INFECTIOUS DISEASES (AMENDMENT) BILL

INFECTIOUS DISEASES (AMENDMENT) BILL: Order for Second Reading read.

2.29 pm

The Minister for Health (Mr Khaw Boon Wan): Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time.”

Five years ago, SARS appeared suddenly and, for three months, caused havoc around the world. We lost 33 lives in Singapore. SARS taught us many lessons.

First, infectious diseases are here to stay and new diseases will continue to surprise mankind. We cannot let our guard down.

Second, in the fight against infectious diseases, being proactive is necessary to pre-empt the escalation. Reacting to the epidemic will grant the disease a headstart which can prove disastrous.

Third, fighting infectious diseases requires a joint effort by all. The public, in particular, plays an important role. Mobilising and galvanising the people into action, in turn, require transparency and timely information. Prompt sharing of information with the people, what we know and what we do not yet know, helps to build trust, reduce speculation, fears and panic.

Fourth, we need effective legislation to mount a successful war against an epidemic.

The Infectious Diseases Act is our principal legislation for the control and prevention of infectious diseases. SARS exposed some gaps in our legislation which we promptly plugged. The House would recall that we met in the middle of the SARS crisis to make urgent amendments to the Act to provide the Health Ministry with additional powers to bring SARS under control.

We have since significantly strengthened our capacity and capability to detect, prevent and control outbreaks of infectious diseases. For example, we have acquired stronger capability in disease surveillance, contact tracing and quarantine. Our hospitals have updated their infection control protocols to deal with potentially infectious patients. They have created many more isolation rooms and built up a stockpile of essential medical supplies and drugs. We conduct regular exercises among Government agencies and healthcare institutions to test our response. Internationally, we also work closely with the World Health Organisation and other countries to reduce the threat of the spread of infectious diseases across international border.

Nevertheless, we have to be prepared for new public health threats that could be a lot more severe than SARS. While SARS is infectious, it requires intimate intensive contact with a patient who is quite ill before transmission can succeed. That was why most of the SARS victims were doctors, nurses and other hospital staff and close relatives who cared for the patients. An exception was a minority of patients who for some reason ended up with very heavy virus load; they became highly infectious even for short encounters. Fortunately, their number was small. Moreover, only patients with clear symptoms such as fever were infectious. They could therefore be identified through temperature screening and can be promptly isolated.

But what if a virus comes along which is a lot more contagious than SARS and not easily identifiable? For example, if it is air-borne, a patient in a cinema or a shopping centre can easily infect many others who happen to be in the same enclosed space. Or what if an infected person can be infectious yet without showing any physical signs? This is not theoretical. One such threat is that of a global influenza pandemic should the current bird flu mutate and become much more efficient in human-to-human transmission. It had happened before. The Spanish flu of 1918 was just one such example.

Influenza spreads rapidly because its incubation period is short, about two days, and it is highly transmissible. Unlike SARS, those infected may develop no or very mild symptoms, yet they are infectious. So contact tracing and quarantine may not be totally effective.

In such a scenario, what we can do is to restrict and reduce social interactions through “social distancing” measures – this is a technical term and it just means prohibiting mass gathering – in order to slow the spread of the disease in the community. For instance, schools can be closed. Cinemas and shopping centres may have to be closed too. This will buy us valuable time until an effective vaccine becomes available. Social distancing will also reduce the peak of the pandemic, in other words, reduce the maximum number of casualties, thus minimising the burden on our hospitals and healthcare institutions.

To be effective, social distancing measures have to be implemented soon after the first local cases appear, before the outbreak has become widespread. But we would need to have the powers to effect social distancing measures swiftly.

The current IDA allows the Ministry to prohibit specific meetings, gatherings and public entertainments when the holding of such events is judged to increase the spread of any infectious disease. But it requires us to issue individual prohibition order to prohibit each meeting or each gathering. This will be too slow in a major crisis like the flu pandemic. Valuable time and scarce public health resources will be wasted to bring all the premises under control. This gap in our legislation will need to be closed.

This is the main purpose of this Bill, to provide my Ministry with the necessary powers to impose social distancing measures speedily in response to a potential severe public health emergency as described. At the same time, I am taking the opportunity to do three things: (a) to refine the existing legislation, (b) tighten one aspect of HIV/AIDS control measures, and (c) to update our laws to conform with the 2005 WHO International Health Regulations.

Mr Speaker, Sir, let me elaborate on each set of the proposed amendments.

Public health emergencies

First, the amended Act authorises the Minister to declare a public health emergency if he is satisfied that an outbreak or an imminent outbreak of an infectious disease poses a substantial risk for significant deaths and disabilities in the population. Once such a declaration has been made, my Ministry will be able to take measures necessary to (a) prevent the spread of disease through social distancing measures, and (b) mobilise civil resources to help fight the outbreak.

Restricted zones

Clause 12 of the Bill inserts provision in the Act under which the Minister may establish restricted zones, after a public health emergency is declared. The entry and stay of persons in any premises or the holding of public gatherings in such restricted zones may then be restricted or prohibited, in order to minimise opportunities for disease transmission through person-to-person contact or contact with the contaminated environment. This can be quickly and effectively implemented by allowing the blanket prohibition of all or selected gatherings, meetings or public entertainment or closure of all or selected premises island-wide. Police and other authorised officers will be empowered to enforce compliance in a restricted zone.

Invoking such a provision has serious implications as it will cause major disruptions to the businesses and the daily lives of Singaporeans. Such a decision will not be taken lightly. We have therefore put in safeguards. First, every declaration of a public health emergency and restricted zone will expire after 14 days unless it is renewed. Second, the Minister must ensure that such orders are published through appropriate media so that the public will have notice of it. Third, every order must be presented to Parliament as soon as possible after it is made. The Minister will have to argue his case and justify the declaration of such an order. Parliament may annul the order if it does not agree.

Requisition of resources

Fighting a disease outbreak requires the participation of many sectors. The Ministry of Health and its resources alone will not be sufficient. For example, during SARS, we had to use holiday chalets and hostels as quarantine facilities. Auxiliary police officers were called upon to deliver quarantine orders and monitor those who were quarantined. From the SARS experience, we can anticipate that in the event of a more serious outbreak, massive resources, both from the Government as well as from the private sector, will need to be mobilised. To effect this, clause 36 of the Bill makes consequential amendments to the Requisition of Resources Act so that civil resources and services, including those found in the private sector, such as private hospitals, ambulances, doctors, nurses and other paramedical personnel, may be mobilised to help combat the outbreak.

Specifically, when a public health emergency has been declared under the Infectious Diseases Act, the Minister may order Part III of the Requisition of Resources Act to be brought into operation if additional land, property and services are needed to secure public safety. Owners of these assets will be suitably compensated in accordance with the Requisition of Resources Act.

Strengthening existing powers

Mr Speaker, Sir, let me now discuss the second set of proposed amendments to strengthen the management and control of infectious diseases under normal circumstances.

Enhanced powers for infectious disease surveillance

To respond to an infectious disease, we need sensitive and robust disease surveillance, to alert us to any outbreaks or imminent outbreaks. Currently, we monitor the local infectious disease situation through a system of mandatory disease notification by doctors and laboratories, and studies to measure population immunity against various infectious diseases. Clause 4 of the Bill will enhance our disease surveillance powers, by amending section 7 of the Act to empower the Director of Medical Services to obtain residual blood or body samples in the healthcare institutions to determine the level of immunity within the population or to monitor and track infectious diseases trends.

