this hypothetical case with you, so that you may all sleep over the problem too. A 30 year old Singapore man develops HIV. He decides to go to another country and gets himself a bride who he brings back to Singapore and marries. He does not tell her he has HIV. She now becomes positive. What should we do?

The fight against AIDS is not going to be easy. Many will oppose public health measures like contact tracing and compulsory testing arguing that the right of the individual over-rides the safety of society. In the end, we must convince these people that public health measures protect everyone and it is better to have living people complaining about their rights than dead people buried with their last rights. Everyone has a role to play in this battle. As healthcare workers, you can mobilize the public and public opinion in support of CDC and the measures it may recommend in this fight. Then we will make progress. Progress in this battle will be the sum of small victories won by each of you.

Thank you.