INFECTIOUS DISEASES (AMENDMENT) BILL

Order for Second Reading read.

The Senior Minister of State for Health (Dr Aline K. Wong): Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time."

This Bill seeks to amend the Infectious Diseases Act (Chapter 137 of the 1985 Revised Edition) and the Infectious Diseases (Amendment) Act 1992, to strengthen the public health control of Acquired Immune Deficiency Syndrome (AIDS) in Singapore.

The Infectious Diseases Act was passed in 1976 to prevent the introduction and spread of all infectious diseases in Singapore. AIDS, which is caused by the Human Immunodeficiency Virus (HIV), became a notifiable disease under the Infectious Diseases Act in 1985. In 1992, the Act was amended to include provisions to tighten the control of AIDS and to provide for the confidentiality of infected persons. However, changing trends of HIV infection in recent years require us to make further amendments to the Act in order to strengthen the public health control of AIDS in Singapore. Before I go into the details about the Bill, let me brief the House on these trends and therefore the need for changes to the existing law.

HIV/AIDS situation in Singapore

The number of HIV infected Singaporeans has been increasing over the years since 1985 when the first case was reported. Between 1985 and 1990, a total of 61 cases were reported. The rate of increase has accelerated since then. In 1991 alone, 42 new cases of HIV/AIDS were reported, as against the total of 61 cases between 1985-1990. Over the last four years, the number of cases shot up to more than 100 per year. Last year, 1998, the number climbed to nearly 200. The exact number was 199. In total, there were 930 Singapore residents notified to be HIV infected between 1985 and 1998, of whom 423 had asymptomatic infection, 196 had full blown AIDS and 311 had passed away. In addition, a total of 2,813 foreigners had been tested to be HIV positive while they were in Singapore. About 80% of such foreigners were work permit holders and applicants. They have already left Singapore.

The pattern of transmission of the HIV infection has changed over the years, from a predominantly homosexual infection to one that is mostly spread by heterosexual transmission. Over the last three years, heterosexual transmission accounted for an average of 78% of all new cases. Most of these cases had unprotected sex with prostitutes and casual acquaintances in Singapore or abroad.

The pattern of heterosexual infection itself has also changed. The proportion of married men among new cases of HIV infection among male Singaporeans has increased from 10% in 1991 to 30% in 1998.

With this shift of the infection to the married population, infected men are bringing the infection home to their wives. A further tragic consequence is that there are more reports recently of children with HIV infection. The first HIV infected child was reported in 1991. Since then, eight more cases have been reported between 1997 and l998. All of them have been infected perinatally. Families have been devastated by the HIV infection. We have had at least two families where all members were infected. This emerging trend needs to be addressed.

Another major concern that has arisen recently is HIV transmission through blood transfusion. In 1997, my Ministry reported the first case of HIV transmission through blood transfusion. Two persons became infected after they received blood from a donor who was in the window period of the HIV infection. This is despite the stringent measures taken by the Singapore Blood Transfusion Services (SBTS) to exclude donors with risk factors because the donor had lied in this case. The HIV infected donor admitted to a total of six offences under section 182 of the Penal Code. He was charged in court early last year and given a sentence of 12 months. This penalty is hardly commensurate with the harm the donor had caused to the two recipients who received his blood.

In 1997, my Ministry was also notified of a health care worker who was HIV infected. All the health care worker's patients, who were exposed to the risk of acquiring the infection through clinical procedures that were carried out on them, were informed, counselled and offered HIV screening. This look back programme to trace the contacts of the health care worker cost my Ministry $400,000. Fortunately, none was infected.

Sir, with the changing pattern of transmission of HIV infection in Singapore, we have to address these new and emerging issues pertaining to the HIV infection here. My Ministry has reviewed the law and put up new strategies to ensure that the health of our people is not compromised. Timely actions need to be taken to prevent further spread of the disease within the population. My Ministry has studied the existing Infectious Diseases Act and has proposed several amendments to the existing Act to tighten the control of HIV infection in Singapore.