The primary focus of this additional measure will be the pooled statistical data. However, if there is a need to contact a patient from whom a sample was obtained, such as for the purposes of contact tracing or to provide urgent medical treatment, we may invoke our powers to do so under the Act.

Compliance by minors and those mentally or physically incapacitated

Clauses 5, 9 and 10 of the Bill amend the Act so that the Director of Medical Services may require the parent or guardian of a minor to ensure his compliance with an order to undergo medical examination, treatment, surveillance or quarantine in order to control the spread of an infectious disease. These provisions will only be invoked if it is assessed that the minor will not be able to understand and comply with an Order given to him. Furthermore, clause 30 amends the Act so that a police or Health Officer may take necessary measures to give effect to an Order for the medical examination, treatment, surveillance or quarantine of a person who is mentally or physically incapacitated.

Enforcement of orders issued under the IDA

Currently, to prevent or limit the spread of an infectious disease, the Director of Medical Services may order an overcrowded building, food establishment or a business to be closed, or to prohibit a meeting, gathering or public entertainment. Clauses 13 to 16 of the Bill will amend the Act to empower the Director to enter premises to enforce such an order. As a safeguard, any person aggrieved by such an order may appeal to the Minister within seven days of the order. As an additional safeguard, an order to prohibit gatherings or close premises will expire after 14 days unless it is renewed.

Appointment of Health Officers

The Act provides for Health Officers to be appointed with extensive powers to effect the prevention and control of infectious diseases. Clause 3 of the Bill will amend section 4 of the Act, so that an employee of an institution which the Minister must prescribe in subsidiary legislation may be appointed as a Health Officer. This will enable the Ministry to appoint the healthcare staff in public restructured healthcare institutions such as the Communicable Disease Centre for this purpose. These officers perform important public health duties, such as contact tracing, patient counselling and epidemiological investigations, as part of their course of work. The intent is to designate the public restructured healthcare institutions as the “prescribed institutions” under subsidiary legislation, which operate with MOH oversight.

Powers of investigation and arrest

To ensure compliance with the Act, clauses 29 and 30 will introduce provisions to empower my Ministry to investigate offences under the Act. These include powers to record statements, enter and search premises, and seize evidence. It will also allow Health Officers to arrest a suspect without warrant for certain offences under the Act.

National public health research

When faced with a new infectious disease threat, it may be necessary for us to expedite research into more effective control measures or new diagnostic tests or treatment. Clause 32 of the Bill will amend the Act to empower the Director of Medical

Services to acquire information or existing samples from patients, or order a doctor to obtain, with consent, additional samples from patients under his care, to facilitate such national public health research. The information and samples will be anonymised to protect medical confidentiality. In deciding whether to invoke this power, the Director must first consider the public health risk of the disease and the potential benefits of the research to Singapore. MOH will work with the relevant clinicians, researchers and other stakeholders to carry out such research.

Enhanced measures to prevent and control HIV/AIDS

Mr Speaker, Sir, let me now discuss the third set of proposed amendments concerning HIV/AIDS. HIV remains a problem in Singapore. The number of new cases continues to grow. In 2001, there were 237 newly notified HIV cases. Last year, that number has almost doubled to 422. The main mode of transmission of HIV in Singapore is through unprotected sex with a HIV-infected person. Section 23 of the current Act states that before sexual intercourse, a person who knows of his HIV status is required to inform his sexual partner of the risk of contracting HIV from him. If the partner willingly accepts the risk, no offence is committed. Doctors regularly inform HIV patients about this law at the point of diagnosis.

This law, however, is effective only when a person knows that he is HIV positive. Despite the easy access to testing in Singapore, it is estimated that for every known HIV case, there could be another one to two cases who are infected but remain undiagnosed, until the symptoms appear. The latter group may continue transmitting HIV unknowingly to their partners for many years during the asymptomatic period.

Clause 18 amends section 23 of the Act to shift greater responsibility to individuals whose sexual behaviour, for example, puts their spouses and partners at risk of contracting HIV/AIDS. A person who has reason to believe that he has or has been exposed to a significant risk of contracting HIV/AIDS must take reasonable precautions to protect his sexual partner, such as by using condoms, even if he is ignorant of his HIV positive status. Alternatively, he can go for a HIV test to confirm that he is HIV-negative. Otherwise, he must inform his partner of the risk of contracting HIV from him, leaving the partner to voluntarily accept the risk, if he or she so wishes. The objective of this amendment is therefore to help promote condom use and regular HIV testing, while sending a strong message that no one has a right to put others at risk through his irresponsible behaviour.

It is not our intention to go after every HIV infected person. We will only act if there is a complaint from an aggrieved victim, and only after a thorough investigation to establish the facts.

The Bill will also amend the Act to raise the penalty for HIV/AIDS related offences. The increase in the penalty reflects the seriousness with which society views such offences and, we hope, would deter potential offenders.

2005 WHO International Health Regulations

The final set of proposed amendments is technical in nature, to update our legislation to be in line with the 2005 WHO International Health Regulations. Under the regulations, Singapore may be required to disclose the identity of an infected person to the World Health Organisation or a member-state. Clause 31 amends the Act to allow for this. Disclosure of the identity of an infected person in other cases, and which are not governed by other laws, will be subject to strict requirements in order to protect patient confidentiality without compromising the public interest.

Clauses 21 to 27 amend the vaccination requirements in the Act to comply with the WHO International Health Regulations.

Mr Speaker, Sir, no country would welcome a disease outbreak. But, unfortunately, globalisation and jet travel have combined to raise the risk of such a crisis. We hope that it will never happen in Singapore but mere wishful thinking will not protect our people. The more we assume that we will be hit and actively prepare for one, the more likely that we can minimise the number of casualties when a crisis strikes.

This Bill is part of our preparation for such an eventuality. I hope to get the support of all Members for this Bill.

Sir, I beg to move.

Question proposed.

2.50 pm

Mdm Halimah Yacob: Mr Speaker, Sir, I rise in support of this Bill. I want to commend the Ministry of Health for its single-mindedness in dealing with the threat of infectious diseases. This Bill will put Singapore in a better position to deal with the spread of infectious diseases. According to the World Health Organisation, infectious diseases are spreading faster than ever before. In fact, there is a new one shaping up each year. The WHO wants countries to crank up their efforts to fight disease outbreaks and share data on viruses to help develop vaccines. Otherwise, it says that there could be devastating consequences for the global economy and for international security.

In this context, Sir, we are indeed taking a step forward by passing this Bill which would provide us with additional ammunition in the fight against infectious diseases. We did a wonderful job in dealing with SARS and obviously the shortcomings that the Ministry of Health found in our legislation which constrained its efforts at that time have formed the basis for some of the current changes. However, while the objective is noble and clear the fact that the Bill gives pretty extensive powers to the Ministry of Health as part of the social distancing measures has raised some concerns. A case in point is the blanket prohibition of all or selected gatherings, meetings or public entertainment or closure of all or selected premises islandwide. As the Minister himself acknowledged, such a provision has serious implications as it will cause major disruptions to the businesses and the daily lives of Singaporeans, not to mention the curbing of certain civil liberties. There are also other examples, such as the power given to health officers to arrest a suspect without warrant for certain offences under the Act.

It is important, Sir, that with such extensive powers accorded to the Government agencies, Singaporeans are given a clear assurance that these powers will be invoked only in very grave situations where alternative arrangements are not workable. I would like the Ministry to explain further on the safeguards that are in place to protect Singaporeans from arbitrary use of such powers. I am not aware of any other country that has such laws and I do not recall the Minister mentioning that such powers exist elsewhere which, therefore, calls for greater caution before they are exercised here as we do not really know the impact. At the end of the day, Sir, we all understand that this is a matter of balance, the right of individuals and businesses to carry on with their tasks uninterrupted as against the interest and common good of the public, but we have to draw the line and how it is implemented are also important issues.

Sir, I also think that it is important, even as we talk about information, resources and systems, that the Ministry focuses on adequate training for our healthcare professionals, whether in the public or private sectors, so that they are well equipped to deal with an emergency if one arises. We may have experience with SARS but we cannot take things for granted as at the end of the day, it is the people factor that makes the big difference. I would also like to urge the Ministry to engage the public, perhaps through the community engagement programme, so that Singaporeans are better prepared if there is an outbreak of infectious diseases.

Sir, the other comments I have to make with regard to this Bill are in relation to the provisions on HIV/AIDS. Again, I understand the objective for the amendment and I support efforts to curb the rise of HIV/AIDS infection in Singapore. The numbers have been increasing rapidly and there are now more than 3,000 HIV infected Singaporeans. At the same time, the rate of voluntary testing has not been fantastic. Only 13% of the HIV cases were detected through voluntary testing and 78% were detected when they were tested for HIV while receiving other medical care. Also, while two-thirds of those infected through sexual intercourse got it from heterosexual sex, just 3% of infected heterosexuals were found through voluntary screening. With such a dismal record of voluntary testing, MOH's concern of infections spreading through the reckless behaviour of high risk individuals is not without basis. However, we know that the heavy hand of the law alone is not sufficient to deal with this problem. Education and empowerment, particularly among women, are equally important. Women need to be taught that they have a right to safe sex, a healthy life and, most importantly, the right to say no.

The new section 23, Sir, now provides that a person who has reason to believe that he has or has been exposed to a significant risk of contracting HIV/AIDS must take reasonable precautions to protect his sexual partner, even if he is ignorant of his HIV status, otherwise he must inform his partner of the risk of contracting HIV from him. The objective of this change is good as its intention is to curb irresponsible sexual behaviour. However, Sir, the implementation and enforcement of this law can present serious problems. This law will kick in only if there is a complaint from an aggrieved victim. This requirement practically means that the law may end up quite ineffective. First, no one is going to admit to high-risk behaviour and it is not something that you can monitor. In the first place, what amounts to "reason to believe" or high risk behaviour? Does this include someone who has sex with multiple partners but who practises safe sex? Which husband would be prepared to reveal to his wife about his infidelities and risk breaking up his marriage? Would a spouse who is tested positive be prepared to complain against the husband and, therefore, exposing him to the risk of being jailed and bringing more misery to the family?

There is also the question of proof. The law will kick in only if a person is tested as HIV positive and his or her partner is also tested positive, by which time it may be too late. There are no preventive elements under this law. Hence, Sir, I would like to ask the Ministry to consider the following to make the law more effective:

First, if a patient is diagnosed to be HIV positive but does not complain about the partner, the Ministry should still investigate the case to establish whether the partner, if he or she is HIV positive and has informed the patient of the risk involved before sex, and take the offender to task.

Second, since all newly diagnosed HIV cases are required to be reported to the Ministry, I suggest that the Ministry look into these cases to confirm whether the offence of failing to inform partners of the risk has been committed under the law.

Third, could the Ministry also clarify if the victims are unable to provide details of their partner(s) for investigation, especially for those with multiple partners, how will the offenders be brought to justice? Also, how will the case proceed if the victims are unwilling to testify against their spouses or partners?

Fourth, as the rate of voluntary testing is still very low in Singapore, could the Ministry invest more resources to set up anonymous testing sites to encourage people to get tested voluntarily and with full confidentiality? This is in line with the objective of this new law which is to push those in the high risk group to go for HIV testing to prove that he or she is HIV negative to exonerate himself or herself under the law.

Fifth, could the Ministry indicate what are its plans and strategies to curb the rise of HIV/AIDS as the number of new cases reported last year has now almost doubled that in 2001 and it is cause for concern?

Sir, I would also raise three other points and this is arising from the written reply given by the Minister in response to my Oral Question yesterday, and that is with regard to voluntary HIV testing by our doctors in the public hospitals. The Minister had said that the risk is only two to 24 per million of such an incident happening, that is a doctor who is HIV infected and, therefore, infecting the patients. I would like to ask the Ministry whether the Minister would agree that even if the risk is only two to 24 per million, it is still a risk. But doctors who have agreed to uphold the Hippocratic oath should not expose their patients to

risk, how would the Ministry explain to a patient who contracts AIDS that he had contracted it from a doctor who has refused to undergo HIV testing?

Second, would the Minister also agree that if doctors themselves are not prepared to subject themselves to HIV testing, then would it not make it even more difficult for the Ministry to persuade ordinary Singaporeans who seek treatment at public hospitals to agree to this testing, which is currently voluntarily done in hospitals such as CGH?

Third, Sir, I welcome the establishment of an expert committee, mentioned also in the Minister's written reply to my Oral Question yesterday, but I would appreciate a further elaboration from the Minister on the objective of this committee and when this committee will come up with its recommendations.

Sir, infectious diseases have become a serious menace worldwide. As someone has observed, "the worst case scenario is the pandemic of a disease, such as influenza, which spreads rapidly and out of control, going from person to person and from country to country, with inadequate supplies of drugs or vaccines to deal with it, with a large number of deaths and a huge number of illnesses. And beyond the human cost, there are gigantic economic costs and disruptions".

Sir, this Bill is aimed at dealing with such a tsunami, before it hits us. It is aimed at helping us to move quickly, have access to timely information and galvanise all available resources. It is also aimed at making sure that individual Singaporeans too take ownership and responsibility for containing the spread of infectious diseases.

On this note, Sir, I support the Bill.

3.02 pm

Prof. Thio Li-ann (Nominated Member): Sir, the spread of infectious diseases such as SARS, Avian influenza and AIDS, has global, national and personal implications. Containing infectious disease, through precautionary and control measures, is a pressing public health priority. In moving these amendments to the Infectious Diseases Act, the Government seeks to discharge its obligations to its citizens as trustee of the common good of public health, while managing concerns about confidentiality concerns and other individual interests.

Section 59A, for example, requires the anonymisation of information or human samples provided in relation to national public health research.

Conversely, compelling public health imperatives may outweigh confidentiality interests. Section 57A(1)(b) authorises the Director of Medical Services to disclose information to the World Health Organisation in order to comply with Singapore's international obligations. Clearly, infectious diseases are transnational in nature, as viruses are no respecters of physical borders.

Sir, the proposed new section 8 details what "medical examination" of a person "who is or is suspected to be" a "case or carrier or contact" of an infectious disease might entail. Section 8(2) states this may include X-rays, taking blood samples and "other body samples for testing and analysis." No consent is needed.

I have two comments. First, a person is guilty of a section 8 offence if he fails to undergo a compulsory medical examination, where the Director so requires, "without reasonable excuse".

This places a legal obligation on the individual to act reasonably or be penalised; acting reasonably is a defence for non-compliance with the Director's orders. Beyond law, this duty to act reasonably is also part of our unwritten social constitution. This relates to the unwritten but fundamental rules of honour, decency and responsibility which make our common life possible, form the backdrop to our laws and shape how we understand the rights and duties of citizenship.