Several countries responding to the AIDS epidemic, like the United States, Britain and Australia, have legislation to protect the public. Legislation in these countries has been enacted to allow for the disclosure of the HIV status of a patient to the spouse, sexual partner or contact. Provisions have also been made for disclosure to health care providers and other personnel who had come in contact with blood or body fluids of an infected person, and to the next of kin upon death of the infected person as well as in the interest of public health if it is threatened. Even in the United States where there were earlier laws to protect the civil liberties of HIV infected persons, new legislation has been introduced more recently to identify, notify and make it an offence for those who intentionally place others at risk of contracting the infection.

Infectious Diseases (Amendment) Bill

Sir, I will now deal with the main provisions of the Bill.

Currently, a person who furnishes false information at the Blood Bank is charged under section 182 of the Penal Code. This carries a maximum penalty of $1,000 and/or a maximum jail sentence of six months.

My Ministry proposes to make this an offence under the Infectious Diseases Act so that the appropriate penalty commensurate with the severity of the offence can be meted out. In the Amendment Bill, under a new section 10A, it is an offence to furnish false or misleading information in relation to the donation of blood. The maximum penalty under this section is a fine of $20,000 or a term of imprisonment not exceeding two years or both.

Consequent to such a new provision, section 20C of the principal Act is amended to raise the penalty for a person who knows that he is HIV infected and yet donates blood or does any act that is likely to result in the spread of the disease from $10,000 to $50,000.

Exceptions to Medical Confidentiality

The identity of the person with AIDS/HIV infection is protected under section 20D of the existing Act, where disclosure of identity and HIV status is allowed only to specified categories of persons. To address the public health issues that have arisen over recent years which I have described just now, my Ministry proposes that new exceptions to medical confidentiality be included. The main objective of such new exceptions is to prevent transmission of the infection through irresponsible behaviour by persons who are infected and to allow those who have been exposed to the risk of the infection to be informed early, counselled and tested. With the availability of newer anti-retroviral drugs, early diagnosis will allow such victims to be treated to delay the progress to full blown AIDS. The treatment will also allow for a better quality of life on the part of the patients.

Under clause 7(d) of the Amendment Bill, new provisions have been provided to allow the disclosure of the HIV status and the identity of the HIV infected person to his/her spouse and contacts. This amendment is to cater to the increasing incidence of HIV infection among married persons. From our experience, the infected person is sometimes reluctant to inform the spouse or contact despite numerous counselling sessions and advice from the doctors. Some have even refused to do so. Under the existing Act, my Ministry is unable to take any further action should the patient refuse to inform his or her spouse or contact. The new provision will allow the doctor to disclose the HIV status of the patient to the spouse or contact if the patient refuses to do so despite repeated counselling by the doctor. My Ministry strongly views that the spouse or contact who has been exposed to the risk of infection has a right to know so that they can be counselled and screened for the infection. Those who are not infected can take the necessary precautions to protect themselves against any further exposure to the HIV while those who may be infected will have a chance to undergo anti-retroviral therapy while they are in the early stages of the infection and make the relevant choices.

For example, for infected wives who are pregnant, early diagnosis will allow a choice to abort the pregnancy or to take prophylactic measures to prevent transmission of HIV to the baby.

My Ministry will continue to counsel those who are infected on the importance of disclosure so that they inform their spouses and contacts themselves and to bring them forward for counselling and screening. However, we will need to apply this legal provision if the counselling fails.

Clause 7(d) of the Amendment Bill also enables the disclosure of the identity of a HIV infected person to the health care workers who have previously treated him/her, or to any other person who, in the act of rendering emergency assistance to a HIV infected person, has therefore been exposed to the risk of infection with the HIV.

Other new provisions under clause 7(c) of the Amendment Bill would allow my Ministry to disclose the identity of HIV infected foreigners to the Controller of Immigration for the purposes of the Immigration Act, and the disclosure to the next of kin of the HIV infected person in the event of death, because special burial arrangements have to be made to ensure that public health is safeguarded.

Under the Amendment Bill, the Minister is empowered to authorise the publication of information which may identify the HIV infected person in instances where the health or safety of the public is threatened. I would like to assure the House that this provision would only be evoked under extreme circumstances, such as when an infected person wilfully continues to place others at risk of contracting the infection, and the disclosure can only be done with the Minister's approval.