I would suggest that the duty to act reasonably cuts both ways. The Director would also be expected to act with reasonable grounds but the current section 8(1) does not legally oblige him to do so. While we may expect someone entrusted with high public responsibility to act reasonably, the law should provide for worst case scenarios.

This could be addressed by amending section 8(1) to read: "The Director may require any person who is reasonably suspected to be ...". The reference to reasonable suspicion would underscore the importance of having an objective evidential basis to justify the making of orders. Discretion must never be unfettered; legislators can facilitate the principled exercise of discretionary powers by identifying clear guidelines that condition how administrative actors deploy such powers. This would strengthen the rule of law.

My second comment relates to section 8(2). This gives examples of what may be taken from a person's body during a medical examination such as blood or "other body samples" for testing and analysis. This is an intrusive procedure, though justifiable on public health grounds.

To clarify that what should be taken should be no more or no less than what is necessary for testing and analysis, it may be prudent to insert the words "as is necessary", to prevent the gratuitous extraction of blood or body samples.

I would appreciate it if the Minister could clarify what "other body samples" might include - tissue samples for example? If a person was suffering from encephalitis (which causes brain inflammation), would the "body samples" include a part of his brain? Or a spinal tap?

Would that person be guilty of an offence under section 8 if he submitted to routine medical examinations, like X rays and blood tests, but refused to submit to more invasive 'examinations' such as removing part of an organ?

Sir, the defence of "reasonable excuse" applies for offences committed under various sections, including sections 7, 8 and 15. Under section 8(4), non-submission by a suspected person to a medical examination without reasonable excuse is an offence. What might the content of this defence be? Could the Minister elaborate on what might constitute a reasonable excuse or identify factors relevant to assessing the reasonableness of an excuse?

For example, what if a person from a high risk group refuses to go for AIDS testing, because of the stigma, and claims a putative right to privacy in that respect? Would this be a reasonable excuse, given the compelling public health issue involved?

What kind of "reasonable excuse" can be offered under section 15 where a suspected carrier of an infectious disease like SARS refuses to comply with the Director's quarantine order that he be detained and isolated in a hospital, given the clear and present danger to the community's health in epidemic situations? It would be helpful if the Minister could provide some examples as guidelines, either from experience or study, which will help in interpreting these provisions.

Sir, the power under section 17A to declare a public health emergency and to declare all or part of Singapore to be a restricted zone to secure public health and safety is an intrusive and extensive one. The Minister must be satisfied there is an outbreak or imminent outbreak of an infectious disease which poses a "substantial risk" of causing a significant number of human deaths or incidents of serious disability in Singapore. It is worth noting that the drafting of section 17A reflects the intent that this power should not be lightly used, such as if a 'trigger happy' Minister invokes this power where an outbreak is merely speculative and the risk of human deaths is relatively minor. This would presumably be an abuse of discretion.

Under section 17A, the Minister may regulate the entry and stay of persons within the Restricted Zone and prohibit public meetings - this will limit associational rights and the freedom of citizens to move freely throughout Singapore under Articles 14 and 13 of the Constitution. Such rights are not absolute, as the Constitution recognises.

But neither are ministerial powers, absolute powers - section 17A orders have time limits; they expire every 14 days and are renewable for 14-day periods. As the rule of law requires that laws be known so that people can direct their behaviour accordingly, section 17A(5) requires such orders to be brought to the notice of all persons who, in the Minister's opinion, ought to have such notice. Such orders take effect without publication in the Gazette , which is a form of constructive notice, even though the average man on the Yishun MRT does not read the Gazette . Can the Minister speak to what practical steps will be taken to ensure that affected persons will receive actual notice of such orders?

Sir, the amended section 23(1) embodies the ancient Latin maxim of volenti non fit iniuria , which means that if you consent to a risky venture, you cannot complain when the risk materialises. It entails the voluntary taking of a risk. This implies that a person needs to know about the risk, such as consenting to undergo risky surgery.

Section 23(1) is a partner-notification measure; it requires a person who knows he has AIDS or HIV, not to engage in sexual activity with another person unless two conditions are met:

First, the other person must be informed of the risk of contracting AIDS/HIV from the infected person;

Second, that person voluntarily agrees to accept that risk. Section 23(5) provides that a person is deemed to know he has AIDS/HIV if the positive results of a serological or other relevant test have been communicated to him.

I read a Wall Street Journal article entitled "The Charge is Murder, the Weapon, AIDS". It described how prosecutors in various jurisdictions struggled to apply legal codes authored before Gay-Related Immune Deficiency or GRID, as AIDS was originally known, existed.

For example, a New York county district attorney wanted to charge a certain person who knew he carried the AIDS virus with attempted murder, as he claims to have slept with 50-75 women after he knew he was infected. However, the difficulty lay in the need to prove the carrier intended to kill.

AIDS is deadly. The amendment to section 23(3) to enhance the penalty for failing to inform another person of the risk of contracting AIDS from a known carrier before sexual activity correctly reflects the gravity of the matter. Offenders may now be fined a maximum of $50,000, up from $10,000; the maximum period of imprisonment has been raised from two to 10 years. This reflects the seriousness with which knowingly exposing others to the risk of AIDS/HIV is viewed. This is compounded by the fact that a potentially large pool of victims may be involved.

In addition, the net of culpability has been widened in section 23(2) to include a person who does not know he has AIDS or HIV but who has "reason to believe" he has been exposed to a "significant risk" of contracting AIDS/HIV.

A "reason to believe" must rest on an objective state of affairs, for example, engaging with multiple sex partners regularly or at any one occasion. Promiscuity has its costs in terms of health risks to the participant but, obviously, the community at large also suffers the greater prospects of infectious disease transmission. The final impact of this undesirable behaviour could be geometric.

A person who consciously engages in high-risk behaviour should be held to a high standard of responsibility; he owes a duty of care to protect sexual partners or, at least, give them the choice to opt out of risky sexual activity. However, the Act correctly recognises that the sexual activity of persons with AIDs/ HIV is a public health issue involving third parties. Given the seriousness of the problem, any claims to confidentiality must be trumped by the duty to protect sexual partners and the community's right of self-defense against the grave risk posed by deadly infectious diseases.

Under section 23(2)(b), this duty is discharged if the person who reasonably believes he might have contracted AIDS undergoes the relevant medical tests to ascertain he does not, in fact, have AIDS/ HIV at the time of sexual activity. Alternatively, the person at risk must take "reasonable precautions" under section 23(2)(c) to ensure the other person is not exposed to the risk of contracting AIDS/HIV.

Presumably, this means using a prophylactic; however, there is no scientific consensus that external contraceptives are 100% effective. Those who protest otherwise are more interested in protecting lifestyle than life. Could the Minister clarify whether using prophylactics alone would constitute a reasonable precaution?

The regulation of risky sexual behaviour and the dangers of sexually-transmitted diseases and AIDS must go hand in hand with educative measures by the Government and social groups to discourage such irresponsible behaviour; promiscuity should never be socially affirmed. The only effective protection against such diseases is abstinence or monogamy, fidelity within marriages, though this will be mocked as unrealistic or repressive in today's declining moral climate.

As free moral agents, we bear the consequences of our actions, whether wise or foolish. This Act is realistic in assigning duties to infected or 'at risk' persons to notify their sexual partners and allow them to decline to engage in risky sexual activity.

Sir, this law imposes sanctions for lying about being healthy or not taking necessary measures to ascertain one's health status. It sanctions HIV-positive individuals who intentionally or recklessly do not inform their partners about their health status. The Government has an obligation to punish criminal behaviour; in the case of a promiscuous person with AIDS having multiple sex partners, the perpetrator may be responsible for the eventual deaths of dozens, if not more, men and women.

Justice will not be served, if efforts are not taken to deter such deplorably irresponsible, anti-social behaviour. We should not place the privacy concerns of the infected individual who acts irresponsibly or recklessly, above the rights of the partners he might infect or give the equivalent of a death sentence to. We certainly would not do so in relation to SARS, given the recent memory of the heavy toll it exacted from our country just a few years ago.

Sir, section 23(1) provides that if an infected person informs his potential sexual partner of the possibilities of contracting AIDS/HIV from him, and if the informed person accepts this risk, the infected person cannot be charged with a section 23 offence. In other words, the volitional assent of the other person to this risk would mean the elements of the offence cannot be made out. It is not a strict liability offence. The question is, what kind of evidence will be accepted to show whether the other person has, without duress and with due consideration, voluntarily accepted the risk? What if both parties present conflicting evidential accounts?

In addition, what if a person who knows he has AIDS only represents to the other person that he might have AIDS? Does the voluntary acceptance of risk turn on the nature and accuracy of the information given - it may be less risky to engage in sexual activity with someone who might have AIDS as opposed to someone who definitely has AIDS. How will such misrepresentation be treated?

Section 23(2)(a) requires someone at risk of contracting AIDS to inform and obtain consent from his partner prior to sexual activity.

Section 23(2)(b) provides that if a "at risk" person has medically ascertained he does not have AIDS/HIV at the time of the sexual activity, he commits no offence by engaging in sexual activity. This is, presumably, because he will now have an objective basis to know he does not have AIDS/HIV, assuming the accuracy of medical tests and their ability to effectively detect the virus, which may take some time to fully manifest.

If the conditions for section 23(2)(b) are satisfied, if an "at risk" person ascertains he does not have AIDS/HIV, does this person have to adhere to the section 23(2)(a) requirement to notify and obtain the consent of his sexual partner?

In addition, are sections 23(2)(a) and 23(2)(c) to be read disjunctively or together? In other words, if a person duly notifies his sexual partner of the relevant risk under section 23(2)(a), is that person still obliged to take reasonable precautions during sexual activity as section 23(2)(c) requires?

In short, could the Minister clarify whether all three requirements in section 23(2)(a), (b) and (c) must be met or just two of these conditions and in which combination?

In relation to section 23(7), "Sexual activity" is defined in clauses (a) and (b). Would it not be prudent, rather than to use the phrase "sexual activity means" to re-word it to "sexual activity" includes the acts described in clauses (a) and (b)? This is because clauses (a) and (b) may be under-inclusive in failing to capture other forms of sexual activity which conduces to transmitting infectious diseases.

Sir, if my reading is correct, there appears to be differentiated duties imposed on persons who know they have AIDS/HIV and those who reasonably believe they potentially have AIDS/HIV.

A person under section 23(2)(c), who reasonably believes he is at risk of contracting AIDS/HIV, is obliged to inform his sexual partner of the risk of contracting AIDS/ HIV from him prior to the sexual activity taking place; also, during the sexual activity, he must take reasonable precautions to ensure his partner is not exposed to the risk of contracting AIDS/ HIV from him.

However, this obligation to take reasonable precautions during sexual activity is not imposed on a person who has AIDS or HIV and knows this! If the intention of the proposed amendment to section 23 is to prevent the spread of AIDS/HIV, should not the obligation to take reasonable precautions during sexual activity also be imposed on persons known to be infected with AIDS/HIV?

Sir, under section 24(2), a person who knows he has AIDS/HIV infection and commits certain acts, such as donating blood at a blood bank in Singapore, will be subject to more severe penalties. This is correct as such an Act would be the height of both callousness and narcissistic irresponsibility. Imprisonment has been increased from two to 10 years. A person is deemed to know he has AIDS if the positive medical test results have been communicated to him.

Sir, what about during the period between taking the tests and awaiting the results - does any penalty apply to a person if he donates blood or performs any act likely to transmit or spread AIDS/HIV during the interim period? It would be consistent for the law to require responsible conduct during this period as well, given the paramount importance of ensuring the safety and integrity of blood stocks for the good of the entire community.

Sir, I hope the Minister can address these queries and concerns. With that, I support the Bill.

3.18 pm

Ms Sylvia Lim: Sir, I have two queries on the Bill. The first is in relation to section 17A. Sir, clause 12 inserts the new section 17A which allows the Minister for Health to declare either the whole of Singapore or a part of it as a restricted zone and he can do this if he considers that a serious outbreak has occurred or is imminent. As the outcome of this order is very drastic and will affect the movement and livelihood of our people, should this be a decision left to the Minister alone? Is it not possible to have an urgent Parliament session to decide whether the order should be made in the first place? Section 17A(6) provides that the Minister should present the order to Parliament as soon as possible after it is made and Parliament will have a chance to annul the order, in which case the order will cease to have effect. Is it the intention for the Members to have a free vote to support or rescind the order, or will the Whip remain in place in which case the Minister's order will be endorsed as a rubber-stamping exercise?

Sir, my second query relates to sexual activity by a person who has reasonable cause to believe he has been exposed to AIDS or HIV. The existing section 23 only requires those who know that they have AIDS or HIV to take certain steps to inform their partner and obtain consent before the sexual activity. Clause 18 of this Bill amends section 23 to include this category of persons who do not know but have reasons to believe that they have been exposed to a significant risk of contracting AIDS or HIV to take certain steps.

During the Ministry's e-consultation with the public, I noted that there was feedback that the phrase "reason to believe that he has been exposed to a significant risk" was ambiguous. MOH's reply to the feedback was helpful in listing some examples of activities considered risky by the Ministry, for example, intercourse with sex workers, unprotected sex with multiple partners and sharing needles when misusing drugs. While the list can never be exhaustive, I would support putting into the Act some examples as illustrations which should be helpful to people trying to understand and comply with the law, rather than to make them read Hansard, the website and so on, to have a sense of the ambit of the section.

3.21 pm

Dr Fatimah Lateef (Marine Parade): Mr Speaker, Sir, it was 2003, in the midst of the SARS outbreak, a doctor walked into the hospital’s emergency room, the beginning of a 12-hour shift. A young lady just back from an overseas shopping trip, lay on a trolley, breathless and gasping for air. Her oxygen saturation was low and her chest X-ray showed patchy infiltrates suggesting pneumonia.

What are the things that go through the doctor’s mind? How easily this lady got infected and caught an airborne infectious disease? What if he, as a doctor, got infected by it? And who will look after his aged parents and his family? And the list of questions goes on.

It stresses the need to have an effective, rapidly implementable, robust as well as adaptable programme in place for approaching infectious diseases. That is why I strongly support the authority given to the Director to institute public health surveillance programmes and undertake investigations as necessary. In fact, consistent and continuous syndromic surveillance is the way to go and to be vigilant in identifying trends early. A good network of compliance cannot be over-emphasised. In fact, this is where I would like to reinforce and seek the Ministry's agreement on getting inputs from TCM or traditional practitioners because usually they are the first to see certain trends as a large segment of our population still seeks treatment from them at the first sign of any symptoms.