Re-disclosure of information

To ensure that there is no abuse despite the increase in the categories of persons to whom information on the HIV infected person can be disclosed to, the Bill has included a provision under clause 7, subsection 9, in which no person to whom any information on a HIV infected person has been disclosed, shall re-disclose such information to anyone except to persons stipulated in the Act. Unauthorised re-disclosure will be dealt with seriously. The penalty is a fine of $10,000 or imprisonment for a term not exceeding three months or both.

In conclusion, with the increasing incidence and changing pattern of HIV infection in Singapore, the amendments to the Infectious Diseases Act are necessary to ensure that the health of our people is not compromised. All of us, doctors, neighbours and friends, members of the public, should continue to empathise with HIV patients and their families. AIDS is a dreadful disease that causes great suffering and social stigma to the victims and their loved ones. We must continue to help them and treat them humanely and with great compassion. My Ministry will ensure that the new provisions under the Infectious Diseases Act will not be abused and the rights and confidentiality of the infected person are protected as far as possible. At the same time, we will continue and step up our public education on AIDS, so that all Singaporeans will become fully aware of the danger of the infection and take preventive measures to avoid the risk of being infected.

Sir, the proposed amendments to the Infectious Diseases Act will enable my Ministry to step up the public health control of AIDS in Singapore. It will help to prevent further transmission of the infection among the population, and allow those who may be innocently infected to seek screening and early treatment. It will also enhance further the safety of our national blood supply.

Sir, I beg to move.

Question proposed.

Mr Bernard Chen (West Coast): Mr Speaker, Sir, I support the amendments proposed by the Senior Minister of State. The Senior Minister of State has mentioned about the rise in incidence of AIDS in Singapore, which is alarming by itself. But let me refer Members to some statistics for the world which point out even more starkly the spread of AIDS. Many of us are aware that the spread of AIDS is increasing but not to the extent that is being done in certain areas. For example, this survey was done by Time magazine and published in the Annual 1996. The number of people living with HIV AIDS in North America as at the end of 1996 amounted to 750,000 people. The change from 1992 to 1996 was minus 13%. That means, they have actually a reducing incidence of people with AIDS. Maybe they died. The death in 1996 was 61,000. In Western Europe, the total number of people with AIDS is half a million. The change from 1992 to 1996 is 2%, and death in 1996 was 10,000.

This shows that at least, for the time being, the increase in AIDS in people has stabilised for the developed countries in North America and Western Europe. In the Sub-Sahara Africa area where AIDS started actually, the number of people living with AIDS now amounted to 14 million. Changes from 1992 to 1996, 37%; and death in 1996, 783,000. The interesting one is for South and South-east Asia. By this, I think India and Pakistan, and also all parts of Southeast Asia included, the number of people living with AIDS and HIV is 5.2 million. But the change between 1992 and 1996 was 261%, which is the highest among all the continents; and death in 1996 was 43,000. This could be because of detection, but the high increase could not hide the fact that the spread of AIDS in this region is getting out of control.

Singapore is particularly vulnerable because we are exposed to the region. We have people coming into Singapore in far greater numbers, and Singaporeans are travelling abroad even more frequently. The possibility of being affected by this disease will be only increasing with time, rather than lessening. Therefore, I fully endorse the Ministry's policy to enhance the punishment for not revealing this illness to the spouses or contacts and to empower our Immigration Officers to be on the lookout for foreigners coming in.

The punishments recommended are not as harsh as those under the Misuse of Drugs Act. In fact, AIDS is worse than drugs. It is a death sentence. The moment you get it, that is it. And if we are so conscious in controlling drug abuse and drug trafficking, and we have been successful at it, all the more reason we should make sure that we apply the same methods to an even more dangerous disease - AIDS. Therefore, I fully support the enhanced punishment proposed by the Ministry. But, I think, ultimately, it is much better to look at prevention rather than cure. In this case, cure is not even secure. Whatever punishment you have is only after the event. As the Minister says, it is better to see how we can prevent the disease.