In the same context, greater cooperation and sharing of information with NEA becomes necessary. In fact, greater cooperation will also be in place as we saw during the SARS outbreak where home surveillance and monitoring, home isolation and strict enforcement all come hand in hand with the Ministry of Home Affairs, Ministry of Education, Ministry of Community Development, Youth and Sports as well as the Ministry of Health. We may need to invest a little more in training these personnel in epidemiological data collection and monitoring, contact tracing, infectious diseases, nursing, etc.

In future, perhaps we can consider if our population is ready to take on the responsibility of perhaps self-reporting as and when they experience certain symptoms. This is useful especially when many self-medicate and do not present to any healthcare clinic or institution. This information can be used to track outbreaks very early. However, it would take a lot of discipline, compliance and cooperation on everyone's part for this to work.

This Bill allows a health or police officer to enter premises and carry out the necessary checks where animals, food and water are handled. I see this responsibility as a necessary cooperation, again, with NEA and AVA as well. This will definitely come in useful with new and emerging infectious diseases such as in the recent avian flu outbreak. There was much controversy and discussion as to whether animal to human transmission was possible and of course strategies for the prevention.

Section 18 empowers designated personnel to enter buildings and take measures to abate overcrowding or close the building in the event of non-compliance of the owner. Here, I would like to urge for greater efforts in looking at our foreign workers quarters. It is not uncommon that we get outbreaks of chicken pox/varicella, even dengue, in these overcrowded rooms and apartments where they live in rather unhygienic circumstances. To wait for an index case to surface may be too late as the spread can be rampant during the incubation phase itself, especially in such close proximity. Anyway, the emphasis should be on preventive measures.

Section 19 on the closure and disinfection of premises becomes a reality for us all when the Prima Deli incident happened. Even in Clean Singapore, this is still a real possibility for us and we must never take this for granted. Hence, I support this enforcement proposed by the Bill.

Next, let us consider this scenario: a known HIV positive patient arrives at the hospital with fever and cough. As the paramedics are transferring him, he threatens the staff that he will contaminate them if he is not attended to immediately. He has a wound on his arm which is oozing blood. A very real scenario, and I have personally encountered such patients. This Bill mentions clearly about the sexual mode of transmission but does not mention the non-sexual aspects which can certainly happen. Can I ask the Minister if it will be possible to have some guidelines written in black and white to also cover these other circumstances because, certainly, we need to empathise with our healthcare workers who may encounter this in the course of their work.

Sir, in principle, I also support the amendments made under clause 19 (section 24.2) whereby the term of imprisonment is extended from two to 10 years. This re-enforces the moral, ethical and public health responsibility of a person. However, I would like to caution that we do an extensive assessment of such cases, especially pertaining to the phrase "who has reason to believe that he has, or has been exposed to a significant risk of contracting AIDS or HIV". Firstly, people may not always be forthcoming and truthful; and, secondly, for those who have already reached an established state of the disease, they may not have a lifespan which reaches up to 10 years or more. So it may be beyond their lifespan!

For public health emergencies, Singapore needs to be prepared to handle any outbreak more serious than SARS. In the event of a highly contagious infectious disease outbreak, we need to be able to ringfence areas, implement control measures and limit spread as much as possible, and this is especially so as we are an open country, with high international travellers traffic. In such an emergency, we must harness all resources, including those from the private sectors, private ambulances, doctors, nurses and other medical and paramedical staff. The Ministry will have the power to requisition these resources under the Requisition of Resources Act (RORA). This is the most important and appropriate action and the only way forward for us as a team, especially in a small nation like Singapore where resources are scarce and should be shared and coordinated effectively.

On the International Health Regulation, which was drawn up by WHO and member states (which include Singapore), it is there to protect against and limit the international spread of diseases, including infectious diseases. This rule requires countries to improve international surveillance and reporting mechanisms by member countries, strengthening their own national surveillances and response capabilities. One of the new additions is for countries to notify WHO of all public health emergencies of international concern as it will help mount a response internationally. The amended Infectious Diseases Bill will have the opportunity to be fine-tuned and to take this new requirement into account.

Mr Speaker, Sir, let me continue in Malay:

( In Malay ): [For vernacular speech, please refer to Appendix A.] Infectious Diseases are a potentially serious health problem in Singapore. Although, on the whole, our nation is considered safe, we are not totally protected, for example, when we faced SARS some years ago. Fortunately, with the authorities’ effective steps, and cooperation from each citizen, we managed to overcome that deadly outbreak.

However, we cannot take things for granted as we still face many infectious diseases, like bird flu, dengue, and the hand, foot and mouth disease (HFMD). Other than these diseases, AIDS is also a threat to us if we are not careful. Just take a look at the dengue epidemic we face. The number of victims continued to rise, even with the NEA’s massive effort to prevent mosquitoes from breeding. All these show the need for us to stay vigilant and alert. Each person plays a part to help us overcome infectious diseases, so that it will not spread.

We must not take it easy. That is why I applaud the move to amend the Infectious Diseases Act, to give the Health Ministry more power to act quickly when controlling the transmission of infectious diseases. It is a timely move as it further strengthens our defence against infectious diseases.

With regard to the surveillance of infectious diseases, that will be carried out using residual blood samples from the cohort that had undergone blood examination, I would like to emphasise that ethical and anonymity issues are critical. On the one hand, confidentiality issues must be upheld, while on the other hand, in order to make the data useful, we need to know the facts like age, sex and race, among other things. So, MOH must have clear SOPs or guidelines for those involved in such duties, in order to avoid misunderstandings. However, apart from laws, we must also continue with more public awareness and education campaigns, to explain to the public of our responsibilities.

*Cols. 2713-2714.

Mr Speaker: Order. I propose to take the break now. I suspend the Sitting and will take the Chair again at 4.00 pm.

Sitting accordingly suspended

at 3.35 pm until 4.00 pm.

Sitting resumed at 4.00 pm

[Mr Speaker in the Chair]:

INFECTIOUS DISEASES (AMENDMENT) BILL: Debate resumed.

Dr Lam Pin Min (Ang Mo Kio): Mr Speaker, Sir, I rise in support of the Infectious Diseases (Amendment) Bill.

Throughout history, the movement of infectious diseases across the globe has been intimately associated with the movement of man himself. The most spectacular example of this was the spread of bubonic plague throughout Europe during the 14th Century, which closely mirrored the migration of the civilian population in advance of the Monguls' invasion from the East. This indirectly led to the first attempt at control of communicable diseases related to travel. In England, several small communities attempted to isolate themselves by preventing all contact with outsiders. The most famous of these was the village of Ian in Derbyshire which now has a museum dedicated to the disease.

The impact of commercial airliners on communicable diseases cannot be underestimated. The profile of the traveller has changed from someone moving through necessity, such as businessmen, immigrants or soldier, to someone travelling through choice, ie, the holiday-maker. As a consequence, many people are exposed to an increasingly diverse array of infectious diseases. Air travel and globalisation have brought a whole new dimension to the epidemiology, surveillance, spread and control of infectious diseases. The world has shrunk literally and diseases can spread from one end of the world to the other within a short span of one to two days. Many experts have warned of the possibility of another influenza pandemic occurring. It is not about the certainty of it happening but rather the question of when and how soon. During the Spanish flu pandemic in the early 20th Century, the mortality rate of the disease was 2%-5%, with the number of deaths estimated between 20 and 40 million worldwide. More recently, SARS infected a total of 8,096 persons between November 2002 and July 2003, with 774 reported deaths. This works out to a mortality rate of 9.6%. To date, the number of confirmed H5N1 human cases stands at 369, with 234 deaths so far. This works out to a mortality rate of 63%.

With the world population today having more than tripled since a century ago, coupled with the ease of air travel and the potential high virulence of the H5N1 virus, what is to stop a modern flu pandemic from claiming upwards a hundred million lives? This is no science fiction story but a highly possible scenario that every nation must be cognisant of in their planning and preparation against any worst case scenario infectious disease outbreak. Fighting such an infectious disease is like fighting a war with an invisible enemy.

As alluded by the Minister, SARS was a wake-up call to the nation and the world to the real threat of infectious diseases in this globalised world. Speaking as a medical professional who was at the forefront in the battle against SARS and having witnessed the unexpected loss of fellow friends, colleagues and their loved ones, I strongly support MOH's move to further strengthen its capabilities to detect, prevent and control the outbreaks of infectious diseases.

SARS has taught us an important lesson – to be prepared for all eventualities. During that dark period, as a precaution, my wife and I shifted out of our family home so as to minimise the potential exposure of the disease to our parents and child since we were both healthcare workers and were considered high risk personnel for contracting SARS. The SARS episode has also taught us the vulnerability of human lives. It was during this period that my wife and I actually talked about plans for our then 2-year-old daughter should anything untoward happen to either or both of us.

I can understand the public's apprehension of empowering the Ministry with so much power to limit the movements of people, closure of public areas to contain the outbreak of the disease and the seizure and arrest of properties and suspects respectively. However, these measures are absolutely necessary from a public health, safety and infectious disease control standpoint as any unnecessary delay may result in the rapid spread of the disease with unimaginable magnitude of potential lives lost. In this context, I disagree with Ms Sylvia Lim's suggestion that urgent Parliament be convened instead of investing the necessary powers to the Minister to handle such an emergency.

Next, I would like to applaud the Ministry for enhancing measures to prevent and control HIV/AIDS. HIV/AIDS is presently a pandemic, with an estimated 33 million people infected worldwide and having claimed about 2.1 million lives. Tough actions to curb the spread of the disease are needed to prevent further escalation in Singapore.

However, the proposed amendments to the Bill have cast some doubts on the intent and the practicality of enforcing section 23 of the Act. Clause 18 amends section 23 of the Act to shift greater responsibility to individuals whose sexual behaviour puts their spouses and partners at risk of contracting HIV/AIDS. What then is the definition of "high risk groups"? What is the definition of "promiscuity"? Is it more than one, two or three partners? The Bill requires the person who has reason to believe that he has or has been exposed to a significant risk of contracting HIV/AIDS to take reasonable precautions to protect his sexual partner, such as by using condoms. If a promiscuous person practises safe sex by using the condoms every time he engages in sexual activities, is he considered as high risk of contracting HIV/AIDS? Will he be considered safe and therefore be absolved of contravening section 23 of the Act?

Section 23 also states that the person can go for a HIV test to confirm that he is HIV negative. Otherwise he must inform his partner of the risk of contracting HIV from him, leaving the partner to voluntarily accept the risk. Unfortunately, there is a window period for which an infected person can still be tested negative since it takes about three to six months to seroconvert to test positive. Will there be a validity period of the HIV negative results after which the high risk person will not be granted immunity from the law? What about intravenous drug abusers, especially those who share contaminated needles? Should they also be covered under this Act when they engaged in sexual activities with their spouses or partners?

Last but not least, I would like to clarify with the Minister that section 23 of the Act is gender neutral and that it applies to both, the males and the females.

Sir, on that note, I support the Bill.

Mr Khaw Boon Wan: 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, and 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 businesses. 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 very difficult problem. After SARS in 2003, many countries have implemented new legislation to enable the 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, and others are seriously considering similar legislation.

In drafting the 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 public health emergency should be declared. This is because of the urgency of the situation, as pointed out by Dr Lam. We have taken heed of this foreign legislation provision and also make it a ministerial executive decision subject to Parliamentary oversight, and 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 judgment and decisive action. In the absence of complete information, a delay in sounding the alarm will cause many lives. Dr Lam gave us a good account of what a worst case scenario may look 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 aggressively when a plausible trend appears. Signals will come from clinics, whether they are western or eastern. So I agree with Dr Fatimah Lateef that we should tap on the TCM practitioners for this purpose of surveillance. Surveillance data will be treated in the strictest confidentiality. However, in the larger interests of public health, we do need the power of section 7 to examine the affected patients promptly so that there is no delay and the results will not be skewed by patients who may refuse examination.

I agree with Mdm Halimah on the importance of regular training of our healthcare workers, whether they are in the public or private sectors, on how to deal with an emergency, and that is why we have regular exercises to test and finetune our emergency plans and 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 and a good example is the recent Chikungunya outbreak in Little India where the public, private and people sectors came together and worked as one Singapore. It was a success story which we can be proud of.

Epidemiological investigation does require a medical examination of an infected person during which a body sample may have to 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 will be a blood sample.

Prof. Thio asked what might constitute "reasonable excuse" for rejecting a medical examination. I think this will depend on the circumstances. For example, I think it will 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 are sure that he no longer poses a threat to public health. As I said, the key objective is public health. It is not so much prosecution and seeing that he be penalised in some way or the other.

Prof. Thio also asked what practical steps to ensure that affected persons will receive the actual notice of the orders under the new section 17A. We will make full use of the media extensively to disseminate such information. Singapore, being so small, I think disseminating such information should not be too difficult. In addition, where appropriate, we will work with the licensing agencies to inform their licensees of such orders and, on the ground, our officers will also assist in disseminating such information when directing the movement of persons in the restricted zones.

Dr Fatimah Lateef highlighted the potential public health problems of unhygienic, overcrowded 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 which I have noted for future reference.

Let me now address the comments on HIV/AIDS. Dr Fatimah asked whether the law provides protection against transmission of HIV through non-sexual means. She gave a personal account of how a HIV-infected patient threatening to infect the healthcare workers if he did not receive immediate attention. Existing law does confer such protection for our staff. For instance, a patient as described may be liable for criminal intimidation under section 503 of the Penal Code. The hospital should have taken up the case and pressed charges.

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, and in HIV prevention public education remains the key strategy. But the mode of public education should take into account the nature of our society. The ABC campaign against HIV - Abstinence, Be faithful and Condom usage - cannot be broadcast nationwide with equal intensity. Many parents would be upset with such a campaign and we will be accused of promoting promiscuity. So the general broadcast will have to be ABC with a small "c". On the other hand, the ABC campaign targeted at high risk groups will have a huge "C", enlarged "C", as the main theme. I agree with Mdm Halimah that we should pay special attention to vulnerable groups such as the young and women.

We are also 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 over the next two years to expand on these efforts.

As for the new provision under section 23 to tighten the control of HIV, let me repeat here 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. In my job, I have come across a handful of such innocent victims, totally unaware that their husbands had gone to different places, had fun and then passed on the HIV to them. But what can they do in the circumstances? So these are real situations on the ground and are not theoretical.

Members have asked what amounts to "reason to believe", what is high-risk behaviour and who are high-risk individuals. I think they are quite straightforward. Let me give an illustration. A man who has unprotected sex with prostitutes or with other men, or a man who has unprotected sex with multiple partners, or a man who shares injection needles with other drug addicts would clearly be aware of his activities and he should have reason to believe that he has been exposed to a significant risk of contracting HIV.