This brings us into the social realm. The Government cannot legislate this. The best thing to do it is, as the Chinese say, if you do not want people to know about it, do not do it. If you do not want it to happen to you, do not do it. The first thing is if we can maintain spouse fidelity, we will never have a chance of passing any of these things to our children, to our wives and to the children; a proper lifestyle, perhaps, when you travel to countries where the incidence of AIDS is very high. But these are human behaviour which the Government cannot force on our people because they have the freedom of choice. But HIV to me is almost a death sentence which in this case not only affects oneself, it affects all those with whom they come into contact. I do not think the Government will take much joy in getting more revenue from fines. That is the least of the problem. But I think the more adverse impact coming from this is: should AIDS spread through the children, through the spouses and families, the resultant social problems that arise would be a much bigger price to pay. And I think we should do what we can to ensure that this is minimised. The message to Singaporeans at large is the laws are meant to protect you but, ultimately, you have got to protect yourself. The Government cannot do that.

I support the Bill.

Dr Tan Cheng Bock (Ayer Rajah): Mr Speaker, Sir, I would like to declare my interest. I am a family practitioner.

Disclosing patients' medical records is a breach of medical confidentiality. Medical confidentiality is the cornerstone of medical practice, that is, we doctors never reveal any patient's problem even to close relatives who call up to find out what is wrong, unless the patient's consent has been given, and this builds up trust between a patient and his doctor. However, as disease patterns change, and new illnesses, like AIDS, which pose a danger to the society at large, doctors are prepared to compromise and surrender their medical confidentiality under very special circumstances. This is for the better good.

This Bill, amongst others, seeks for more exceptions to medical confidentiality with regard to patients suffering from AIDS, Human Immunodeficiency disease. But in seeking this breach of confidentiality, this Bill very carefully avoided indiscriminate disclosures by imposing strict guidelines as to who, when and how these disclosures can be made. Thus, in section 20D of the Infectious Diseases Act, and under clause 7, amendments to section 20D of the original Act, there is a list of personnel and departments where such disclosures can be made under certain conditions. This is very reassuring and I support the amendments.

However, let me bring Members to the attention on the Explanatory Statement on pages 6 and 7. This is where I want to seek clarification from the Minister. If you look at the Explanatory Statement in the two pages I have mentioned, there is a phrase "any other sexually transmitted disease". It is not present in the Amendment Bill itself. Thus, clause 7, which amends section 20D, as stated in the Explanatory Statement, and I quote:

'provide for more exceptions to medical confidentiality [in subsection (1)] in relation to information that would identify a person who is suffering from AIDS, Human Immunodeficiency Virus Infection or any other sexually transmitted disease.'.

Mr Speaker, Sir, this last phrase "any other sexually transmitted disease" is all encompassing. Unlike AIDS, many sexually transmitted diseases are not fatal with modern management of the illnesses and thus pose no serious danger to society. Take, for example, this Protozoa infection called Trichomonas. It is sexually transmitted but easily treatable and is fairly common even among married couples. I am not sure whether, according to what I interpret from the Explanatory Statement, that this Trichomonas infection needs to be disclosed. In fact, I wonder why this particular statement was introduced in this Bill. It seems to be out of place.

In the original Act, the Infectious Diseases Act (Chapter 137), all infectious diseases listed in a specific form must be notified to the Ministry. And this is correct, as it allows the medical body to monitor the pattern and spread of these diseases. I have a form here for Members who want to know or want to see it. They can come and see me afterwards. In this form, there was no mention of Trichomonas infection. Therefore, to make matters clearer and to avoid any ambiguity in interpretation in the future, I would suggest that we add the word "designated" before "sexually", so that the phrase would now read: "any other designated sexually transmitted disease". I think this is much clearer. Mr Speaker, Sir, the Ministry is now run by non-doctors at the top as administrators. If they choose to interpret the Bill according to what is stated, then we may face problems in future, and this goes for the other future medical Bills.

Finally, Sir, I wish our Bills can be drafted in a manner which is easy for lay people like myself to follow. The number of times I have to turn the pages to understand which section relates to which, and which clause must be inserted into which statement, I find all this tiring. I am sure in my discussion today when I mentioned those sections, some of you are also quite blur. Mr Speaker, Sir, I must confess that each time I read a Bill, I find that to get a coherent understanding it eats too much into my time and understanding.

Mr Speaker, Sir, I support this Amendment Bill and hope the Minister will look into what I have suggested, that is, inserting the word "designated" before "sexually".