Ms Sylvia Lim has suggested that we hardwire these illustrations into the Act. But we think this is not necessary, firstly, because the examples will never be exhaustive; secondly, because our public health education programmes will clearly emphasise what activities put a person at risk of contracting HIV/AIDS and the necessary precautions to be taken to reduce that risk. Let me clarify that the new provision does not ban such a person from sex. It merely requires him to take any one of the following three measures before he has sex with another person:

(1) Inform his partner of the risk and then allow the partner to make an informed decision as to whether to accept the risk and have sex with him;

(2) Undergo regular HIV testing to determine that he is not HIV-infected at the time of the sexual intercourse; or

(3) Take reasonable precautions to protect the partner, eg, by using the condom. Any one of these procedures would then protect him legally. While we encourage such a person to take all three steps to protect his partner, he is legally protected if he takes any one of the three steps.

Prof. Thio asked what constitutes "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 practises safer sex, by using condoms every time he engages in sexual activity, is not considered at high risk of contracting HIV/AIDS. This is for the purpose of this Bill. If you ask me, from the public health point of view, I think he is still at risk by being promiscuous.

Dr Lam asked me to define "promiscuity" by giving a number. 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, meaning strangers, eg, one who is not your wife, simply increases the risk. And, honestly, you do not need many encounters to get HIV. Sometimes, it is one unfortunate encounter and your life is ruined. So please do not do it.

I agree with Mdm Halimah's observation that in the dynamics of a marital relationship, the husband is unlikely to be truthful about his infidelities and the wife is unlikely to testify against her husband. Such complexities in human relationship cannot be avoided. But this new legislation will 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. That has been our experience. 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 raises the possibility of conflicting evidence. Let us return to the spirit of this provision. The intention is for a person who knows that he is HIV-positive or that he has 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 that 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 has 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 anger or jealousy, witnesses may be uncooperative because of embarrassment or because they have feelings for the accused. We will be sensitive to 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 the prosecution. If the Attorney-General decides that there is, we would 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 which is reported to us for contact tracing. This way, every known sexual partner who has been put at risk can 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 three months, although the majority would have detectable antibodies within two to eight weeks after infection. The standard practice for the doctors today is to advise anyone, who has a negative test within three months of last exposure to the risk of HIV infection, to be retested more than three months after that exposure to ascertain that, indeed, he does not have HIV or its 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 to 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, for example, using condoms, to protect his partner, whereas the new provision would seem to apply to those who are at risk but are not aware of their HIV status. As I 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 that 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". Maybe, we were not creative enough. Her comment is fair, but I think the present definition does sufficiently capture the range of activities which present a risk of HIV transmission. But if we are proven wrong, then we can always amend it in due course.

Prof. Thio also asked how a high-risk person who donates blood while waiting for 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 will 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, it is up to the courts to 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 only the first step. The 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 testing so that the appropriate clinical management, counselling and contact tracing can be carried out. Nearly 100 medical clinics now offer HIV testing using the new 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-risk individuals to practise safer sex and regularly test themselves. That is the spirit of the new legislation.

Before I end, let me address Mdm Halimah's additional queries. She asked about HIV testing of doctors in hospitals, which we introduced recently. She noted that not 100% of doctors took part in the HIV screening. First, let me clarify that, globally, nobody prescribes mandatory HIV testing, whether of healthcare workers or of patients. But the recommendation is to go for one. In the case of doctors, as we discussed yesterday, they operate within their medical ethical framework, and one major ethical rule is: "do no harm". So if you are engaged in exposure-prone activities and you know that there is a risk, even though the risk is low or minimal, you should ascertain your HIV status. This way, you can then better decide if you should engage in such exposure-prone activities. This is the ethical framework which they operate under. Let us say they are a high-risk group and yet refuse to be screened for HIV and if one day,

one of their patients is infected, they would have to answer to the law. Their legal liability and their own ethical oath would then determine their behaviour.

The reason why not all participated in screening, based on our focus group discussions, is because many have done the screening before. For instance, some of them are regular blood donors, so they would have known their HIV status. They would also know their sexual activities. These are knowledgeable people and they will know what is the likelihood of them being HIV-positive. Not participating in this particular round of health screening does not mean that they will not take part in future health screening. So I was not surprised that the participation rate is not 100% or close to 100%.

Mdm Halimah asked about the expert committee which I mentioned in my written reply to her yesterday. Supposing we discover a hospital worker who turns out to be HIV-positive, then we will have to decide whether we go back to all previous cases treated by him. Let us say he is a surgeon and he has operated on some patients. Do we need to go back and trace the patients and then get them to come forward to be HIV-screened, in case there was an infection in the past? To help us make that kind of decision, we will convene, as and when a case crops up, an expert committee to look into this.

I would add that, over the years, the need to convene, what we call, a look-back study has become less and less. In fact, I have not read of any such look-back studies in the world in recent years. The reasons are several. One is better awareness of how HIV may be transmitted during exposure-prone procedures and therefore enhanced infection control procedures. Staff are serious in compliance. That has diminished the risk to a tiny risk, and that is part of the reason too why, globally, we have not heard of any HIV transmission from doctor to patient for many years.

Mr Speaker, Sir, I thank the House once again for their support of the Bill.

Ms Sylvia Lim: Sir, I wonder if the Minister could clarify this point which he did not refer to. It is concerning section 17A(6) where he mentioned that after making the order, he would have to come to Parliament to convince Parliament that the order was necessary. My query during my speech was whether at that time MPs would be given a free vote on the matter or would the Whip be in place.

Mr Khaw Boon Wan: Sorry, I forgot this particular query on Whip. It is not for me to decide whether the Whip will be lifted. But all I know is our MPs, Whip or no Whip, will have the full interest of the public at heart, and I am sure they will vote according to what is needed to protect them. The key point of making such a declaration is not straightforward. It is not one of politics. It is about accessing information which almost certainly will be limited and incomplete, and to make a judgment call – do you declare or not to declare?

Let us see the current outbreak of hand, foot and mouth disease where the number of cases has exceeded last year's. I have received many emails. Many have asked me to close down all primary schools and nurseries, to break the transmission. But how to do so? Because hand, foot and mouth disease has been around for years, and it will continue to be around for years. If each time there is a cluster, we were to close down nurseries, we will end up not having any nursery open at all throughout the year, because it is one of those infections that spread throughout the year. People will vary according to their risk appetite. So it is not easy to make a call. A couple of months ago, you may remember, Hong Kong declared a closure of all their schools because of the flu outbreak. After the event, it is easy to comment whether that decision was premature, necessary or correct. But while you are in the midst of the outbreak, having to judge what is likely to happen next and what you should do now is not an easy decision to take. That is why, in my speech, I emphasised that this is a heavy responsibility and a decision which we will take very carefully, after weighing the options. Because if I were 'trigger happy', I think Prof. Thio used the words – I am always happy but I am not 'trigger happy' – and I cry wolf every now and then, I lose credibility. And when the real wolf appears, nobody believes me; I may declare social distancing and people still go out to restaurants and elsewhere, and it defeats the whole purpose, because I have lost credibility. That, to me, is the single most important safeguard against any abuse of these very harsh measures and powers which we are asking the House to provide us.

Question put, and agreed to.

Bill accordingly read a Second time and committed to a Committee of the whole House.

The House immediately resolved itself into a Committee on the Bill. – [Mr Khaw Boon Wan].

Bill considered in Committee; reported without amendment; read a Third time and passed.